Community Health Needs Assessment and Implementation Plan

Transcription

1 Community Health Needs Assessment and Implementation Plan Adopted by Community Health Board: June 27, 2016

2 Table of Contents I. EXECUTIVE SUMMARY... 2 II. OVERVIEW... 6 State, Regional and Community Partners... 6 Community Health Framework... 8 III CHNA REVIEW... 9 IV. CLARK COUNTY DEMOGRAPHIC AND SOCIOECONOMIC PROFILE V. KEY HEALTH INDICATORS Method Healthy, Active Living Child & Family Wellbeing Health Delivery Systems Equity VI. COMMUNITY CONVENING Method VII. IMPLEMENTATION PLAN Introduction Needs Not Addressed Appendix 1: Organizations Participating in Community Convening

3 I. EXECUTIVE SUMMARY Overview PeaceHealth Southwest Medical Center PeaceHealth Southwest Medical Center (PeaceHealth Southwest) is one of ten hospitals within PeaceHealth, an integrated, not-for-profit health system in the Pacific Northwest. Located in Vancouver, Washington, the primary service area for PeaceHealth Southwest is Clark County, Washington. Community Health Needs Assessment PeaceHealth Southwest and partners conducted a Community Health Needs Assessment (CHNA), a systematic process involving the community to understand community health needs in order to prioritize, plan and outline solutions. The 2016 CHNA was carried out with community input, including public health and nonprofit community groups representing minority and low-income residents. Both primary and secondary data were collected and incorporated. We also interviewed key informants and held a community forum in which needs were affirmed and possible strategies to address the needs were identified. Data and local perspectives are presented and analyzed according to a four-pillar structure of community health: 1) Healthy, Active Living; 2) Child & Family Wellbeing; 3) Integrated Health Delivery Systems (including medical dental and behavioral health services); and 4) Equity. PeaceHealth Southwest conducted this CHNA in conjunction with state, regional, and local community health planning in Washington, Southwest Washington, the Columbia-Willamette area, and Clark County CHNA The problem of health care access and lack of insurance coverage was identified in all PeaceHealth communities in 2013 as a major need and was therefore chosen as a major focus area in our 2013 CHNA implementation plans. PeaceHealth worked as part of the community coalitions that were formed across the state for the purpose of helping people sign up for commercial health insurance and Apple Health, i.e. Medicaid. By any measure these efforts were successful. 2

4 Summary of the 2016 Community Health Needs Assessment Demographic and Secondary Data Clark County has about 440,000 residents. 28% are children 0-19 years old, 61.6% are adults age 18-64, and the remaining 12.6% are seniors age 65+. Vancouver is the largest city in the county representing nearly 37% of the county s population. Approximately 33% of Clark County residents are either Asset Limited, Income Constrained, Employed or live below the poverty line. 8.1% of the County s population is Hispanic. Key health indicators were organized into the four community health pillars using primary data from Robert Wood Johnson s 2016 County Health Rankings and other state sources. Health outcomes gaps in each area are summarized below. HEALTHY, ACTIVE LIVING: Major issues identified include youth smoking and physical inactivity. The county is below the state average for both these measures. CHILD & FAMILY WELLBEING: Readiness to Learn among kindergarteners entering school and food insecurity among children are major concerns for children in Clark County. While these measures are similar to State of Washington rates, these are important factors to monitor to improve children s lives. HEALTH DELIVERY: Data show that there are significant differences in rates of being insured by race/ethnicity, and racial/ethnic differences in the quality of preventive care received by Medicare beneficiaries. Addressing these inequities is vital to the health of the community. EQUITY: Affordable housing is a key component of financial wellbeing and stability, and forms the basis of good health. There are many pockets of people in Clark County burdened by high housing costs. Clark County has less income inequality than the majority of counties in Washington State, an important marker of community health resilience. Community Engagement and Local Perspectives PeaceHealth Southwest interviewed 12 key informants from organizations throughout the County representing public health and minority health to identify health gaps and possible health solutions. The key informant interviews were conducted in advance of a convening that was held on May 11, 2016 wherein more than 50 community leaders from public health, health and social services, business, schools, and government met to confirm, refine, and identify health needs/gaps and possible solutions. Table 1 summarizes the results of the community stakeholder meeting. It should be noted that the lists of gaps and strategies represented in the table were generated in two separate set of group conversations, processes, i.e. the strategies were not necessarily identified as specific solutions to the identified gaps. 3

5 Table 1. Results of the Community Stakeholder Meeting Healthy, Active Living Major Health Problems/Gaps Adult and teen chronic diseases Social isolation Prioritized Evidence-Based Strategies Community Health Worker programs School nutrition programs Child & Family Wellbeing Housing affordability for homeless and low income families Maternal/child health Financial literacy/independence Postpartum depression Health care for women in recovery Prenatal and early childhood home visiting programs Preschool programs with family support services Health Delivery Systems Equity Health care still unaffordable for many despite insured status Poor outcomes for people who have chronic mental illness Lack of health care access for people who are undocumented Mass incarceration Cost-burdened housing Poverty disparities by race/ethnicity Integration of behavioral health and primary care Supported housing programs School-based health centers Expanded Housing First programs 4

6 Implementation Plan The Implementation Plan strategies summarized below were extrapolated from the data and from community input. Our plan is comprehensive in the sense that there are strategies that impact the focus areas within each of the community health pillars (and a number of strategies cross pillars). The display of strategies is not intended to be a complete listing of all the activities that PeaceHealth will undertake with its community partners to affect the health status of the community. Rather, it is a statement of our community health priorities. PeaceHealth Southwest CHNA 2016 Priorities Ensure effective information exchange and care coordination for select populations (e.g. PeaceHealth Medical Group patients with complex health and psychosocial conditions who are served by multiple organizations) through the PeaceHealth Transforming Clinical Practice Initiative (TCPI) and other community collaborations. Increase participation in the PeaceHealth employee wellness program, particularly for caregivers at the lower end of the compensation scale. As part of our ongoing efforts to create an inclusive organization that exercises cultural humility, recruit for and support a workforce that reflects the changing ethnic, racial and cultural diversity of the communities that we serve. Develop a Community Health Worker initiative that empowers individuals within specific communities to serve a liaison/linking/intermediary role between health/social services and the community to facilitate access and improve the quality and cultural competence of service delivery. Partner with local agencies to ensure the ongoing availability and potential expansion of prenatal and early childhood home visiting programs. Advocate for and actively support the development of a comprehensive continuum of services including integrated primary clinical and behavioral health, access to crisis stabilization, transitional and long-term housing, substance abuse treatment and psychiatry services for all ages. Advocate for and actively support strategies that provide short and longer-term interventions addressing homelessness and the affordable housing crisis in Vancouver. 5

7 II. OVERVIEW Founded by the Sisters of St. Joseph of Peace in 1890, PeaceHealth is a Catholic Healthcare Ministry serving in the communities of Alaska, Washington and Oregon. Today, PeaceHealth is a 10 hospital integrated not-for-profit health system that offers a full continuum of health and wellness services. PeaceHealth s mission is to carry on the healing mission of Jesus Christ by promoting personal and community health, relieving pain and suffering, and treating each person in a loving and caring way. The fulfillment of our Mission is our shared purpose. It drives all that we are and all that we do. We have embraced the Community Health Needs Assessment (CHNA) process as a means of engaging and partnering with the community in identifying disparities and prioritizing health needs, and importantly, in aligning our work to address prioritized needs. Caring for those in our community is not new to PeaceHealth; it s been in practice since the Sisters of St. Joseph of Peace arrived in Fairhaven, Washington to serve the needs of the loggers, mill workers, fishermen and their families more than 125 years ago. Even then, they knew that strong, healthy communities benefit individuals and society, and that social and economic factors can make some community members especially vulnerable. The Sisters believed they had a responsibility to care for them, and that ultimately, healthier communities enable all of us to rise to a better life. This philosophy inspires us today and guides us toward the future. State, Regional and Community Partners PeaceHealth s 2016 CHNA process was undertaken in the context of other recent or concurrent planning activities in the State, region and County related to community health: The Washington State Health Improvement Plan ( Creating a Culture of Health in Washington) provides a statewide framework for health improvement efforts. Clark County Public Health Department publishes a periodic Community Health Assessment which is developed in partnership with the community. Its most recent 2015 Community Health Assessment identifies three community priorities: chronic disease prevention related to physical activity and healthy eating; access to health care; and behavioral health, including mental health and substance abuse. Wellness is something we nurture, something we build into our policies, something we come together to create as public health professionals, doctors, nurses, lawyers, transportation planners, neighborhood advocates and PTAs, and others. John Wiesman, DrPH, MPH Washington State Secretary of Health 6

8 Southwest Washington Regional Health Alliance for Clark, Skamania counties is a non-profit with the dual role of governing the area Accountable Community of Health (ACH) and the Early Adopter Behavioral Health activities. An Accountable Community of Health Map 1. Accountable Community of Health Regions (ACH) is a regional coalition consisting of leaders from a variety of different sectors working together to improve health in their region. As part of the Healthier Washington Initiative, nine ACHs began formally organizing across Washington in They are intended to strengthen collaboration, develop regional health improvement plans and projects, and provide feedback to state agencies about their regions health needs and priorities. The Health Source: Washington Health Care Authority Care Authority (HCA) is supporting ACH development through guidance, technical assistance (TA), and funding. Healthy Living Collaborative of Southwest Washington (HLC) is an organization that focuses on upstream solutions that support community-based initiatives to improve health and wellness. With a strong commitment to health equity, HLC supports the development of a network of community health workers and improving the health and stability of all residents in Southwest Washington by incorporating health considerations into decision making across all sectors, systems, and policy areas to prevent and mitigate chronic disease and poverty. 7

9 Community Health Framework Drawing from the CHNAs conducted by PeaceHealth hospitals in 2013, and after reviewing existing community health improvement plans and collecting public data on health status and the social determinants of health, a PeaceHealth Community Health Framework was developed. This four-pillar framework, depicted below, was used to organize data and collect input from community stakeholders. The subcategories, or focus areas were used as guideposts for considering community health improvement strategies. Figure PeaceHealth Community Health Framework Pillars Healthy, Active Living Child & Family Wellbeing Integrated Health Delivery Systems Equity Physical activity Healthy Eating Tobacco, alcohol and other drug prevention Maternal-child health Adverse Childhood Experiences (ACEs) and family resiliency Access to quality and affordable medical, behavioral health and dental services Assistance for people who are homeless Cultural humility Social engagement There are two terms that are used in the above table that perhaps need to be defined, and they are: Adverse Childhood Experiences (or ACEs) are traumatic events that occur in childhood and cause stress that changes a child s brain development. Exposure to ACEs has been shown to have a dose-response relationship with adverse health and social outcomes in adulthood, including but not limited to depression, heart disease, COPD, risk for intimate partner violence, and alcohol and drug abuse. Cultural humility is a term used to describe a way of infusing multiculturalism into a workplace. Replacing the idea of cultural competency, cultural humility is based on the idea of focusing on self-reflection and lifelong learning. 8

10 III CHNA REVIEW During the timeframe, PeaceHealth Southwest, in collaboration with Clark County Public Health, the Healthy Columbia Willamette Collaborative and other community partners in Southwest Washington and the greater Portland, OR metro area, conducted a comprehensive CHNA. The CHNA described the health status of the entire region and recommended areas for improvement. The PeaceHealth Southwest CHNA focused on the Clark County, WA data. The table below summarizes our CHNA and includes available metrics which summarize measurable progress to date. Table CHNA Summary and Current Status Objectives Objective 1: Increase Access to Affordable Care Objective 2: Improve Mental Wellbeing Objective 3: Reduce Substance Abuse Objective 4: Improve Healthy Habits Strategies Increase the number of children and adults with health insurance Improve access to low-cost medical and dental services Increase screening for mental health Increase awareness of mental health conditions Increase access to mental health services Early intervention for substance abuse Social support for substance-free living Increase access to substance abuse services Screening and early detection Increase physical activity Increase consumption of healthy food Increase the physical activity opportunities in neighborhoods Increase access to healthy foods Incorporate weight control into health care services Enhance physical activity and nutrition promotion in the clinical setting *data methods changed/can t compare to prior years Baseline Uninsured adults: 14% Suicide death rate: 13.0 (age-adjusted per 100,000 population, 2010) Adults who drink to excess: 16% Adults who are obese: 29% Adults who report no leisure time physical activity: 19% Outcomes Current Uninsured adults: 8% Suicide death rate: 15.9 (age-adjusted per 100,000 population, ) Adults who drink to excess*: 19% Adults who are obese: 30% Adults who report no leisure time physical activity: 19% Sources: Robert Wood Johnson County Health Rankings, Enroll America, Washington State Department of Health: Center for Health Statistics, Washington State Behavioral Risk Factors Surveillance System 9

11 As we move forward in adopting the 2016 CHNA, we reflect on lessons learned and accomplishments of our process, goals, and implementation of the previous (2013) CHNA: Lessons Learned While the 2013 PeaceHealth Southwest CHNA was a comprehensive assessment with extensive community involvement and partnership, with the exception of increasing access to insurance, our subsequent plan execution was not as robust as intended due to lack of sustained leadership and funding. Going forward this has been addressed in a number of ways, including with the hiring of a Community Benefit director (January 2016) who is charged with leading the CHNA Implementation Plan in collaboration with our community partners. The new PeaceHealth Director for Community Benefit will provide staff support for the newly formed PeaceHealth Southwest Community Health Board. With a Community Collaboration Committee that will include representatives from public health and other community-based health and social services, it is expected that the Community Health Board will provide the sustained community engagement at the leadership level necessary to advance the 2016 CHNA implementation plan. Accomplishments The 2013 PeaceHealth Southwest CHNA identified the problem of health care access and lack of insurance coverage as the one issue that we wanted to focus on across all of our communities. PeaceHealth worked as part of the community coalitions that were formed across the state for the purpose of helping people sign up for commercial health insurance and Apple Health, i.e. Medicaid. By any measure these efforts were successful. Between 2013 and 2014 there was nearly a 30% increase in Medicaid enrollment. Enrollment continued to increase in 2015 but not at the pace of the initial increase. Adult enrollment rose 45% from 2013 to 2015 and child enrollment rose 44% over the same period. As a result, uninsured adults in Clark County decreased from 14% in 2013 to 8% in Figure 2. Medicaid Enrollment and Percent Uninsured, Clark County % %

12 Figure 3. Medicaid Enrollment by Adults and Children, Clark County, Adults Children Source: Health Care Authority, State of Washington. Children are defined as under age 19. Access to behavioral health services was noted as a significant community need the 2013 CHNA. As an early adapter of the State of Washington s plan to fully integrate the delivery of primary and behavioral health services by 2020, Clark County has taken significant steps to meet a number of the behavioral health related issues in the CHNA. As of April 2016, Medicaid clients now access a continuum of physical health, mental health and substance use disorder services through a single integrated health plan, instead of navigating multiple systems to receive care. While this step is significant, during our 2016 community convening, we heard that while funding is now coordinated, more work needs to be done to assure that actual service provision is coordinated. 11

13 IV. CLARK COUNTY DEMOGRAPHIC AND SOCIOECONOMIC PROFILE PeaceHealth Southwest serves the Columbia-Willamette area of Oregon and Washington, with Clark County being its primary service area, and the focus of this CHNA 1. Current Profile Map 2. Clark County Of Note: The 2015 United Ways of the Pacific Northwest ALICE report summarizes the status of ALICE families an acronym that stands for Asset Limited, Income Constrained, Employed. These are families that work hard and earn above the Federal Poverty Level (FPL), but do not earn enough to afford a basic household budget of housing, child care, food, transportation, and health care. Most do not qualify for Medicaid coverage. In Clark County, 33% of all households are either in poverty or are ALICE households. This is similar to Washington State overall, wherein 32% of all households are either ALICE or in poverty. Clark County has about 440,000 residents 28,925 (6.6%) are preschoolers under age 5 94,501 (21.5%) are 5-19 years old 269,859 (61.6%) are adults age ,232 (12.6%) are seniors age ,620 (8.1%) are Hispanic, a 21.0% increase since All data in this section is from the American Community Survey (US Census Bureau) unless otherwise noted. 12

14 More than 37.8% of Clark County residents live in Vancouver proper. In terms of the socioeconomic determinants, the County, as depicted in Table 3 is: 91% of adults have a high school diploma. 12% of individuals live below the Federal Poverty Level. 33% of all households are either in poverty or cannot afford basic household expenses 671 people are homeless in Clark County, both sheltered and unsheltered (Homelessness in Washington State: 2015 Annual Report on the Homeless Grant Programs, Department of Commerce). In the Vancouver, WA school district, 830 children in grades k-12 are reported from homeless families (248) or doubled up (living with other families) (582) ( Homeless Student Data Report, Office of Superintendent of Public Instruction). City High school diploma (%) Table 3. Clark County, WA Sociodemographic Profile Individuals living below the FPL (%) Median Household Income People over age 5 who are linguistically isolated Battle Ground 89.2% 12.2% $57, % Camas 95.4% 5.8% $84, % La Center 96.3% 5.2% $71, % Ridgefield 98.3% 5.8% $91, % Salmon Creek 91.7% 13.6% $68, % Vancouver 89.4% 15.7% $50, % Washougal 92.2% 10.9% $60, % Woodland 84.6% 23.4% $65, % Yacolt 89.6% 9.1% $58, % Clark County 91.2% 11.8% $59, % Washington State 90.2% 13.5% $60, % 13

15 The Community Need Index, a tool created by Dignity Health, measures a community s social and economic health on five measures: income, cultural diversity, education level, unemployment and health insurance, and housing. The CNI demonstrates that within Clark County, there are pockets of higher and lower need: Map 3. Clark County Community Need Index Map, 2015 Key Take-Aways Source: Dignity Health A third of all Clark County residents are either below the Federal Poverty Level (FPL), or do not earn enough to afford a basic household budget of housing, child care, food, transportation, and health care. Within Clark County, there are pockets of high poverty and low educational attainment, with highest need areas concentrated in and around Vancouver 14

16 V. KEY HEALTH INDICATORS Method Data for each of the four PeaceHealth pillars is detailed on the following pages. For each pillar, we provide a description, how the community compares to other Washington counties, provide a profile of the community, identify important indicators and provide key takeaways. PeaceHealth selected the most currently available data from publicly available sources. Data elements were selected that align with the focus of the CHNA. The goal was to identify metrics that could be consistently measured, monitored and benchmarked for all PeaceHealth communities throughout the Pacific Northwest. Data from the Robert Wood Johnson Foundation (RWJF) was used as a primary source. RWJF s county health rankings data compare counties within each state on more than 30 factors. Counties in each of the 50 states are ranked according to summaries of a variety of health measures. Counties are ranked relative to the health of other counties in the same state. RWJF calculates and ranks four summary composite scores used in this report: Overall Health Outcomes Overall Health Delivery Factors Health Factors Health behaviors Health Factors Social and economic factors This is a nationally recognized data set for measuring key social determinates of health. RWJF is committed to continually measuring these metrics. Data in this evaluation is also supplemented with sources from state and local agencies in Washington. Unless otherwise noted all data cited in this section is from RWJF or the following sources: Behavioral Risk Factor Surveillance System; Washington Healthy Youth Survey; Washington Department of Health, Vital Statistics; US Census Bureau; The University of Washington s Alcohol and Drug Abuse Institute; WA Office of the Superintendent for Public Instruction; Feeding America; Enroll America; Centers for Medicare & Medicaid Services; Community Commons. Next to each local indicator we've shown whether the local rate (percentage) is less than, greater than, or equal to the state rate (percentage). With any indicator, there is a range of possible 'true' values because data collection always entails some error. Often, percentages that appear different are rated as 'equal.' This is because, statistically speaking, there is a large chance that the 'true' value of the data at the state and county level is equal, rather than different, due to error inherent in the data collection process. 15

17 Healthy, Active Living: Clark County Health Indicators, 2016 What is Healthy, Active Living? Healthy, Active Living is a key pillar of a healthy community. We envision a community where the environment and resources of that community allow adults, teens, and children to be physically active, to eat nutritious meals, to be free of the burdens of substance abuse and chronic disease, and to live with an ample sense of wellbeing and connection to others. How Does Clark County Compare to Other Counties? Clark County is ranked 13 out of 39 Washington Counties for its food and physical activity environment, as well as the adult behavioral health indicators like excessive drinking and smoking. This means we re doing well compared to over half of counties in the state. Healthy, Active Living Profile Adults: Adult obesity: 30% (=WA: 27%) Adult physical inactivity: 19% (=WA: 18%) Adult diabetes: 8% (=WA: 9%) Youth: 10th graders who are obese: 10.7% (=WA: 11.2%) 10th graders reporting physical inactivity: 13.4% of 10th graders (=WA: 12.0%) Environment: Reasonable access to exercise opportunities: 96% of residents (>WA: 88%) Food environment index: 2016: 7.3 (=WA: 7.5) Substance abuse: Adult smoking: 14% (=WA: 15%) 10th graders smoking cigs in past 30 days: 10.2% (>WA: 7.9%) Deaths attributed to any opiate: 7.9 per 100,000 population (=WA: 8.6 per 100,000 population) 16

18 Closer Look Youth smoking 10th graders in Clark County are significantly more likely than 10th graders in Washington State to report smoking cigarettes in the past 30 days. Cigarette use leads to heart disease and cancer later in life, and is a major factor in wellbeing. Access to exercise opportunities and physical inactivity Clark County has better access to exercise opportunities than the majority of Washington counties, yet the percentage of adult and teen residents that report not participating in any physical activity is equal to the average Washington resident. Figure 4. Percent of Residents That Have Access to Outdoor Physical Activity Opportunities by County, Washington State, 2016 Of Note: Caregiver Wellness As the largest employer in the community, PeaceHealth is working to support Active Healthy living in its workforce by offering an employee wellness program. Workplace wellness programs are evidence-based strategies to improve physical fitness and risk factors. At PeaceHealth, we can make an impact on community wellness by improving our employees wellness, but there are differences based on income levels: 63.8% of eligible PeaceHealth Southwest employees participate in a wellness program. 22.4% of eligible PeaceHealth Southwest employees earning $25,000 - $40,000 participate in a wellness program. Growth in opiate use and abuse The use and abuse of opiates in the form of heroin and prescription drugs has increased dramatically in Washington state as a whole and Clark County in particular. Deaths from any opiate have increased nearly 58% in Clark County since , while increasing only 31% in Washington State overall. The rate of opiate-related deaths in Clark County was similar to Washington State s overall rate. Participation by Income 17

19 Figure 5. Increase in Opiate-related Deaths by County, Washington State, to Source: Univ. of WA Alcohol & Drug Abuse Institute, Opioid Trends Across Washington State, April 2015) Additional Indicators with Trend Data The Behavioral Risk Factor Surveillance System is used to measure chronic diseases and health behaviors among a population of adults in all 50 states at the county level. The Washington Healthy Youth Survey measures health risk behaviors and outcomes among 6th, 8th, 10th, and 12th graders in Washington State. The Washington Department of Vital Statistics measures causes of death and circumstances of prenatality and birth. The Robert Wood Johnson Foundation County Health Rankings aggregates BRFSS, Vital Statistics, US Census, and business data to provide an overview of measures that matter for health. The University of Washington s Alcohol and Drug Abuse Institute measures markers of opiate abuse over time in Washington counties. Table 4. Healthy, Active Living: Clark County Health Indicators vs. Washington State, 2016 Better Equal Worse Trend Chronic Conditions Adult diabetes ** Heart disease death rate ** Adult obesity ** Risk behaviors Adult physical inactivity stasis Excessive alcohol use ** Adult smoking ** Drug overdose death rate ** Deaths due to any opiate worsening Suicide death rate ** Environment Grocery availability & food insecurity worsening Access to exercise opportunities improving **can t show trend over time due to change in data collection methods 18

20 Chronic Conditions Table 5. Healthy, Active Living: Clark County 10th Graders, Health Indicators vs. Washington State, 2016 and Trend Since 2010 Better Equal Worse Trend Obesity stasis Depression worsening Risk behaviors Smoking cigarettes improving Drinking alcohol improving Using marijuana/hashish stasis Binge drinking improving Eat 5+ fruits/vegetables per day* stasis Consumed no sugar-sweetened beverages in past 7 days Reports no leisure-time physical activity for 60 min/day in past 7 days ** stasis Reports seriously considering suicide worsening Environment Bought sugar-sweetened beverages at school improving *trend since 2012 **no trend data available due to methodology change Key Take-Aways The rate of deaths from opiate use in Clark County are similar to the Washington state rate overall. The death rate from opiate use in Clark County has risen dramatically since and calls for solutions to prescription drug and heroin abuse in Clark County. Despite ample access to exercise opportunities and a food environment similar to Washington overall, many Clark County adults and teens are physically inactive and obese. Clark County teens are more likely to smoke cigarettes than Washington teens overall, but the trend does not continue into adulthood. 19

21 Child & Family Wellbeing: Clark County Health Indicators, 2016 What is Child & Family Wellbeing? Child & Family Wellbeing is a key pillar of a healthy community. Circumstances in pregnancy through early childhood are key predictors of health and wellbeing later in life. We envision a community where all pregnant women and families with children are well-fed, safe, and equipped with resources and knowledge to succeed in school, from kindergarten to high school graduation. How Does Clark County Compare to Other Counties? In social and economic factors, including the percentage of adults who have completed high school and have some college education, as well as the percentage of babies born to single mothers, Clark County is ranked 10th of 39 counties in Washington. Child & Family Wellbeing Profile Percent of students who demonstrate expected skills in 6 of 6 domains: 39.0% (=WA: 39.5%). Childhood food insecurity: 22.1% (=WA: 21.0%) Graduation rate: 78.6% (=WA: 77.2%) Maternal smoking in third trimester of pregnancy: 7.9% (>WA: 6.3%) Low birth weight: 6% (=WA: 6%) Prenatal care beginning in first trimester: 76% (=WA: 74.7%) month olds up-to-date with vaccinations: 57% (=WA: 56%) Teens up-to-date with vaccines: 30% (<WA: 34%) WIC infants fully or partially breastfed: 43.1% (Sea Mar CHC) (=WA: 38.4%) Closer Look Readiness to Learn In the Vancouver School District, as in Washington State, children from low-income families and children with limited English are significantly less ready for kindergarten than their peers as measured by skills in six domains of ability of average 5-year olds. These domains include social/emotional functioning, physical functioning, language ability, and cognitive, literacy, and math abilities. These kindergarten deficits are difficult to make up over time and can lead to lower levels of high school completion and a host of vulnerabilities later in life. 20

22 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Figure 6. Percentage of Entering Kindergarteners Demonstrating Kindergarten-Level Skills in 6 of 6 Domains, % 40% 26% 31% 18% 21% All Low Income Limited English Of Note: 61% of kindergarteners entering school are not ready for kindergarten in at least one domain in Clark County. 70% of 10th graders in Clark County are not up-todate with vaccinations. Nearly a quarter of Clark County children lack access to adequate, nutritious food. Vancouver School District Washington Adverse Childhood Experiences (ACEs) Adverse Childhood Experiences, or ACEs, are traumatic events that occur in childhood and cause stress that changes a child s brain development. Exposure to ACEs has been shown to have a dose-response relationship with adverse health and social outcomes in adulthood, including but not limited to depression, heart disease, COPD, risk for intimate partner violence, and alcohol and drug abuse. Adverse Childhood Experiences include emotional, physical, or sexual abuse, emotional or physical neglect, seeing intimate partner violence inflicted on one s parent, having mental illness or substance abuse in a household, enduring a parental separation or divorce, or having an incarcerated member of the household. Figure 7. Association between ACEs and Negative Outcomes Source: Centers for Disease Control & Prevention, "Association between ACEs and negative outcomes" 21

23 We can examine ACEs reported by adults in Washington and see that many Clark County adults are bearing childhood traumas that put them at risk for poor health and social outcomes in adulthood. Figure 8. Adverse Childhood Experiences Reported by Adults in Clark County and Washington State, % 60% 50% 40% 30% 20% 10% 0% 1+ ACEs 2+ ACEs 3+ ACEs 4+ACEs WA State Clark County Child & Family Wellbeing Data Sources Source: Washington State Behavioral Risk Factor Surveillance System The Washington Department of Vital Statistics measures causes of death and circumstances of prenatally and birth. The Robert Wood Johnson Foundation County Health Rankings aggregates BRFSS, Vital Statistics, US Census, and business data to provide an overview of measures that matter for health. The Office of the Superintendent for Public Instruction measures Readiness to Learn among entering kindergarteners in Washington State in 6 domains: social-emotional, physical, language, cognitive, literacy, and math. The USDA Women, Infant, and Children nutrition program measures breastfeeding among its program recipients by individual WIC site the numbers for Clark County come from the Clark County Sea Mar WIC site. Low birth weight is compiled in a seven-year period by RWJF County Health Rankings from WA State Vital Statistics data ( ). Childhood food insecurity is measured by the USDA, and is characterized by a lack of consistent, sufficient, and varied nutrition. The Food Research & Action Center publishes analyses demonstrating the connections between food insecurity and overweight/obesity. 22

24 Table 6. Child & Family Wellbeing: Clark County Health Indicators vs. Washington State, 2016 *Data aggregated from **no trend data available Key Take-Aways Better Equal Worse Trend Social Indicators High school graduation rate worsening Childhood food insecurity improving Entering kindergarteners demonstrating Readiness worsening to Learn in 6 of 6 domains Health Indicators Prenatal care in 1st tri. of pregnancy stasis Maternal smoking in 3rd tri. of pregnancy stasis Low birth weight* * WIC infants partially or fully breastfed ** Toddlers up-to-date with vaccines ** Teenagers up-to-date with vaccines ** There are children in Clark County who are hungry, lack access to a variety of nourishing, balanced foods, and not prepared for kindergarten. Toddler vaccination rates are similar to Washington overall but teenage vaccination rates are lower than the State. On the positive side, and contributing to an overall healthy community the rates of timely prenatal care, and breastfeeding are strong. Over half of in Clark County endured at least one Adverse Childhood Experience that puts them at greater risk of poor health outcomes, negative health behaviors, and poor social outcomes. 23

25 Health Delivery Systems: Clark County Health Indicators, 2016 What are Health Delivery Systems? Health Delivery Systems are a key pillar of a healthy community. Access to quality, affordable, comprehensive care throughout the life course is an important facet of community wellness. We envision a community where all people have access to quality, affordable preventive and acute care, including mental health and dentistry, throughout the life course. How Does Clark County Compare to Other Counties? In health delivery factors including the ratio of physicians, dentists, and mental health providers to the population, as well as certain measures of quality of care like the percentage of Medicare recipients that receive mammograms and diabetic monitoring, Clark County ranks 24th out of 39 counties in Washington lower than the majority of Washington Counties. Health Delivery Systems Profile Ratio of residents to medical, dental, and mental health providers: Primary care: 1,510:1 (>WA) Dentists: 1,500:1 (>WA) Mental health: 410:1 (>WA) Uninsured rate among adults below age 65: 8% (=WA: 8%) 10th graders who saw a doctor for a physical in the past year: 62.7% (=WA: 66.1%) 10th graders who saw a dentist for a checkup, exam, teeth cleaning, or other dental work: 76.1% of 10th graders in 2014 (=WA: 79.0%) Closer Look Health Insurance Inequities Though Clark County s overall insurance rate is improving, there are significant inequities in health insurance rate by race/ethnicity. 24

26 14% 12% 10% 8% 6% 4% 2% 0% Figure 9. Uninsured Rate among Adults <65 years, % 12% 8% 8% 8% 8% 8% 7% 7% 7% All Black White Hispanic or Asian Latino Clark County Washington State Of Note: Clark County Medicare beneficiaries have a rate of 51 preventable hospital stays per 1000 beneficiaries per year, higher than WA State (36 preventable hospital stays). Racial/ethnic disparities in access to insurance and preventive care exist in Clark County. Preventive Hospital Stays Preventable Hospital Stays is the hospital discharge rate for ambulatory care-sensitive conditions per 1,000 fee-for-service Medicare enrollees. Ambulatory care-sensitive conditions include: convulsions, chronic obstructive pulmonary disease, bacterial pneumonia, asthma, congestive heart failure, hypertension, angina, cellulitis, diabetes, gastroenteritis, kidney/urinary infection, and dehydration. This measure is age-adjusted. Hospitalization for diagnoses treatable in outpatient services suggests that the quality of care provided in the outpatient setting was less than ideal. The measure may also represent a tendency to overuse hospitals as a main source of care. Lower number on this measure are the goal. Clark County ranks below the nation, but above the State of Washington average, and near the bottom of all Washington counties. The data suggest that there are opportunities to better serve populations with improved primary care delivery. 25

27 Figure 10. Preventable Hospital Stays, Clark County, WA Preventive care inequities among Medicare beneficiaries The preventive care received by Hispanic Medicare beneficiaries in Clark County is worse than the preventive care received by white Medicare beneficiaries in Clark County. High-quality preventive care, like seeing a primary care doctor frequently and monitoring one s blood sugar and blood pressure, can improve health outcomes. One way to look at possible differences in the quality of care is to examine Medicare beneficiaries (people aged 65 years and older that have access to government-sponsored health insurance) of different races and ethnicities, since they have the same source of health insurance. In order to understand if differences in quality of preventive care exist, we can look at the rate of shortterm complications from diabetes using a composite measurement called Prevention Quality Indicators (PQI) among Hispanic and White Medicare beneficiaries by county in Washington State. Short-term complications are adverse events that could be avoided with proper preventive care. The data in the map below show that Clark County white Medicare beneficiaries have 93 PQIs per 100,000 beneficiaries, while Clark County Hispanic Medicare beneficiaries have 0 PQIs per 100,000 beneficiaries. In Clark County, Hispanic Medicare beneficiaries are more likely to have short-term complications from diabetes than white Medicare beneficiaries, despite having the same source of health insurance. The preventive care received by Hispanic Medicare beneficiaries in Clark County is worse than the preventive care received by white Medicare beneficiaries in Clark County and leads to higher rates of 26

28 short-term diabetes complications among Hispanic adults. Greater access to quality primary care among minority communities is an important strategy to mitigate these unequal health outcomes. Figure 11. Short-term Diabetes Complications, Hispanic Vs. White Medicare Beneficiaries, Washington State, 2014 Source: Center for Medicare & Medicaid Office of Minority Health, Disparities Mapping Tool Emergency Room Use Treating patients with low-acuity conditions in the ED is an issue because it is not the best care setting for those conditions, and it contributes to unnecessary overcrowding and cost. Approximately 8.3% of emergency room visits to Southwest Medical Center could be considered avoidable given their low acuity. When viewed by payer, Medicare patients have the lowest rate of these visits, representing nearly 2.5% of all Medicare ED encounters. Medicaid patients have the highest rates, and in 2015 showed a large increase in visits that were considered low acuity (14.6%). Figure 12. Low-Acuity ED Visits by Payer, Southwest Medical Center, % 6.90% 6.40% 1.80% 7.60% 7.10% 2.00% 8.60% 2.50% Medicare Medicaid Commercial/All Other Source: PeaceHealth Internal Data 27

29 Health Delivery Systems Data Sources: The Washington Healthy Youth Survey measures health risk behaviors and outcomes among 6th, 8th, 10th, and 12th graders in Washington State, including health care access. The Robert Wood Johnson Foundation County Health Rankings aggregates provider and US Census data to provide an overview provider to resident ratios and overall clinical care relative measures. Enroll America aggregates measures of insurance across all 50 states at the county and state level. The Centers for Medicare & Medicaid Services Office of Minority Health Disparities Mapping Tool shows measures of health inequities at the county level across the US for different health delivery indicators. Table 7. Health Delivery Systems: Clark County Health Indicators vs. Washington State, 2016 and Local Trend since 2010 Better Equal Worse Trend Primary Care Provider to resident ratio stasis Dentists to resident ratio stasis Mental Health Providers to resident ratio improving Uninsured adults below age 65 improving Saw a doctor for a physical in the past year (10th improving graders) Saw a dentist for checkup, cleaning, or other work stasis in past year (10th graders) Key Take-Aways Poor access to primary care, dental care, and mental health care is a contributor to poor health in Clark County. Nearly half of Clark County 10th graders did not have a physical in the past year, and nearly a quarter did not see the dentist. Racial/ethnic minorities in Clark County have worse access to quality preventive care than white residents of Clark County, even when controlling for health insurance access. 28

30 Equity: Clark County Health Indicators, 2016 What is Equity? Equity is a key pillar of a healthy community. Health equity will be achieved when everyone is given the opportunity to reach their full health potential. Affordable, safe housing, and employment that allows sufficient resources to meet a household budget are important facets of equity. How Does Clark County Compare to Other Counties? In social and economic factors, including the percentage of children in poverty, violent crime, and income inequality, Clark County is ranked 10th of 39 counties in Washington. Equity Profile Individuals living below FPG: 11.8% (=WA: 13.5%) Linguistic isolation: 6.0% (=WA: 7.8%) Households with severe housing problems, including cost-burdened housing: 17% (=WA: 18%) Unemployment rate: 10% (=WA: 8.8%) Veteran population: 11% (=WA: 11%) Income inequality (ratio of income at the 80th percentile to income at the 20th percentile): 3.9 (<WA: 4.5) Closer Look Cost-burdened housing Affordable housing is a key component of financial wellbeing and stability, and forms the basis of good health. There are many pockets of people in Clark County burdened by high housing costs that undermine their health and wellbeing, particularly in the Vancouver area. Figure 13. Percentage Households Where Housing Costs Exceed 30% Of Household Income, Clark County, Source: Community Commons 29

31 Equity Data Sources The US Census measures the percentages of individuals living in poverty, in linguistic isolation, and adults who are unemployed. The Robert Wood Johnson County Health Rankings provide estimates of individuals who have severe housing problems, meaning individuals who live with at least 1 of 4 conditions: overcrowding, high housing costs relative to income, or lack of kitchen or plumbing, as well as a measure of income inequality at the county and state level, which is the ratio of household income at the 80th percentile to income at the 20th percentile. Community Commons provides maps of census-tract level data, including housing cost burden. Key Take-Aways Clark County is doing well on most measures of social equity and wellbeing relative to Washington State. Low levels of income inequality are a particular area of resilience and should be maintained. Of Note: Changing demographics call for employers to monitor their workforce so that it reflects the composition and diversity of the community. Increasing racial and ethnic diversity among licensed health professionals is particularly important because evidence indicates that among other benefits, it is associated with improved access for non-majority patient groups, increased patient satisfaction and an overall decrease in health care disparities. A high percentage of cost-burdened housing in certain areas of Clark County imperils the wellbeing of affected households and the community as a whole. Table 8. Equity: Clark County Health Indicators vs. Washington State, 2016 and Local Trend since 2012 Better Equal Worse Trend Individuals living below the poverty line stasis Individuals over age 5 in linguistic isolation stasis Households with severe housing problems stasis* Unemployment rate improving Income inequality ** *baseline trend data aggregated from **no trend data available 30

32 VI. COMMUNITY CONVENING Method Key informant Interviews PeaceHealth Southwest interviewed key informants from organizations throughout the County representing perspectives from public health and medically underserved and vulnerable groups. The interviews were conducted to elicit perspectives on the health needs and gaps of the community, to get feedback on the continuing relevance of the 2013 CHNA priorities and health priorities found through the secondary data gathering of the 2016 CHNA, and to understand possible solutions that local experts support. Table 9. Organizations to which key informants belong, 2016 CHNA Organization Clark County Public Health Department Free Clinic of SW Washington DSHS SW Area Agency on Aging and Disabilities Vancouver School District Healthy Living Collaborative Population Served All Clark County residents; 0-25 ages for individual services, medically underserved Medically underserved, homeless, immigrant, early childhood to senior groups Seniors, disabled Children K-12, low-income families Medically underserved, homeless, immigrant, children, families, and seniors Community Convening The key informant interviews were conducted in preparation for a community convening session that was held on May 11, More than 50 community leaders from local and regional public health, health and social services, business, schools, and government were convened for approximately three hours. Community convening participants were led through a two-part process to identify gaps and needs and then to rank community health improvement strategies that were organized into the community health pillars. The process was designed to build on the considerable amount of time and effort that the County Health Department, PeaceHealth and others have put into health assessments over the last several years and to focus more on what we can actually do together to address the problems. 31