Community health needs assessment. Prepared for Children s Hospitals and Clinics of Minnesota by Verité Healthcare Consulting, LLC

Transcription

1 Cmmunity health needs assessment 2013 Prepared fr by Verité Healthcare Cnsulting, LLC

2 Cntents Intrductin t the CHNA prcess... iv Executive summary... vi The cmmunity served by Children s... vii Demgraphics... viii Ecnmics... viii Scial factrs... viii Behaviral factrs... ix Mrtality and mrbidity... ix Lcal envirnment... ix Care access and delivery... ix Cmmunity-wide pririty needs... xi Appendix Methdlgy... 1 Analytic methds... 1 Priritizatin prcess and criteria... 1 Infrmatin gaps... 1 Cllabrating rganizatins... 1 Definitin f cmmunity assessed... 2 Secndary data assessment... 9 Demgraphics... 9 Ecnmic indicatrs Peple in pverty Husehld incme Unemplyment rates Hmelessness Crime The impact f budget cuts in Minnesta Utilizatin f gvernment assistance prgrams Insurance status Cunty-level health status and access indicatrs Cunty Health Rankings Cmmunity Health Status Indicatrs Prject Minnesta Department f Health Minnesta Student Survey Minnesta Department f Human Services Ambulatry care sensitive cnditins Cunty-level analysis Hspital-level analysis ZIP cde and census tract-level health status and access indicatrs Dignity Health Cmmunity Needs Index Fd deserts ii

3 Overview f the health and scial services landscape Medically Underserved Areas and Ppulatins Health Prfessinal Shrtage Areas Descriptin f ther facilities and resurces within the cmmunity Findings f ther recent cmmunity health needs assessments Hennepin Cunty Human Services and Public Health Department, et al., Fairview Health Services, Kids Cunt Minnesta and Children s Defense Fund, The Minneaplis Fundatin and Wilder Research, St. Paul Ramsey Cunty Public Health, Family Health Sectin, Washingtn Cunty Cmmunity Services, Wilder Research, Hennepin Cunty Human Services and Public Health Department and Statewide Health Imprvement Prgram (SHIP), Dakta Cunty Public Health Department, Minnesta Department f Health Cmmunity and Family Health Divisin, Blue Crss and Blue Shield Fundatin f Minnesta and Wilder Research, Wilder Research, Wilder Research, Carver Cunty Public Health Department Data Resurce Center, Carver Cunty Public Health Department, Anka Cunty Gvernment Center and Cmmunity Health and Envirnmental Services Department, Dakta Cunty Human Services Advisry Cmmittee, Washingtn Cunty Department f Public Health and Envirnment, Wilder Research, St. Paul-Ramsey Cunty Department f Public Health, Secndary data indicatrs f cncern Disparities f cncern Gegraphic areas f cncern Primary data assessment Summary f interview findings Individuals prviding cmmunity input Health r ther departments r agencies Cmmunity leaders and representatives Persns representing the brad interests f the cmmunity Surces Abut Verité Healthcare Cnsulting iii

4 Intrductin t the CHNA prcess 1 (Children s) undertk the fllwing Cmmunity Health Needs Assessment (CHNA) t better understand the health needs in lcal cmmunities and t infrm an effective implementatin strategy t address the pririty needs. This CHNA als respnds t cmmunity benefit regulatry requirements. Federal regulatins require that tax-exempt hspitals prvide and reprt cmmunity benefits t demnstrate that they merit exemptin frm taxatin. As specified in the instructins t IRS Frm 990, Schedule H, cmmunity benefits are prgrams r activities that prvide treatment and/r prmte health and healing as a respnse t identified cmmunity needs. Cmmunity benefit activities r prgrams seek t achieve certain bjectives, including:» imprving access t health services,» enhancing public health,» advancing increased general knwledge, and» relief f a gvernment burden t imprve health. 2 T be reprted as a cmmunity benefit, cmmunity need fr the activity r prgram must be established. Cnducting a CHNA is ne methd fr establishing the cmmunity need. The 2010 Patient Prtectin and Affrdable Care Act (PPACA) requires each tax-exempt hspital t cnduct a [CHNA] every three years and adpt an implementatin strategy t meet the cmmunity health needs identified thrugh such assessment. 3 CHNAs seek t identify pririty health status and access issues fr particular gegraphic areas and ppulatins by fcusing n the fllwing questins:» Wh in the cmmunity is mst vulnerable in terms f health status r access t care?» What are the unique health status and/r access needs fr these ppulatins?» Where d these peple live in the cmmunity?» Why are these prblems present? Pririty needs are identified regardless f a hspital s ability t address such needs; hspitals are nt required t address all the needs identified in the CHNA. The questin f hw the rganizatin can best use its limited resurces t respnd t pririty needs will be addressed in a separate dcument. This assessment cnsiders multiple data surces regarding the health needs f the cmmunity served by Children s, including secndary data, assessments prepared by ther rganizatins in recent years, and primary data derived frm interviews with persns wh represent the brad interests f the cmmunity, including thse with expertise in public health. 1 perates tw hspital campuses, lcated in Minneaplis and St. Paul, which are licensed as a single hspital facility. Thrughut the reprt, the campuses are referred t as ne hspital. 2 Instructins fr IRS Frm 990, Schedule H, Patient Prtectin and Affrdable Care Act. iv

5 The fllwing tpics and data are assessed in this reprt:» Demgraphics, e.g., numbers and lcatins f vulnerable children;» Ecnmic issues that affect children, e.g., pverty and unemplyment rates, and impacts f state r lcal budget changes;» Cmmunity issues, e.g., hmelessness, husing, envirnmental cncerns, crime, and availability f scial services;» Health status indicatrs, e.g. mrbidity rates fr varius diseases and cnditins, and mrtality rates fr leading causes f death;» Health access indicatrs, e.g., uninsurance rates, discharges fr ambulatry care sensitive cnditins (ACSC), and use f emergency departments fr nnemergent care;» Health disparities indicatrs; and» Availability f healthcare facilities and resurces. The assessment identifies a priritized list f cmmunity health needs. Children s will prepare an Implementatin Strategy that respnds t the issues identified in this assessment. v

6 Executive summary Children s is ne f the largest freestanding pediatric health care systems in the U.S., with hspitals in St. Paul and Minneaplis as well as 12 clinic sites and a number f ambulatry lcatins in the surrunding suburbs. Children s is a statewide and reginal resurce, prviding a brad spectrum f pediatric services thrughut the Upper Midwest. Fr purpses f having a clearly defined gegraphic bundary and cnsistency with accepted appraches t CHNAs, this assessment fcuses n the needs f the seven-cunty area surrunding the Minneaplis and St. Paul hspital campuses. Thrughut the assessment, the cmmunity being assessed will be described as the immediate cmmunity, cmpsed f 42 ZIP cdes in five schl districts arund the Children s hspital campuses. The brader cmmunity is cmprised f the seven-cunty metr area. The brader cmmunity benchmarks favrably n a number f health indicatrs cmpared t natinal and Minnesta averages. Hwever, there are health status and access prblems and this assessment seeks t identify the mst pressing issues regarding the wellbeing f children. Scial and ecnmic factrs, including incme, educatin, race and/r ethnicity, and lcal envirnment play a significant rle in a child s health. Amng children, racial and ethnic minrities, and thse with cmplex needs are mre likely t lack the scial and ecnmic resurces necessary t maintain ptimal health. Such inequalities can create barriers t access (t health services, emplyment, quality educatin, healthy fd, husing, and ther necessities and pprtunities) and thus cntribute t pr health. Analysis f primary and secndary data reveals prblematic health disparities in bth the immediate and brader cmmunity. Gegraphically, the greatest sci-ecnmic need and prest health status is fund in Minneaplis and St. Paul and certain lw-incme, less ppulus areas n the uter edge f the brader cmmunity. The fllwing is a brief prtrait f cmmunity health in the seven cunty metr area. Children s cmmunity by the numbers» 42 ZIP cdes in the immediate cmmunity in five schl districts: Minneaplis, St. Paul, Suth St. Paul, Richfield, and West St. Paul Mendta Heights Eagan» Brader cmmunity encmpasses seven cunties: Anka, Carver, Dakta, Hennepin, Ramsey, Sctt, and Washingtn» Estimated pediatric ppulatin (2011): 192,325» 6.9% f ttal hspital discharges within this area were fr pediatric ambulatry care sensitive cnditins» Prjected ppulatin change ( ): Grwth f 3.2% verall; 4.0% decrease in ppulatin» Significant pverty in Hennepin and Ramsey cunties» Grwing diversity: Rapidly grwing Asian, Black, and Hispanic r Latin ppulatins 19% nn-white in 2011; 21% nn-white by 2016 vi

7 The cmmunity served by Children s vii

8 Demgraphics The pediatric ppulatin is grwing, especially in Minneaplis and St. Paul and the surrunding suburbs. The ppulatin als is increasingly diverse, with particularly high grwth expected in the Hispanic r Latin ppulatin. Minneaplis-St. Paul, surrunding suburbs, and the nrthern prtins f Dakta and Sctt cunties are currently hme t relatively high prprtins f racial and ethnic minrity ppulatins. Thse same lcatins reprt cmparatively high percentages f linguistic islatin and lw educatinal achievement. These factrs can cntribute t pverty, health care access barriers and pr health thrughut a child s life. Ecnmics Overall, the brader cmmunity has enjyed lwer unemplyment rates than the U.S. and Minnesta averages. Hwever, Hennepin and Ramsey cunties reprt cmparatively high rates f pverty. In all seven cunties, child pverty rates are higher than thse f the ttal ppulatin. Lw-incme husehlds, students eligible fr free and reduced-price lunch, and discharges fr Medicaid (prxy measures f pverty) are mst prevalent in areas prximate t the hspital. Hennepin and Ramsey cunties als reprt rates higher than the state average f hmeless children and families, uninsured children, and vilent and prperty crime. Anka Cunty als exhibits cmparatively high rates f crime, and, while nt abve the state average, the cunty ranks just behind Hennepin and Ramsey cunties fr rates f pverty, unemplyment, hmelessness, and uninsured yuth. The cst f living in the brader cmmunity is cmparatively high and ften accmpanied by lng wait times fr husing assistance. The cst f child care is als mre f a burden fr lwincme families. Increasingly, peple are being frced t chse between meeting basic needs, such as fd and husing, r btaining health care. State budget reductins in Minnesta ver the past decade have affected health and human service prviders. These reductins affect children and yuth services, mental health prgrams and services, and health and scial services departments. Scial factrs Language and cultural barriers between patients and prviders, differing cultural expectatins f behavir, cncerns abut immigratin status, scial stigma, and the cmplexity f navigating the health system prevent sme residents frm seeking timely and apprpriate health services fr themselves and their children. Educatin abut health and health care is als a pressing need. Many parents thrughut the cmmunity need supprt in the frm f health educatin, basic life skills training, techniques fr prviding guidance and discipline t adlescents, and assistance translating health care knwledge int behaviral changes. There is hesitancy amng the adlescent ppulatin t seek sexual and reprductive services due t fear f scial repercussins frm family and/r peer grups. Cntinued attentin needs t be paid t access t these services by apprpriate prviders. viii

9 Fr families and caregivers f children with cmplex needs, cnducting the activities f daily life can feel verwhelming and sme families express a feeling f islatin. Greater awareness and empathy is needed frm the wider cmmunity as well as assistance with daily caregiving, scial and emtinal needs, and the lgistics f traveling t the hspital fr medical services. Behaviral factrs Amng lder students, alchl and drug abuse is prevalent. Pr diet, lack f exercise, and incmplete immunizatins were cncerns fr yuth f all ages. Lw-incme families and children in the cmmunity typically have prer diets, limited physical activity and higher rates f smking and substance abuse than higher-incme families resulting in higher rates f chrnic diseases like diabetes, besity, and cardivascular issues. Anka, Hennepin, and Ramsey cunties demnstrate higher rates f teen pregnancy than Minnesta verall. Additinally, wmen in Hennepin and Sctt cunties are nt accessing prenatal care at ptimal rates which may lead t pr health utcmes fr infants. Mrtality and mrbidity Unintentinal injury and perinatal cnditins are the leading causes f death fr yuth (ages 0-24) in the state. In the seven-cunty area, unintentinal injury and suicide are the mst prevalent types f pediatric injury mrtality. Disparities exist between rates f nn-white and White infant mrtality and lw birth weight infants. Pr mental health and chrnic diseases are als issues fr yuth and adults acrss the cmmunity but are particularly prblematic fr lw-incme and hmeless residents. Asthma and allergies are issues fr the pediatric ppulatin and fr the prviders and schls that serve them. In general, mre children in the brader cmmunity served by Children s reprt having asthma than the statewide average. Hennepin and Ramsey cunties demnstrate high rates f cmmunicable diseases, especially sexually transmitted diseases and tuberculsis. Dakta Cunty demnstrates high rates f pertussis. Lcal envirnment Children in Hennepin and Ramsey cunties are at greater risk f living in a pr physical envirnment by experiencing unsafe neighbrhds, inadequate infrastructure t supprt activities (e.g. parks, walking areas), and fd deserts with a lack f access t healthy fds. Additinally, children Hennepin and Ramsey cunties experience cmparatively high rates f abuse and neglect. Care access and delivery Health system cmplexity, lack f care integratin acrss prviders, regulatry and administrative burdens, and payment reductins result in frustratin fr bth patients and prviders. Cst, lack f insurance, and a lack f prviders accepting Medicaid create signficiant barriers t accessing primary, mental, and dental care fr children. The cmmunity has a variety f resurces striving t meet the needs f patients that experience access barriers. Children s is a safety net prvider, with Medicaid accunting fr an average f 42 percent f patients seen. Thirty-nine Federally Qualified Health Centers (FQHCs) in Hennepin ix

10 and Ramsey cunties and ne in Washingtn Cunty serve medically underserved areas and ppulatins. Twin Cities area residents face barriers t accessing care as demnstrated by the presence f federally-designated Medically Underserved Areas r Ppulatins (MUA/MUPs) and Health Prfessinal Shrtage Areas (HPSAs) in Hennepin and Ramsey cunties. Anka, Washingtn, and Sctt cunties als cntain HPSA facilities and ppulatins. Even with these resurces, insufficient Medicaid acceptance is a particular issue fr mental and dental care. These same issues and additinal factrs related t the level f understanding abut the health care system cntribute t veruse f the emergency rm fr nn-emergent cnditins. Of ttal discharges at Children s, seven percent are fr ambulatry care sensitive cnditins (ACSC), which are thse cnditins that are ptentially preventable if patients were accessing primary care resurces at ptimal rates. The mst cmmn cnditins are: asthma, urinary tract infectin, perfrated appendix, and diabetes shrt-term cmplicatins. x

11 Cmmunity-wide pririty needs Pr health status can result frm a cmplex interactin f challenging scial, ecnmic, envirnmental and behaviral factrs cmbined with a lack f access t care. Addressing these rt causes is an imprtant step t imprve a cmmunity s quality f life and reduce mrtality and mrbidity. This dcument explres these factrs in rder t develp a list f pririty health needs. All primary and secndary data presented in the Appendix f this reprt were analyzed and findings were ranked t determine the pririty issues. The table that fllws describes results f the ranking prcess. The needs are listed in alphabetical rder. Access t care Cultural and linguistic barriers affect access t care A lack f culturally cmpetent health services, stigma assciated with a diagnsis, wrk demands, language barriers, and fear f judgment fr accepting services prevent residents frm seeking timely and apprpriate care. Vulnerable ppulatins lack sufficient access t care Lw-incme and minrity ppulatins have difficulty accessing health care services, insurance and specialists due t cst. Safety net prviders are struggling with grwing demand fr services, inadequate prvider payment rates and insufficient capacity. Many prviders, especially fr mental and dental health, d nt accept Medicaid patients. Maternal and child health Prevalent infant health risk factrs and disparities exist, particularly in Hennepin and Ramsey cunties Mthers in Ramsey cunty are nt accessing prenatal care at ptimal rates. Hennepin and Ramsey cunties reprted cmparatively high rates f teen pregnancy. Nn-White ppulatins in Hennepin and Ramsey cunties exhibited high infant mrtality rates cmpared t the White ppulatin. Mental health Pr mental health and lack f access t pediatric mental and behaviral health services is present Additinal, cmprehensive mental health services are needed t address the needs f children and families, particularly lw-incme, uninsured/underinsured residents and Medicaid beneficiaries. Depressin amng yuth and adults and PTSD amng refugee grups are prevalent in the cmmunity. Mrbidity and mrtality Diet, exercise, envirnment, and insufficient knwledge cntribute t besity Pr diet, lack f exercise, insufficient access t nutritius fd and safe recreatinal spaces, and lack f knwledge abut healthy fd chices and preparatin cntribute t issues with besity. Yuth suffer frm asthma at high rates Imprved management f asthma is needed fr yuth in the cmmunity. Scial and ecnmic factrs Families/caregivers f children with cmplex needs lack sufficient supprt These families require assistance fr daily caregiving and meeting the scial and emtinal needs f the entire family. Fstering greater awareness and empathy frm the wider cmmunity arund special needs wuld alleviate feelings f islatin. These families als need lgistical and ecnmic supprt fr recurrent travel t the hspital fr medical services. xi

12 Appendix

13 Methdlgy Analytic methds This Appendix begins by identifying the cmmunity served by Children s. Findings based n varius quantitative analyses regarding health needs in thse areas are discussed, fllwed by a review f health assessments cnducted by ther rganizatins in recent years. The Appendix then presents infrmatin btained frm interviews with stakehlders wh represent the brad interests f the cmmunity, including public health fficials and experts, and Children s-affiliated clinicians, administratrs, and staff. Interviews were cnducted in the fall f Identifying pririty cmmunity health needs invlves benchmarking and trend analysis. Statistics fr several health status and health access indicatrs were analyzed and cmpared t statewide and natinal benchmarks r gals. The assessment cnsiders multiple data surces, including indicatrs frm lcal, state, and federal agencies. Including multiple data surces and stakehlder views is imprtant when assessing the level f cnsensus that exists regarding cmmunity health needs. If alternative data surces including interviews supprt similar cnclusins, then cnfidence is increased regarding the mst prblematic health needs in a cmmunity. Priritizatin prcess and criteria Verité applied a ranking methdlgy t help priritize the cmmunity health needs identified by the assessment. Verité listed the identified health issues and assigned t each a severity scre based n the extent t which indicatrs exceeded Minnesta r U.S. averages. An average severity scre was calculated fr each categry f data (secndary data, previus assessments, and interviews) t accunt fr the number f surces that measured each health issue. These averages were assigned a weight: 45 percent, 10 percent, and 45 percent, respectively. A final scre was calculated by summing the weighted averages. The methdlgy takes int accunt severity scres fr each health issue and the number f surces that measure each issue. Infrmatin gaps N infrmatin gaps have affected Children s ability t reach reasnable cnclusins regarding pririty cmmunity health needs. Cllabrating rganizatins Children s did nt establish a frmal cllabratin with ther rganizatins fr this assessment. 1

14 Definitin f cmmunity assessed This sectin identifies the cmmunity assessed by Children s. Children s is ne f the largest freestanding pediatric health care systems in the U.S., with hspitals in St. Paul and Minneaplis and fur utpatient sites in the surrunding suburbs. In additin t prviding a brad spectrum f pediatric services t its lcal cmmunity, Children s is a statewide resuce and referral center fr pediatric care acrss the upper Midwest.» The hspital s cancer and bld disrders prgram is ne f the largest in the regin, caring fr mre than 55 percent f children diagnsed with cancer and bld disrders in Minnesta.» Children s has the largest high-risk nenatal referral center in the regin and the furthlargest in the U.S., with mre than 2,000 nenatal admissins in Children s is a primary referral center fr ther NICUs in the regin.thirty-five percent f the hspital s nenatal admissins are lw birth weight r very lw birth weight infants. In 2012, nenatal patients came t Children s frm ten states and 58 Minnesta cunties.» The Minnesta Sudden Infant Death Center at Children s is a statewide prgram that prvides infrmatin, cunseling, and supprt t anyne experiencing a sudden and unexpected infant death frm any cause. The center cntinues t be Minnesta's resurce fr infrmatin n Sudden Infant Death Syndrme (SIDS) and SIDS risk reductin. Exhibit 1 illustrates the statewide reach f Children s. Unique patients frm every cunty in the state were served thrugh services including inpatient discharges, emergency department visits, and utpatient care. 2

15 Exhibit 1: Statewide Unique Patients Served, 2011 Surce: Micrsft MapPint and Children s, Althugh Children s prvides services t children thrughut Minnesta, this assessment fcuses n the needs f the lcal gegraphic cmmunity served by the hspital. Verité relied n the seven-cunty metr area as the brader cmmunity and an immediate cmmunity surrunding each hspital campus fr the hspital. Children s immediate cmmunity is cmprised f 42 ZIP cdes in five lcal schl districts, Minneaplis, St. Paul, Suth St. Paul, Richfield, and West St. Paul Mendta Heights Eagan (Exhibits 2A). The brader cmmunity encmpasses seven cunties: Anka, Carver, Dakta, Hennepin, Ramsey, Sctt, and Washingtn (Exhibit 2B). Children s is cmprised f tw campuses: Children s Minneaplis in ZIP cde and Children s St. Paul in ZIP cde

16 Exhibit 2A: Pediatric Ppulatin, 2011 Schl District Minneaplis St. Paul West St. Paul - Mendta Heights - Eagan ZIP Cde Ppulatin Aged 0-17 Percent f Ttal Ppulatin % % % , % , % , % , % , % , % , % , % , % , % , % % , % , % , % , % , % , % % % Subttal 93, % % , % , % , % , % , % , % , % % , % , % , % , % Subttal 79, % , % , % , % % Subttal 8, % Richfield , % Suth St. Paul , % Immediate Cmmunity Ttal 192, % Brader Cmmunity Ttal 736, % Surce: Thmsn Reuters via Children s, The pediatric ppulatin frm the five schl districts in the immediate cmmunity accunts fr 26% f the ttal cmmunity ppulatin 4

17 Exhibit 2B: Pediatric Ppulatin, 2011 Cunty Ppulatin Aged 0-17 Percent f Ttal Pediatric Ppulatin Anka 96, % Carver 27, % Dakta 112, % Hennepin 274, % Ramsey 119, % Sctt 41, % Washingtn 65, % Ttal 736, % Surce: Thmsn Reuters via Children s, Of the seven cunties in the brader cmmunity, Carver Cunty is the least ppulus, accunting fr 4% f the pediatric ppulatin In 2012, the Children s brader cmmunity had a pediatric ppulatin (thse yunger than 18) f apprximately 736,800 persns 4. Apprximately 37 percent f the ppulatin resided in Hennepin Cunty, fllwed by 16 percent in Ramsey Cunty and 15 percent in Dakta Cunty (Exhibit 2B). The immediate cmmunity definitin was cnfirmed by examining the gegraphic rigin f Children s inpatients and emergency department encunters. In 2011, 39 percent f inpatient discharges and 60 percent f emergency department visits riginated frm the immediate cmmunity. In the brader cmmunity, apprximately 30 percent f the hspital s inpatients riginated frm Hennepin Cunty, fllwed by 17 percent frm Ramsey Cunty and 11 percent frm Dakta Cunty. Cllectively, the seven cunties accunted fr 76 percent f the hspital s inpatient discharges. In 2011, apprximately 85 percent f Children s emergency department visits riginated frm Hennepin, Ramsey, and Dakta cunties; 95 percent riginated frm the brader cmmunity (Exhibit 3A and 3B). 4 The data in Exhibit 2 cnsiders the pediatric ppulatin t be thse residents aged Hwever, elsewhere in the reprt, the pediatric ppulatin is smetimes cnsidered t be thse residents aged 0-19 due t data limitatins. 5

18 Exhibit 3A: Inpatient Discharges and Emergency Department Visits, 2011 Schl District ZIP Cde Percent f Discharges Percent f ED Visits % 0.1% % 0.0% % 0.4% % 4.4% % 0.8% % 1.8% % 6.2% % 3.2% % 1.0% % 0.6% % 2.6% Minneaplis % 1.1% % 0.7% % 0.5% % 0.2% % 0.6% % 1.2% % 1.6% % 1.2% % 0.9% % 0.8% % 0.0% % 0.0% Subttal 17.8% 29.7% % 0.4% % 1.3% % 1.7% % 3.7% % 0.8% % 5.3% St. Paul % 2.2% % 0.4% % 0.1% % 1.2% % 3.3% % 2.5% % 1.9% Subttal 16.4% 24.7% % 2.0% West St. Paul % 0.1% Mendta % 0.3% Heights -Eagan % 0.0% Subttal 2.0% 2.4% Richfield % 1.8% Suth St. Paul % 1.3% Immediate Cmmunity Ttal 38.5% 59.8% Brader Cmmunity Ttal 3,548 52,752 Surce: Children s, The five schl districts in the immediate cmmunity represented 39% f Children s inpatient discharges and 60% f all emergency rm visits in

19 Exhibit 3B: Inpatient Discharges and Emergency Department Visits, 2011 Cunty Percent f Discharges Percent f ED Visits Anka 6.8% 4.0% Carver 2.2% 0.6% Dakta 10.6% 10.4% Hennepin 30.0% 44.3% Ramsey 17.2% 30.0% Sctt 2.4% 1.0% Washingtn 6.5% 4.9% Brader Cmmunity Ttal 75.6% 95.2% Other Areas 24.4% 4.8% All Discharges 12,175 88,302 Surce: Children s, The seven-cunty area accunts fr 76% f all Children s inpatient discharges and 95% f all emergency rm visits 7

20 Exhibit 4 presents the ZIP cdes and cunties that cmprise Children s brader cmmunity and highlights the hspital s immediate cmmunity. Zip cdes are indicated by dtted lines. Exhibit 4: Children s Cmmunity Surce: Micrsft MapPint and Children s,

21 Secndary data assessment This sectin assesses secndary data regarding health needs in the cmmunity served by Children s. Key insights: Demgraphics» The majrity f hspital patients live in Hennepin, Ramsey, and Dakta cunties.» The cmmunity ppulatin is grwing, especially in the suburban and exurban areas f the Twin Cities.» The ppulatin is increasingly diverse, with particularly high grwth expected in the Hispanic r Latin ppulatin. Racial and ethnic minrity grups are mre likely t lack scial and ecnmic resurces, resulting in health disparities and unique health and scial service needs. Minneaplis and St. Paul, surrunding suburbs, and the nrthern prtins f Dakta and Sctt cunties are currently the mst diverse. - These same lcatins reprt cmparatively high percentages f linguistic islatin, which can cntribute t lw health literacy and barriers t accessing care, and lw educatinal achievement, which ften is linked with pverty and pr health. Demgraphics Pediatric ppulatin Ppulatin change plays a determining rle in the types f health and scial services needed by cmmunities. Overall, the pediatric ppulatin (thse yunger than 18) living in the brader cmmunity is expected t increase 3.2 percent between 2011 and 2016 (Exhibit 5). 9

22 Exhibit 5: Percent Change in Pediatric Ppulatin by Cunty and Age in the Brader Cmmunity, Ppulatin Chrt Cunty Ttal Ppulatin Anka 26.9% 27.1% 28.0% 17.9% 96,312 Carver 26.4% 27.3% 29.0% 17.3% 27,914 Dakta 27.5% 27.1% 27.4% 18.1% 112,252 Hennepin 30.2% 28.1% 25.5% 16.3% 274,108 Ramsey 30.4% 27.9% 25.1% 16.6% 119,893 Sctt 29.0% 28.0% 27.0% 16.0% 41,247 Washingtn 25.9% 27.0% 28.5% 18.6% 65,148 Ttal 28.8% 27.6% 26.5% 17.0% 736, Ppulatin Anka 27.8% 27.1% 27.3% 17.8% 97,686 Carver 27.0% 26.1% 28.7% 18.3% 29,884 Dakta 28.2% 27.3% 26.9% 17.6% 114,040 Hennepin 29.3% 28.7% 26.8% 15.2% 284,087 Ramsey 29.9% 28.8% 26.6% 14.7% 121,875 Sctt 28.7% 27.6% 26.8% 16.8% 46,571 Washingtn 27.2% 26.3% 27.4% 19.1% 65,906 Ttal 28.7% 27.9% 27.0% 16.4% 760,049 Percent Change Anka 4.7% 1.5% -1.3% 0.5% 1.4% Carver 9.5% 2.2% 6.1% 12.7% 7.1% Dakta 4.2% 2.5% -0.1% -1.2% 1.6% Hennepin 0.8% 5.8% 9.0% -3.2% 3.6% Ramsey -0.1% 5.0% 7.5% -9.7% 1.7% Sctt 11.9% 11.3% 12.1% 18.8% 12.9% Washingtn 6.2% -1.2% -2.7% 3.5% 1.2% Ttal 3.0% 4.2% 4.9% -1.0% 3.2% Surce: Thmsn Reuters via Children s,

23 Prjected pediatric ppulatin grwth varies by ZIP cde. Althugh Hennepin Cunty has the highest percentage f the ppulatin 17 years f age and under, prjected grwth is cncentrated in Sctt and Carver cunties (Exhibit 6). Exhibit 6: Pediatric Ppulatin Change by ZIP Cde, Surces: Micrsft MapPint and Thmsn Reuters via Children s,

24 Race and ethnicity In 2011, ver 80 percent f the brader cmmunity s ppulatin was White. Nn-White ppulatins are expected t grw faster than White ppulatins in the brader cmmunity. In Hennepin and Ramsey cunties, the White ppulatin is expected t decrease. The Asian/Pacific Islander ppulatin is expected t increase by 14 percent (Exhibit 7). The grwing diversity f the cmmunity is imprtant t recgnize given that health disparities and the need t enhance cultural cmpetency f health care prviders. (Nte that Hispanic r Latin ethnicity is reprted separately frm race. Persns f Hispanic r Latin rigin may be frm any racial grup. Exhibit 10 prvides data regarding ethnicity). Exhibit 7: Distributin f Ppulatin by Race in the Brader Cmmunity, Racial Chrt American Asian/ Indian & Pacific Alaska Native Islander 2+ Races Other Ttal Cunty White Black 2011 Ppulatin Anka 88.3% 3.8% 0.7% 3.8% 2.3% 1.1% 377,356 Carver 92.8% 1.6% 0.3% 2.5% 1.4% 1.4% 97,717 Dakta 86.6% 4.2% 0.5% 4.3% 2.4% 2.0% 440,421 Hennepin 76.7% 10.1% 1.0% 5.8% 3.1% 3.2% 1,190,617 Ramsey 73.9% 9.4% 0.9% 9.5% 3.3% 3.1% 513,092 Sctt 87.4% 2.5% 0.7% 5.7% 1.8% 1.9% 141,624 Washingtn 88.1% 3.3% 0.5% 5.1% 2.1% 0.9% 246,106 Ttal 81.1% 7.1% 0.8% 5.8% 2.8% 2.4% 3,006, Ppulatin Anka 85.9% 4.7% 0.7% 4.7% 2.6% 1.3% 397,394 Carver 91.3% 2.1% 0.3% 3.0% 1.6% 1.6% 108,011 Dakta 84.3% 5.0% 0.6% 4.9% 2.8% 2.4% 460,898 Hennepin 74.9% 10.7% 1.1% 6.2% 3.4% 3.7% 1,209,353 Ramsey 72.2% 10.2% 0.9% 9.9% 3.5% 3.3% 510,111 Sctt 84.4% 3.2% 0.7% 7.3% 2.1% 2.2% 161,743 Washingtn 85.6% 4.0% 0.5% 6.5% 2.4% 1.0% 261,742 Ttal 79.2% 7.8% 0.8% 6.4% 3.0% 2.8% 3,109,252 Percent Change Anka 2.4% 32.7% 8.1% 31.1% 19.1% 24.5% 5.3% Carver 8.8% 43.3% 30.7% 30.3% 30.4% 29.0% 10.5% Dakta 1.9% 27.1% 17.3% 20.3% 18.4% 21.7% 4.6% Hennepin -0.8% 7.3% 3.6% 9.2% 9.6% 17.9% 1.6% Ramsey -2.8% 7.8% 2.9% 2.8% 5.0% 8.5% -0.6% Sctt 10.4% 47.2% 13.0% 46.4% 32.3% 32.5% 14.2% Washingtn 3.4% 28.1% 13.9% 33.8% 22.3% 21.4% 6.4% Ttal 1.1% 12.5% 6.5% 14.2% 12.6% 17.5% 3.4% Surce: Thmsn Reuters via Children s,

25 Nn-White ppulatins are cncentrated in Hennepin and Ramsey cunties; these cunties had the highest percentage f Black residents. Ramsey, Sctt, Washingtn, and Hennepin cunties had the highest percentages f Asian/Pacific Islander residents in 2011 (Exhibits 8 and 9). Exhibit 8: Areas with Highest Cncentratin f Black Residents, 2011 Surces: Micrsft MapPint and Thmsn Reuters via Children s,

26 Exhibit 9: Areas with Highest Cncentratin f Asian/Pacific Islander Residents, 2011 Surces: Micrsft MapPint and Thmsn Reuters via Children s,

27 Prjectins indicate that the Hispanic r Latin cmmunity ppulatin is expected t increase mre rapidly than the nn-hispanic r Latin ppulatin. In terms f verall percent change, the brader cmmunity is prjected t experience grwth in the Hispanic r Latin ppulatin f apprximately 19 percent between 2011 and 2016 (Exhibit 10). Exhibit 10: Distributin f Ppulatin by Ethnicity in the Brader Cmmunity, Ethnic Chrt Cunty Hispanic r Latin Nn-Hispanic r Latin Ttal 2011 Ppulatin Anka 3.0% 97.0% 377,356 Carver 4.1% 95.9% 97,717 Dakta 5.0% 95.0% 440,421 Hennepin 6.6% 93.4% 1,190,617 Ramsey 6.7% 93.3% 513,092 Sctt 4.1% 95.9% 141,624 Washingtn 3.0% 97.0% 246,106 Ttal 5.4% 94.6% 3,006, Ppulatin Anka 3.6% 96.4% 397,394 Carver 4.8% 95.2% 108,011 Dakta 5.8% 94.2% 460,898 Hennepin 7.7% 92.3% 1,209,353 Ramsey 7.4% 92.6% 510,111 Sctt 4.8% 95.2% 161,743 Washingtn 3.5% 96.5% 261,742 Ttal 6.2% 93.8% 3,109,252 Percent Change Anka 26.5% 4.6% 5.3% Carver 29.4% 9.7% 10.5% Dakta 22.8% 3.7% 4.6% Hennepin 19.0% 0.3% 1.6% Ramsey 9.0% -1.3% -0.6% Sctt 33.1% 13.4% 14.2% Washingtn 23.3% 5.8% 6.4% Ttal 18.9% 2.5% 3.4% Surce: Thmsn Reuters via Children s, The Hispanic r Latin ppulatin is prjected t increase mre than 20%in five cunties: Anka, Carver, Dakta, Sctt, and Washingtn The nn-hispanic ppulatin is prjected t decrease in Ramsey Cunty 15

28 Exhibit 11 illustrates the cncentratin f Hispanic r Latin residents in the Children s brader cmmunity. Hispanic r Latin cmmunities are highly cncentrated in Hennepin, Ramsey, and Dakta cunties. At 33 percent, Sctt Cunty is prjected t experience the highest grwth in the Hispanic r Latin ppulatin. Exhibit 11: Areas with Highest Cncentratin f Hispanic r Latin Residents, 2011 Surces: Micrsft MapPint and Thmsn Reuters via Children s,

29 Other demgraphic infrmatin Additinal demgraphic characteristics are presented in Exhibit 12.» In 2010, Washingtn Cunty had a higher percentage f disabled pediatric residents than Minnesta and natinal averages.» All cunties, with the exceptin f Ramsey, had a higher high schl graduatin rate than the Minnesta and natinal average. Ramsey Cunty had the highest percentage f nn-graduates at 10.4 percent.» Hennepin, Ramsey, and Sctt cunties had higher percentages f linguistically islated individuals than the Minnesta average. Linguistic islatin is defined as the ppulatin aged 5 and lder wh speak a language ther than English at hme and wh speak English less than very well. Exhibit 12: Prevalence f Demgraphic Indicatrs and Variatin frm Minnesta in the Brader Cmmunity, 2010 Aged 0-17 With Any Disability Aged 25+ N High Schl Graduatin Aged 5+ Linguistically Islated Cunty Anka 3.8% 5.5% 3.3% Carver 2.8% 3.7% N/A Dakta 3.8% 5.1% 4.1% Hennepin 3.6% 7.9% 6.9% Ramsey 3.8% 10.4% 9.5% Sctt 1.8% 6.1% 4.8% Washingtn 4.6% 4.0% 3.2% Minnesta 3.7% 8.2% 4.2% U.S. 4.0% 14.4% 8.7% Surce: U.S. Census Bureau, Hennepin, Ramsey, and Sctt cunties all reprted a greater rate f linguistic islatin than the Minnesta average Hennepin and Ramsey cunties reprted the lwest percentages f students wh speak English at hme. Bth cunties have a significant number f Spanish speakers; Ramsey Cunty reprts that 14.4 percent f its husehlds speak Hmng at hme (Exhibit 13). Exhibit 13: Primary Language f Students in the Brader Cmmunity, Schl Year 2011 Primary Language Anka Carver Dakta Hennepin Ramsey Sctt Washingtn Minnesta English 86.3% 92.6% 87.7% 79.0% 68.8% 88.9% 91.8% 87.3% Hmng 2.2% 0.1% 0.4% 2.8% 14.4% 0.0% 3.4% 2.4% Karen 0.0% 0.0% 0.0% 0.0% 1.8% 0.0% 0.0% 0.2% Russian 0.7% 0.3% 0.5% 0.5% 0.2% 1.3% 0.2% 0.3% Smali 0.9% 0.3% 1.5% 3.8% 2.7% 0.6% 0.1% 1.6% Spanish 3.7% 4.5% 5.3% 8.4% 6.8% 4.3% 1.3% 4.7% Vietnamese 0.9% 0.4% 0.9% 0.7% 0.8% 1.2% 0.3% 0.5% Other 5.2% 1.9% 3.8% 4.8% 4.6% 3.7% 2.9% 3.0% Ttal Enrllments 62,336 15,769 71, ,124 83,806 21,992 39, ,077 Surce: Minnesta Department f Educatin, Exhibit 14 demnstrates the high schl drput rate in each cunty by race and ethnicity as reprted by the Minnesta Department f Educatin. American Indians/Alaska Natives had the 17

30 highest drput rates in three f the fur cunties fr which their demgraphic figures were reprted; Ramsey Cunty had the highest drput rate at 20.5 percent. Hispanic r Latin students als reprted high drput rates; Hennepin Cunty s 15.9 percent drput rate was significantly higher than Minnesta s average. All cunties reprted higher rates f students receiving free r reduced-price lunch drpping ut than students nt receiving free r reducedprice lunch. Overall, Hennepin and Ramsey cunties reprted higher drput rates than Minnesta s average. Exhibit 14: Drput Rate within 4 Years by Chrt in the Brader Cmmunity, Schl Year 2011 Student Chrt Anka Carver Dakta Hennepin Ramsey Sctt Washingtn Minnesta Race/Ethnicity American Indian/ Alaskan Native 13.9% N/A 4.7% 16.7% 20.5% N/A N/A 18.8% Asian/Pacific Islander 2.2% N/A 3.7% 3.7% 4.9% 6.1% 2.5% 4.3% Black, Nt Hispanic r Latin 7.0% N/A 7.6% 9.2% 8.3% 2.3% 2.1% 8.7% White, Nt Hispanic r Latin 3.0% 2.9% 2.2% 2.7% 6.5% 2.6% 1.3% 3.3% Hispanic r Latin 9.4% 14.5% 11.0% 15.9% 9.9% 13.4% 2.6% 13.5% Lw-Incme Free r Reduced- Priced Lunch 8.5% 11.7% 10.8% 10.6% 9.3% 10.4% 6.1% 10.1% Sex Male 4.3% 5.3% 4.2% 6.3% 7.8% 3.2% 2.1% 5.6% Female 3.3% 3.0% 2.3% 4.8% 5.9% 3.9% 0.9% 3.9% All Students 3.8% 4.1% 3.3% 5.5% 6.9% 3.5% 1.5% 4.8% Surce: Minnesta Department f Educatin,

31 Ecnmic indicatrs The fllwing types f ecnmic indicatrs with implicatins fr health were assessed: (1) peple in pverty, (2) husehld incme, (3) unemplyment rates, (4) hmelessness, (5) crime, (6) State f Minnesta budget cuts, (7) utilizatin f gvernment assistance prgrams, and (8) insurance status. Key insights: Ecnmic Indicatrs» Pverty creates barriers t access (t health services, quality educatin, healthy fd, husing, and ther basic needs and pprtunities) that cntribute t pr health status. The immediate cmmunity demnstrates the greatest sci-ecnmic need, fllwed by Anka Cunty. - Children have a higher pverty rate than the ttal ppulatin; Hennepin and Ramsey cunties have rates higher than state averages. These cunties als have mre uninsured children than the state average. - Lw-incme husehlds, students eligible fr free and reduced lunch, and discharges fr Medicaid/PMAP (prxy measures f pverty) are mst prevalent in the immediate cmmunity. - Cst f living in the area is high, ften with lng wait times fr husing assistance. - The mre urban cunties (Hennepin and Ramsey) reprt cmparatively high rates f child hmelessness as well as vilent and prperty crime.» Unemplyment rates decreased between 2011 and 2012 and were lwer than state and natinal averages.» Anka Cunty exhibits rates f rape and larceny abve the state average.» Health and human services prgrams, including Medicaid, mental health prgrams and managed care rganizatins faced budget cuts. Peple in pverty Many health needs are assciated with pverty. Accrding t the U.S. Census, abut 16 percent f peple in the U.S. and abut 12 percent f peple in Minnesta lived in pverty in The pverty rate fr children was 23 percent natinally and 15 percent in Minnesta. Ramsey Cunty reprted an verall pverty rate that was higher than bth the Minnesta and natinal averages. Hennepin Cunty s ttal pverty rate was higher than the Minnesta average. In all cunties, children had a higher pverty rate than the adult ppulatin. Hennepin and Ramsey cunties als reprted pverty rates fr the pediatric ppulatin that cmpare unfavrably t state and natinal averages (Exhibit 15). 19

32 Exhibit 15: Pverty Rates, 2011 Anka Carver 8.6% 6.3% 8.0% 11.3% Dakta 6.9% 9.2% Hennepin 13.5% 17.9% Ramsey 17.5% 26.0% Sctt Washingtn 6.0% 7.3% 5.9% 7.1% Minnesta 11.9% 15.4% U.S. 15.9% 22.5% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% Pverty Rate, 2011 Surce: U.S. Census Bureau, Ttal Ppulatin Children Husehld incme In the Children s brader cmmunity in 2011, apprximately 15 percent f all husehlds had incmes belw $25,000, an apprximatin f the federal pverty level (FPL) fr a family f fur; 38 percent had incmes less than $50,000, an apprximatin f 200 percent f the FPL fr a family f fur. FPL is used by many agencies and rganizatins t assess husehld needs fr lw-incme assistance prgrams. Ramsey and Anka cunties exhibited the lwest average husehld incme. The immediate cmmunity had the highest rates f husehlds with incmes less than $25,000 (Exhibits 16A and 16B). 20

33 Exhibit 16A: Percent Lw-Incme Husehlds in the Immediate Cmmunity, 2011 Schl District ZIP Cde Number f Husehlds 2011 Average Husehld Incme Percent Less Than $25,000 Percent Less Than $50, ,972 78, % 44.7% , % 59.5% ,436 61, % 64.8% ,360 33, % 80.7% ,617 72, % 55.3% ,148 59, % 52.4% ,754 54, % 56.2% ,249 56, % 61.5% ,046 70, % 45.2% ,934 97, % 29.6% ,966 41, % 71.9% Minneaplis ,389 53, % 56.7% ,860 52, % 60.2% ,473 46, % 70.1% ,378 59, % 58.3% ,958 88, % 37.9% ,191 73, % 39.2% ,341 57, % 53.1% , , % 29.8% ,949 53, % 54.7% ,681 25, % 86.6% , % 93.9% % 0.0% Subttal 189,575 59, % 54.4% ,322 49, % 67.2% ,248 56, % 58.3% ,608 41, % 69.7% ,565 58, % 55.6% ,519 90, % 37.4% ,855 47, % 63.3% St. Paul ,339 51, % 56.2% ,217 65, % 52.3% ,240 47, % 62.7% ,431 73, % 47.4% ,653 54, % 57.2% ,561 63, % 48.6% ,520 44, % 66.6% Subttal 125,078 57, % 55.1% ,169 77, % 45.2% West St. Paul , , % 21.7% Mendta ,240 70, % 40.7% Heights % 0.0% Eagan Subttal 17,279 84, % 41.8% Richfield ,770 61, % 49.7% Suth St. Paul ,079 60, % 47.7% Immediate Cmmunity Ttal 354,781 64, % 53.7% Brader Cmmunity Ttal 1,171,108 82, % 38.3% Surce: Thmsn Reuters via Children s,

34 Exhibit 16B: Percent Lw-Incme Husehlds in the Brader Cmmunity, 2011 Number f Husehlds 2011 Average Husehld Incme Percent Less Than $25,000 Percent Less Than $50,000 Cunty Anka 138,569 75, % 34.2% Carver 34,444 81, % 30.5% Dakta 164,703 83, % 31.7% Hennepin 490,230 84, % 41.2% Ramsey 203,262 65, % 48.5% Sctt 49,346 89, % 26.1% Washingtn 90,554 92, % 27.3% Ttal 1,171,108 82, % 38.3% Surce: Thmsn Reuters via Children s, Ramsey Cunty reprted the highest rates f husehlds with incme less than $25,000 and $50,000 The highest prprtins f husehlds with incmes under $25,000 in 2011 were lcated in the Minneaplis and St. Paul schl districts (Exhibit 17). Exhibit 17: Husehlds with Incmes Less than $25,000 by ZIP cde, 2011 Surces: Micrsft MapPint and Thmsn Reuters via Children s

35 Unemplyment rates High unemplyment rates are assciated with high numbers f uninsured peple due t the lack f emplyer-based insurance. All cunties reprted unemplyment rates in 2011 and 2012 that were lwer than r equal t the Minnesta average (Exhibit 18). Exhibit 18: Unemplyment Rates, Anka Carver Dakta 5.5% 5.2% 4.9% 5.6% 5.0% 6.2% Hennepin Ramsey Sctt Washingtn Minnesta 6.0% 5.4% 6.3% 5.8% 5.4% 4.9% 5.6% 5.2% 6.3% 5.8% U.S. 7.6% 8.8% 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0% Unemplyment Rate September 2011 September 2012 Surce: U.S. Bureau f Labr Statistics, Hmelessness Since 1991, Wilder Research has cnducted a triennial survey f the hmeless ppulatin thrughut Minnesta. Hennepin Cunty reprted the greatest rate f hmeless children, while Ramsey Cunty reprted the greatest rate f hmeless families (Exhibit 19). Hennepin and Ramsey were the nly cunties t reprt rates f hmelessness greater than the Minnesta average. Carver and Sctt cunties reprted the lwest rates f hmelessness in the brader cmmunity. 23

36 Exhibit 19: Hmelessness Rates in the Brader Cmmunity, 2009 Number Rate per 100,000 Hennepin Cunty reprted a child hmelessness rate duble the Minnesta average Cunty Children Families Children Families Anka Carver/Sctt* Dakta Hennepin 1, Ramsey Washingtn Minnesta 3, Surce: Wilder Research 2009 Minnesta hmeless study (cmpiled in 2011) and U.S. Census Bureau: American Cmmunity Survey 5 Year Estimates, * Data fr Carver and Sctt cunties were cmbined in the riginal surce. Crime The Minnesta Department f Public Safety s Bureau f Criminal Apprehensin reprts data n vilent and prperty crime in Minnesta frm cunty plice departments that participate in its Unifrm Crime Reprting (UCR) Prgram. Hennepin and Ramsey cunties reprted higher rates f vilent and prperty crime than the Minnesta average in Within the brader cmmunity, Ramsey Cunty reprted the highest rates f vilent and prperty crime (Exhibit 20). Exhibit 20: Vilent Crime Rates in the Brader Cmmunity, 2011 Vilent Crime Crime Rates Per 100,000 Ppulatin Prperty Crime Mtr Vehicle Theft Vilent Crime Ttal Prperty Crime Ttal Aggravated Cunty Murder Rape Rbbery Assault Burglary Larceny Arsn Anka , ,162 Carver Dakta , Hennepin , ,394 Ramsey , ,773 Sctt , ,974 Washingtn , ,324 Minnesta Key Better than MN 0%-50% wrse than MN 50% t 75% wrse than MN >75% wrse than MN Surce: Minnesta Department f Public Safety Unifrm Crime Reprt, , ,

37 Exhibit 21 reprts pediatric arrest rates by cunty frm 2007 t 2009, the mst recent years available frm the Minnesta Bureau f Criminal Apprehensin. Fur f the seven cunties in the Children s brader cmmunity reprted higher rates f arrests fr serius crimes than the state average in Exhibit 21: Children Aged Arrested fr Serius Crimes* in the Brader Cmmunity, Number Rate** per 1,000 Children Cunty Anka Carver Dakta Hennepin 3,188 3,293 3, Ramsey 982 1, Sctt Washingtn Minnesta 10,895 11,847 11, Surce: Minnesta Bureau f Criminal Apprehensin via Minnesta Department f Health, *Children aged arrested fr Part I crimes: murder, rape, rbbery, aggravated assault, burglary, larceny, vehicle theft, and arsn. Nt all children arrested fr serius crimes cmmitted these crimes, and sme children are nt arrested fr crimes that they actually cmmitted. **Rates may be lw because f the inclusin f children in the yunger age ranges and the inclusin f females, bth f whm have fewer arrests. The impact f budget cuts in Minnesta The recent recessin had majr implicatins fr emplyment and fr the availability f state and cunty resurces devted t health, public health, and scial services. In previus budget cycles, Minnesta significantly reduced funding apprpriated t these services. Funding reductins included Medicaid reimbursement rates cuts t hspitals and prviders, dramatic decreases in public health initiatives such as the Statewide Health Imprvement Prgram (SHIP), reductins in Emergency Medical Assistance (EMA), and cuts t mental health services. Fr the first time in several budget cycles, the 2013 legislative sessin did nt result in cuts r reductins t health and human services. In fact, many prgrams previusly cut were restred t near pre-2011 levels, including funding fr medical educatin training, SHIP, persnal care attendant services and EMA. Investments were als made in mental health, particularly schlbased mental health services and reimbursement fr mental health prviders. In additin, Minnesta enacted legislatin creating its wn state based health insurance exchange and basic health plan, expanding health insurance cverage t an additinal 87,000 Minnestans. Utilizatin f gvernment assistance prgrams Federal, state, and lcal gvernments prvide assistance prgrams fr lw-incme individuals and families. These prgrams include vuchers that subsidize husings csts, free and reducedprice lunches at public schls thrugh the Natinal Schl Lunch Prgram, the Supplemental Nutritin Assistance Prgram (SNAP), Medical Assistance and MinnestaCare, and Temprary Assistance fr Needy Families (TANF). Minnesta refers t SNAP as Fd Supprt and TANF as the Minnesta Family Investment Prgram (MFIP). Husing certificates and vuchers allw residents wh meet certain eligibility criteria t receive mnthly husing assistance under Sectin 8 f the Husing Act f Under that prgram, 25

38 subsidies f rental and mrtgage csts help make husing mre affrdable. Residents wh apply fr these certificates and vuchers may be placed n a waiting list befre funds becme available. Anka, Carver, Hennepin, Ramsey, and Washingtn cunties all reprted average mnths n the waiting list fr Sectin 8 husing certificates and vuchers that were greater than bth the Minnesta and U.S. averages. Average husehld federal cntributins fr all seven cunties in the brader cmmunity were higher than the U.S. and Minnesta averages (Exhibit 22). Exhibit 22: Waiting Time fr Sectin 8 Husing Certificates and Vuchers in the Brader Cmmunity, 2009 Number f Participating Husehlds Spending per Unit per Mnth Average Husehld Average Federal Cntributin Cntributin Average Mnths n Waiting List Cunty Anka 1,390 $ 379 $ Carver 154 $ 384 $ Dakta 2,547 $ 390 $ Hennepin 8,865 $ 365 $ Ramsey 5,349 $ 314 $ Sctt 315 $ 405 $ Washingtn 460 $ 429 $ Minnesta 30,543 $ 330 $ U.S. 2,040,801 $ 319 $ Surce: U.S. Department f Husing and Urban Develpment, Schls participating in the Natinal Schl Lunch Prgram are eligible t receive financial assistance frm the USDA t prvide free r reduced-cst meals t lw-incme students. Schls with 40 percent r mre f their student bdy receiving free r reduced-cst meals are eligible fr schl-wide Title I funding, designed t ensure that students meet grade-level prficiency standards. In the Children s brader cmmunity, 270 schls had greater than 70 percent f the student bdy eligible fr free r reduced-cst lunches (Exhibit 23). These schls are primarily lcated prximate t the hspital campuses, in the immediate cmmunity. 26

39 Exhibit 23: Public Schls with Over 70% f Students Eligible fr Free r Reduced Price Lunches, Schl Year Surces: Micrsft MapPint and Minnesta Department f Educatin,

40 Exhibit 24 shws the percent f the ttal ppulatin enrlled in the Minnesta Fd Assistance Prgram (als knwn as Fd Supprt). This prgram is ffered as part f the U.S. Department f Health and Human Services Supplemental Nutritin Assistance Prgram (SNAP) and prvides financial assistance t eligible lw-incme and n-incme families with dependent children. Minnesta s Fd Supprt prgram als prvides supprt fr certain nncitizens ver the age f 50 wh are nt cvered by SNAP.5 Frm 2006 t 2011, children have exhibited the fastest grwth in enrllment, increasing by 150 percent.6 Exhibit 24: Minnesta Fd Assistance Prgram Enrllment in the Brader Cmmunity, 2011 Percent f Enrllees that are Children Ttal Enrllees Cunty Anka 43.5% 23,390 Carver 46.0% 3,172 Dakta 47.0% 21,511 Hennepin 36.4% 108,054 Ramsey 40.1% 64,070 Sctt 50.0% 5,960 Washingtn 44.7% 9,736 Minnesta 40.7% 448,362 Surce: Minnesta Department f Human Services, Anka, Carver, Dakta, Sctt, and Washingtn cunties reprted a higher percent f Fd Supprt enrllees wh are children than the Minnesta average Exhibit 25 shws the percent f enrllees in Medical Assistance and MinnestaCare wh are children and families in each cunty. Medical Assistance (MA) is Minnesta s Medicaid prgram, which currently prvides cverage fr 733,000 Minnestans up t apprximately 100 percent f the federal pverty level (FPL). MinnestaCare currently cvers an additinal 129,000 Minnestans wh d nt have emplyer-spnsred insurance but d nt meet the incme requirements fr MA.7 Anka Cunty had the greatest prprtin f Medicaid enrllees wh were children and families, at 70.6 percent; children and families made up the greatest prprtin f MinnestaCare enrllees in Sctt Cunty, at 71.5 percent. 5Minnesta Department f Human Services. (2012, 26 Nvember). The Minnesta Fd Assistance Prgram. Retrieved 2012, frm eased&ddcname=id_ Minnesta Department f Human Services. (2012, August). Characteristics f Peple and Cases n the Supplemental Nutritin Assistance Prgram December Retrieved 2012, frm eased&ddcname=dhs16_ Minnesta Department f Human Services(2012, Octber). Minnesta Health Care Prgrams. Retrieved 2012, frm 28

41 Exhibit 25: Medicaid and Minnesta Care Average Mnthly Enrllment in the Brader Cmmunity, 2011 Percent f Cunty Enrllees that are Children and Families Medical Cunty Assistance MinnestaCare Anka 70.6% 61.5% Carver 65.7% 64.5% Dakta 67.6% 66.0% Hennepin 61.1% 55.7% Ramsey 66.7% 59.3% Sctt 69.3% 71.5% Washingtn 67.5% 66.3% Minnesta 65.5% 60.6% Surce: Minnesta Department f Human Services, Anka Cunty reprted the highest percent f children and families as enrllees in Medical Assistance Exhibit 26 shws the percent f the ttal pediatric ppulatin in each cunty that is enrlled in the Minnesta Family Investment Prgram (MFIP). MFIP cmbines cash and fd supprt fr eligible lw-incme and n-incme families. MFIP functins as part f the federal Temprary Assistance fr Needy Families prgram (TANF). Ramsey Cunty had the greatest percent f children enrlled in MFIP, at 1.6 percent. Exhibit 26: Children Enrlled in MFIP in the Brader Cmmunity, 2011 Percent f Children Enrlled in MFIP Cunty Anka 0.6% Carver 0.1% Dakta 0.4% Hennepin 1.3% Ramsey 1.6% Sctt 0.3% Washingtn 0.3% Minnesta 0.8% Surce: Minnesta Department f Human Services, Hennepin and Ramsey cunties bth reprted higher percentages f children enrlled in MFIP than the state average 29

42 Insurance status Exhibit 27 indicates that, in 2011, a higher percentage f residents and children in Hennepin and Ramsey cunties were uninsured than the Minnesta average. Exhibit 27: Uninsured Ppulatin by Age Chrt in the Brader Cmmunity, 2011 Percent Uninsured Cunty Ttal Ppulatin Ppulatin 0-17 Anka 8.9% 6.5% Carver 6.1% 3.8% Dakta 6.7% 6.0% Hennepin 10.4% 7.1% Ramsey 10.7% 6.9% Sctt 8.4% 5.5% Washingtn 6.0% 4.0% Minnesta 9.1% 6.6% U.S. 15.5% 8.0% Surce: U.S. Census Bureau, Hennepin and Ramsey cunties bth reprted higher pediatric uninsured ppulatins than the Minnesta average Exhibit 28A and 28B prtray the distributin f cmmunity-wide discharges in the immediate cmmunity and brader cmmunity by payer. 30

43 Exhibit 28A: Discharges in the Immediate Cmmunity by Payer, 2011 Schl District Zip Cde Discharges Cmmercial/ Self-Pay Medicaid / PMAP Medicare Other Private % 9.1% 0.0% 0.0% 81.8% % 0.0% 0.0% 0.0% 0.0% % 50.0% 0.0% 0.0% 41.7% % 81.3% 0.0% 0.0% 18.1% % 71.9% 0.0% 0.0% 28.1% % 55.3% 0.0% 2.1% 41.5% % 76.1% 0.0% 0.0% 20.2% % 90.7% 0.0% 0.0% 7.8% % 65.6% 0.0% 0.0% 34.4% % 18.2% 0.0% 1.8% 80.0% % 84.5% 0.0% 0.5% 14.4% Minneaplis % 73.9% 0.0% 1.7% 24.3% % 78.4% 0.0% 0.0% 21.6% % 59.3% 0.0% 0.0% 40.7% % 100.0% 0.0% 0.0% 0.0% % 16.4% 0.0% 3.0% 80.6% % 31.6% 0.0% 1.1% 64.2% % 52.2% 0.0% 0.0% 46.7% % 35.5% 0.0% 0.0% 60.5% % 81.5% 0.0% 0.0% 18.5% % 93.8% 0.0% 0.0% 6.3% % 100.0% 0.0% 0.0% 0.0% % 100.0% 0.0% 0.0% 0.0% Subttal 1, % 66.6% 0.0% 0.5% 31.4% % 92.3% 0.0% 0.0% 7.7% % 63.2% 0.0% 0.0% 35.1% % 80.6% 0.0% 0.0% 18.1% % 70.0% 0.0% 0.0% 30.0% % 18.8% 0.0% 0.0% 78.3% % 71.0% 0.0% 0.3% 27.5% St. Paul % 69.4% 0.0% 0.0% 28.2% % 48.2% 0.0% 1.8% 48.2% % 20.0% 0.0% 0.0% 80.0% % 46.0% 0.0% 1.6% 50.8% % 69.0% 0.0% 0.4% 29.8% % 54.0% 0.0% 1.1% 43.4% % 84.1% 0.0% 0.0% 15.1% Subttal 1, % 65.3% 0.0% 0.4% 33.1% % 58.2% 0.0% 0.0% 39.7% West St. Paul % 14.3% 0.0% 0.0% 85.7% Mendta Heights % 20.0% 0.0% 0.0% 80.0% - Eagan % 0.0% 0.0% 0.0% 0.0% Subttal % 48.6% 0.0% 0.0% 49.7% Richfield % 64.0% 0.0% 0.0% 36.0% Suth St. Paul % 46.8% 0.0% 1.1% 52.1% Immediate Cmmunity Ttal 3, % 64.5% 0.0% 0.5% 33.8% Brader Cmmunity Ttal Surce: Children s, , % 44.8% 0.2% 0.7% 53.3% 31

44 Exhibit 28B: Discharges in the Brader Cmmunity by Payer, 2011 Cunty Discharges Cmmercial / Self-Pay Medicaid / PMAP Medicare Other Private Anka % 38.8% 0.0% 0.8% 59.6% Carver % 20.6% 5.3% 0.8% 72.1% Dakta 1, % 36.0% 0.0% 1.2% 61.9% Hennepin 3, % 50.1% 0.1% 0.5% 48.3% Ramsey 2, % 57.5% 0.0% 0.3% 41.0% Sctt % 23.3% 0.0% 1.4% 73.3% Washingtn % 23.5% 0.0% 1.3% 74.4% Ttal 9, % 44.8% 0.2% 0.7% 53.3% Surce: Children s, The percentage f Medicaid discharges was higher in the immediate cmmunity than in the brader cmmunity as a whle. In the immediate cmmunity, Medicaid discharges were highest in the Minneaplis, St. Paul, and Richfield schl districts. Cmmercial/Self-Pay discharges were prevalent in ZIP cdes and in the Minneaplis schl district (Exhibit 29). 32

45 Exhibit 29: Discharges by Payer and ZIP Cde in the Immediate Cmmunity, 2011 Cmmercial/Self-Pay Private Medicaid/PMAP Surces: Micrsft MapPint and Children Minnesta, Sme ZIP cdes were excluded due t small sample size. H icns refer t Children s campus lcatins. 45% f discharges frm the brader cmmunity were fr Medicaid/PMAP cmpared t 65% in the immediate cmmunity Medicaid discharges were highest in ZIP cdes 55454, (Minneaplis), and (St. Paul) 33

46 Cunty-level health status and access indicatrs The fllwing secndary data surces have been used t examine cunty-level health status and access t care indicatrs in the cmmunity served by Children s: (1) Cunty Health Rankings, (2) Cmmunity Health Status Indicatrs Prject, (3) Minnesta Department f Health, (4) Minnesta Student Survey, and (5) Minnesta Department f Human Services.» On average, Hennepin, and Ramsey cunties benchmark prly n the greatest number f indicatrs. Key insights: Cunty- Level Indicatrs» Anka, Hennepin, and Ramsey cunties demnstrate cmparatively high rates f teen pregnancy.» Pr cmmunity safety, pr built envirnment, and higher rates f abuse and neglect create negative physical surrundings fr children in Hennepin and Ramsey cunties.» The majrity f pediatric injury mrtalities in the cmmunity are due t unintentinal injury and suicide.» Hennepin and Ramsey cunties demnstrate high rates f cmmunicable diseases, in particular sexually transmitted diseases and tuberculsis. Dakta Cunty demnstrates high rates f pertussis.» Apprximately percent f children aged mnths have cmpleted the recmmended series f immunizatins.» Disparities between nn-white and White infant mrtality and utf-hme care rates are present.» Wmen in Hennepin and Sctt cunties are nt accessing prenatal care at ptimal rates.» Amng lder students, alchl and drug abuse are prevalent.» Many students reprted having asthma and engaging in 11 r mre hurs f screen time per week. Cunty Health Rankings Cunty Health Rankings, a cllabrative prject between the Rbert Wd Jhnsn Fundatin and the University f Wiscnsin Ppulatin Health Institute, ranks each cunty within each state in terms f health factrs and health utcmes. The health utcmes measure is a cmpsite based n mrtality and mrbidity statistics. The health factrs measure is a cmpsite f several variables knwn t affect health utcmes: health behavirs, clinical care, scial and ecnmic factrs, and physical envirnment. Althugh the health factrs and health utcmes data measured in Cunty Health Rankings are nt specific t children, it is meaningful t assess the scial/familial, ecnmic, behaviral, and envirnmental cntext in which children live; ften children d nt have the agency t alter the factrs that affect their health and wellbeing. Cunty Health Rankings is updated annually. Cunty Health Rankings 2012 relies n data frm 2002 t 2010, with mst data riginating in 2006 t Cunty Health Rankings 2011 relies n 34

47 data frm 2001 t 2009, with mst data riginating in 2006 t In 2011, Cunty Health Rankings was able t rank 85 f Minnesta's 87 cunties. In 2012, Cunty Health Rankings ranked 84 cunties. Exhibits 30A and 30B prvide a summary analysis f the rankings fr the seven cunties in the cmmunity served by Children s. Rankings fr Minnesta were divided int quartiles t indicate hw each cunty ranks versus thers in the State. Exhibits 30A and 30B illustrate the quartile int which each area fell by indicatr in the 2012 editin, and als illustrates whether an area s ranking wrsened r imprved frm Fr example, in the 2012 editin, Anka Cunty was in the bttm half (63 rd ut f 84) f Minnesta cunties fr the verall rate f mrbidity; its ranking in 2012 fell fr this indicatr cmpared t the 2011 editin. 35

48 Exhibit 30A: Cunty-Level Health Status and Access Indicatrs Indicatr Anka Rank Change 2011 t 2012 Carver Rank Change 2011 t 2012 Dakta Rank Change 2011 t 2012 Health Outcmes 34 t 38 5 t 2 17 t 8 Mrtality 21 t 20 1 t 1 12 t 3 Mrbidity 61 t t t 39 Health Factrs 36 t 51 2 t 2 6 t 8 Health Behavirs 71 t 68 6 t 6 14 t 9 Tbacc Use 66 t t t 29 Diet and Exercise* N/A N/A N/A Alchl Use 23 t t t 7 Sexual Activity 58 t 57 6 t 6 46 t 54 Clinical Care 25 t 47 6 t 4 18 t 17 Access t Care 11 t 25 5 t 3 20 t 16 Quality f Care 55 t t t 26 Scial & Ecnmic Factrs 29 t 34 2 t 1 8 t 11 Educatin 46 t 47 5 t 5 7 t 11 Emplyment 50 t t t 34 Incme 7 t 9 2 t 1 4 t 6 Family and Scial Supprt 49 t 42 2 t 2 53 t 39 Cmmunity Safety 53 t t 6 35 t 27 Physical Envirnment 16 t t t 66 Envirnmental Quality 1 t 1 1 t 1 67 t 65 Built Envirnment* N/A N/A N/A Surce: Cunty Health Rankings, 2011 and *The 2012 editin f Cunty Health Rankings used different data surces fr the Diet and Exercise and Built Envirnment indicatrs than the 2011 editin. Therefre, it is nt pssible t draw cmparisns between years fr these indicatrs. Key 2012 Cunty Ranking Cunty Ranking Cunty Ranking 64-84/85** Ranks Nt Cmparable Between 2011 and 2012 N/A Rank Decreased frm 2011 t 2012 **In 2011, CHR was able t rank 85 f Minnesta's 87 cunties. In 2012, CHR ranked 84 cunties. 36

49 Exhibit 30B: Cunty-Level Health Status and Access Indicatrs Indicatr Hennepin Rank Change 2011 t 2012 Ramsey Rank Change 2011 t 2012 Sctt Rank Change 2011 t 2012 Washingtn Rank Change 2011 t 2012 Health Outcmes 48 t t 61 6 t t 7 Mrtality 39 t t t 12 9 t 7 Mrbidity 70 t t t t 32 Health Factrs 5 t t 69 6 t 5 3 t 3 Health Behavirs 1 t 4 15 t t 5 3 t 7 Tbacc Use 20 t t t t 33 Diet and Exercise* N/A N/A N/A N/A Alchl Use 10 t 9 7 t 6 13 t t 14 Sexual Activity 81 t t t t 20 Clinical Care 4 t 5 9 t t 21 2 t 2 Access t Care 4 t 7 7 t t 8 3 t 2 Quality f Care 20 t t t t 11 Scial & Ecnmic Factrs 59 t t 80 8 t 3 3 t 2 Educatin 30 t t 64 7 t 7 3 t 1 Emplyment 25 t t t t 28 Incme 41 t t 80 4 t 2 1 t 3 Family and Scial Supprt 72 t t t 3 16 t 17 Cmmunity Safety 82 t t t t 28 Physical Envirnment 6 t t t t 80 Envirnmental Quality 1 t 1 67 t t 1 83 t 82 Built Envirnment* N/A N/A N/A N/A Surce: Cunty Health Rankings 2011 and *The 2012 editin f Cunty Health Rankings used different data surces fr the Diet and Exercise and Built Envirnment indicatrs than the 2011 editin. Therefre, it is nt pssible t draw cmparisns between years fr these indicatrs. Key 2012 Cunty Ranking Cunty Ranking Cunty Ranking 64-84/85** Ranks Nt Cmparable Between 2011 and 2012 N/A Rank Decreased frm 2011 t 2012 **In 2011, CHR was able t rank 85 f Minnesta's 87 cunties. In 2012, CHR ranked 84 cunties. 37

50 Fr the Children s brader cmmunity, the indicatrs that mst frequently ranked in the bttm ne-half f Minnesta cunties include sexual activity8 and built envirnment. 9 Ramsey Cunty had the highest number f unfavrable indicatrs, ranking in the bttm nehalf f Minnesta areas n the fllwing: Mrtality, mrbidity, health factrs, tbacc use, sexual activity, 10 educatin, incme, family and scial supprt, cmmunity safety, 11 envirnmental quality, 12 and built envirnment. Cmmunity Health Status Indicatrs Prject The Cmmunity Health Status Indicatrs (CHSI) Prject, prvided by the U.S. Department f Health and Human Services, cmpares many health status and access indicatrs t bth the median rates in the U.S. and t rates in peer cunties acrss the U.S. Cunties are cnsidered peers if they share cmmn characteristics such as ppulatin size, pverty rate, average age, and ppulatin density. Exhibit 31 highlights the analysis f CHSI health status indicatrs. Cells in the table are shaded if, n that indicatr, a cunty cmpared unfavrably bth t the U.S. as a whle and t the grup f specified peer cmmunities. Althugh nt all f the data measured by CHSI are specific t children, the selected indicatrs may affect the health and wellbeing f children either directly r indirectly. 8 A cmpsite measure that examines the chlamydia rate per 100,000 ppulatin and the teen birth rate per 1,000 females ages 15 t A measure that examines the percent f the ppulatin withut easy access t fd, the number f fast fd restaurants, and the availability f recreatinal facilities. 10 A cmpsite measure that examines the chlamydia rate per 100,000 ppulatin and the teen birth rate per 1,000 females ages 15 t A measure that examines the vilent crime rate per 100,000 ppulatin. 12 A cmpsite measure that examines the number f air pllutin-particulate matter days and air pllutin-zne days. 38

51 Exhibit 31: Unfavrable Health Status Indicatrs Indicatr Anka Carver Dakta Hennepin Ramsey Sctt Washingtn Lw Birth Weight Infants Very Lw Birth Weight Infants Premature Births N Care in First Trimester Births t Wmen under 18 Births t Wmen age 40-54* Births t Unmarried Wmen Infant Mrtality Hispanic Infant Mrtality White nn Hispanic Infant Mrtality Black nn Hispanic Infant Mrtality Nenatal Infant Mrtality Pst-nenatal Infant Mrtality Hmicide Suicide Mtr Vehicle Injuries Unintentinal Injury Key Better than U.S 0%-50% wrse than U.S. 50% t 75% wrse than U.S. >75% wrse than U.S. Surce: The Cmmunity Health Status Indicatrs Prject, * The Cmmunity Health Status Indicatrs Prject cnsiders a high number f births t wmen age t be an unfavrable health utcme. Cautin shuld be used when interpreting this indicatr; wmen may be chsing t delay having children t pursue career r educatinal gals. Overall, the Children s brader cmmunity cmpared relatively favrably fr mst health indicatrs. Ramsey Cunty cmpared unfavrably n three indicatrs, fllwed by Dakta Cunty with tw. Births t wmen age cmpared unfavrably in five f seven areas. Minnesta Department f Health The Minnesta Department f Health (MDH) maintains a publicly-available data warehuse that includes indicatrs regarding a number f health issues. Exhibits prvide infrmatin n pediatric injury mrtality rates, mtr vehicle safety indicatrs, the ptential life lst due t leading causes f death, mrbidity rates f varius reprtable diseases, vaccinatin rates, and maternal and child health indicatrs. In 2010, unintentinal injury and perinatal cnditins were the leading causes f death fr yuth in the state and in the cmmunity served by Children s. Exhibit 32 reprts injury mrtalities fr residents yunger than age 20 by cunty in Washingtn Cunty reprted a higher prprtin f pediatric injury mrtality than the state average fr three injury types. Anka, Hennepin, and Ramsey cunties reprted higher prprtins f pediatric injury mrtality than Minnesta fr tw injury types. In the brader cmmunity, the majrity f injury deaths were due t unintentinal injury r suicide. 42

52 Exhibit 32: Pediatric Injury Mrtality by Cause in the Brader Cmmunity, 2010 Injury Mrtalities Ages 0-19 Injury Type Anka Carver Dakta Hennepin Ramsey Sctt Washingtn Minnesta Number f Injury Mrtalities Unintentinal Hmicide Suicide Falls Mtr Pedestrian Percent f Injury Mrtalities Unintentinal 47.8% 20.0% 57.1% 52.2% 27.8% 20.0% 22.2% 47.8% Hmicide 4.3% 0.0% 0.0% 23.9% 38.9% 0.0% 11.1% 10.5% Suicide 21.7% 60.0% 7.1% 13.0% 27.8% 60.0% 55.6% 16.3% Falls 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.7% Mtr 17.4% 20.0% 28.6% 8.7% 0.0% 20.0% 0.0% 21.4% Pedestrian 8.7% 0.0% 7.1% 2.2% 5.6% 0.0% 11.1% 3.3% Surce: Minnesta Department f Health, Exhibit 33 demnstrates the prevalence f teen car ccupant fatalities by cunty. Carver, Dakta, Ramsey, and Washingtn cunties all reprted higher percentages f teen vehicle ccupant fatalities than the state average. Carver, Ramsey, and Washingtn cunties reprted a higher prevalence f teen fatalities in which the teen was nt wearing a seat belt than the Minnesta average. Exhibit 33: Mtr Vehicle Safety Indicatrs in the Brader Cmmunity, 2011 Ttal Mtr Vehicle Fatalities Ttal Vehicle Occupant Fatalities Teen Vehicle Occupant Fatalities Percent f Ttal Vehicle Occupant Fatalities Teen Unbelted Vehicle Occupant Fatalities Percent f Ttal Vehicle Occupant Fatalities Cunty Anka % 0.0% Carver % 20.0% Dakta % 0.0% Hennepin % 3.7% Ramsey % 20.0% Sctt % 0.0% Washingtn % 33.3% Minnesta % 8.9% Surce: Minnesta Department f Public Safety, Office f Traffic Safety, June Years f ptential life lst (YPLL) is a measure f premature death calculated by subtracting the age f death frm a standard life expectancy estimate (a cnservative estimate f age 65 was used in this analysis). Exhibit 34 examines the years f ptential life lst (YPLL) by cause f death in the brader cmmunity. Cancer, unintentinal injury, suicide, heart disease, and perinatal cnditins cst the cmmunity the mst years f life. 43

53 Exhibit 34: Years f Ptential Life Lst by Cause in the Brader Cmmunity, ,000 14,988 14,000 12,000 11,815 10,000 8,000 7,030 6,568 6,000 4,000 4,545 4,498 2,630 2,000 1,585 1,560 1,480 1, Surce: Minnesta Department f Health, Years f Ptential Life Lst (Adjusted t Age 65) Exhibit 35 examines disease mrbidity rates by cunty and cmpares them t the state average. Ramsey Cunty cmpared unfavrably t the state average in eight f the twelve diseases fllwed by Hennepin Cunty with six. Bth cunties exhibited high rates f sexually transmitted diseases. 44

54 Exhibit 35: Reprted Disease Mrbidity in the Brader Cmmunity, 2010 Rates per 100,000 ppulatin Disease Anka Carver Dakta Hennepin Ramsey Sctt Washingtn Minnesta Pertussis N/A Campylbacterisis N/A N/A Giardiasis N/A N/A Lyme Disease 32.9 N/A N/A Human Anaplasmsis N/A N/A N/A N/A 13.6 Salmnellsis N/A N/A Shigellsis17 N/A N/A N/A 2.5 N/A N/A N/A 1.2 Tuberculsis 0.9 N/A N/A N/A N/A 2.5 Chlamydia Gnrrhea 26.3 N/A N/A Syphilis - All Stages 6.0 N/A N/A N/A N/A 6.5 HIV N/A N/A N/A N/A N/A 6.2 Key Better than MN 0%-50% wrse than MN 50% t 75% wrse than MN >75% wrse than MN Surces: Minnesta Department f Health, *Certain rates are nt reprted due t insufficient sample size. Rates were calculated using U.S. Census 2010 demgraphic estimates. Exhibit 36 displays the percent f children between the ages f tw and three wh have received a series f age-apprpriate vaccinatins by cunty in the Children s service area. Every cunty reprted lwer rates f Hepatitis B vaccinatin than the state average. Ramsey reprted the smallest percentage children wh had received their cmplete series f vaccine dses at 47.5 percent; Carver reprted the greatest percentage at 60.5 percent. 13 Diarrheal illness caused by bacteria, ften fd-brne. 14 Parasitic disease affecting the digestive tract. 15 Tick-brne disease. 16 Infectin caused by the bacteria salmnella. 17 Fecal-rally transmitted bacterial infectin f the intestines. 45

55 Exhibit 36: Children Aged Mnths* With Recmmended Vaccinatins in the Brader Cmmunity, 2011 MIIC Immunizatins** Anka Carver Dakta Hennepin Ramsey Sctt Washingtn Minnesta DTaP % 79.7% 71.5% 71.5% 63.3% 76.3% 69.2% 72.0% Pli 82.8% 89.0% 84.5% 84.2% 77.4% 87.7% 80.0% 85.6% MMR % 88.8% 84.9% 83.7% 83.1% 87.7% 88.4% 86.0% Hib % 85.2% 80.7% 78.0% 74.7% 84.0% 80.4% 79.7% Hepatitis B 79.1% 79.5% 77.2% 75.7% 73.3% 75.7% 75.6% 79.6% Varicella 84.8% 87.0% 83.6% 83.3% 81.2% 86.5% 86.8% 84.3% Pneumcccal 78.8% 87.1% 78.8% 78.0% 72.6% 83.3% 77.3% 80.0% Rtavirus 68.1% 75.0% 68.0% 65.7% 58.1% 75.8% 65.7% 64.6% Hepatitis A 59.9% 52.1% 58.8% 53.5% 52.2% 60.3% 61.0% 51.8% Cmplete Vaccine Series Dses % 60.5% 53.6% 52.3% 47.5% 56.9% 54.5% 55.7% M Ppulatin with 2+ Shts in MIIC 4,443 1,150 5,369 15,977 7,533 2,025 2,987 70,453 Surce: Minnesta Department f Health, 2011 **Children that were brn July 2008 thrugh June Analyzed August * Data present immunizatins amng children aged mnths with 2 r mre nn-influenza shts in the Minnesta Immunizatin Infrmatin Cnnectin (MIIC) registry. MIIC percentages are affected by prvider participatin in the vluntary registry, management f children wh have mved r gne elsewhere, and brder-state data exchange, which is currently limited t Wiscnsin. Percentages are likely lwer than the actual percent f children receiving the vaccinatins due t these limitatins Exhibit 37 displays infant mrtality by race and ethnicity in the brader cmmunity. Rates were nt age-adjusted; rates als were nt calculated if they represented fewer than 20 mrtalities. Ramsey Cunty reprted rates f infant mrtality fr Blacks, Asians, and Pacific Islanders which were greater than the Minnesta average. The entire cmmunity reprted infant mrtality incidence belw the state s average rate. Exhibit 37: Infant Mrtality Rates by Race and Ethnicity in the Brader Cmmunity, Racial and Ethnic Chrt Anka Carver Dakta Hennepin Ramsey Sctt Washingtn Minnesta White 11.3 N/A N/A Black N/A N/A N/A N/A N/A 65.2 American Indian N/A N/A N/A N/A N/A N/A N/A 65.9 Asian/Pacific Islander N/A N/A N/A N/A N/A 27.6 Other/Unknwn N/A N/A N/A 26.9 N/A N/A N/A 31.1 Hispanic r Latin* N/A N/A N/A 24.3 N/A N/A N/A 38.7 Ttal Ppulatin 12.3 N Surce: Minnesta Department f Health, 2010 Health Statistics Annual Summary, and U.S. Census. *Hispanic r Latin ethnicity is reprted separately frm race. Persns f Hispanic r Latin rigin may be frm any racial grup. Rates are per 100,000 ppulatin. 18 Diphtheria, tetanus, and pertussis. 19 Measles, mumps, and rubella. 20 Haemphilus influenzae type b. 21 Children with all DTaP, Pli, MMR, Hib, HepB, Varicella, and PCV dses. 46

56 Exhibit 38 displays each cunty s teen pregnancy rate, brken ut int age chrts. Hennepin and Ramsey cunties reprted higher rates f teen pregnancy between the ages f 15 and 17 than the Minnesta average. Anka, Hennepin, and Ramsey cunties reprted higher rates f teen pregnancy between the ages f 18 and 19 than the state average. Exhibit 38: Teen Pregnancy Rates in the Brader Cmmunity, Rates per 100,000 Teens Age Chrt Anka Carver Dakta Hennepin Ramsey Sctt Washingtn Minnesta Ttal (15-19) Key Better than MN 0-50% wrse than MN 50-75% wrse than MN Greater than 75% wrse than MN Surce: Minnesta Department f Health and the U.S. Census, Exhibits 39A and 39B examine health indicatrs fr children and mthers in the brader cmmunity. Ramsey Cunty reprted three indicatrs whse incidence was mre than 50 percent wrse than Minnesta s average. Exhibit 39A: Selected Maternal and Child Health Indicatrs in the Brader Cmmunity, 2010 Indicatr Anka Carver Dakta Hennepin Minnesta Births t Unmarried Mthers 30.9% 15.0% 28.0% 33.7% 33.1% Births with N Father n Birth Certificate 7.1% 4.0% 8.1% 10.5% 9.3% Mthers Smked during Pregnancy 9.4% 3.1% 6.4% 5.1% 10.0% Preterm Births 8.3% 6.4% 7.0% 8.2% 8.1% Lw Weight Births 4.4% 4.4% 4.4% 5.4% 4.8% Very Lw Birth Weight Births, % 0.8% 0.8% 1.0% 0.8% Prenatal Care Received in 1st Trimester 87.0% 93.0% 85.9% 86.7% 86.3% *Adequate r Better Prenatal Care 81.0% 86.7% 80.7% 81.4% 80.0% *Intermediate Prenatal Care 15.9% 12.2% 16.6% 15.5% 16.9% *Inadequate r N Prenatal Care 3.1% 1.2% 2.7% 3.0% 3.1% Surce: Minnesta Department f Health, * GINDEX: A prenatal care index determined by cmbining measures f the mnth r trimester prenatal care began, the number f prenatal visits, and the gestatinal age f the infant/fetus at the time f birth. Adequacy f prenatal care is determined by cmbining measures f the mnth r trimester prenatal care began, the number f prenatal visits and the gestatinal age f the fetus at the time f birth. The GINDEX includes gestatinal age f ver 36 weeks and the number f prenatal visits exceeding nine t impute adequacy f prenatal care. Adequate r Better: Prenatal care started in the 1st trimester and the wman had an adequate number f visits. Intermediate: Prenatal care started in the 1st r 2nd trimester and the wman had an intermediate range f visits. Inadequate r Nne: N prenatal care r the prenatal care started in the 3rd trimester r the wman had an inadequate range f visits, regardless f when prenatal care began. Key Better than MN 0-50% wrse than MN 50-75% wrse than MN Greater than 75% wrse than MN 47

57 Exhibit 39B: Selected Maternal and Child Health Indicatrs in the Brader Cmmunity, 2010 Indicatr Ramsey Sctt Washingtn Minnesta Births t Unmarried Mthers 44.4% 19.6% 24.0% 33.1% Births with N Father n Birth Certificate 15.4% 5.0% 6.5% 9.3% Mthers Smked during Pregnancy 9.6% 4.1% 7.4% 10.0% Preterm Births 8.9% 7.0% 8.0% 8.1% Lw Weight Births 5.8% 3.7% 4.6% 4.8% Very Lw Birth Weight Births, % 0.6% 0.7% 0.8% Prenatal Care Received in 1st Trimester 76.4% 89.5% 91.4% 86.3% *Adequate r Better Prenatal Care 69.2% 74.6% 86.7% 80.0% *Intermediate Prenatal Care 26.1% 22.0% 12.2% 16.9% *Inadequate r N Prenatal Care 4.7% 3.4% 1.1% 3.1% Surce: Minnesta Department f Health, * GINDEX: A prenatal care index determined by cmbining measures f the mnth r trimester prenatal care began, the number f prenatal visits, and the gestatinal age f the infant/fetus at the time f birth. Adequacy f prenatal care is determined by cmbining measures f the mnth r trimester prenatal care began, the number f prenatal visits and the gestatinal age f the fetus at the time f birth. The GINDEX includes gestatinal age f ver 36 weeks and the number f prenatal visits exceeding nine t impute adequacy f prenatal care. Adequate r Better: Prenatal care started in the 1st trimester and the wman had an adequate number f visits. Intermediate: Prenatal care started in the 1st r 2nd trimester and the wman had an intermediate range f visits. Inadequate r Nne: N prenatal care r the prenatal care started in the 3rd trimester r the wman had an inadequate range f visits, regardless f when prenatal care began. Key Better than MN 0-50% wrse than MN 50-75% wrse than MN Greater than 75% wrse than MN The Wmen, Infants and Children s (WIC) prgram, administered by the U.S. Department f Agriculture, prvides assistance fr families at r belw 185 percent f pverty. Exhibit 40 presents besity and breastfeeding data gathered frm Minnesta WIC participants. Of Ramsey Cunty WIC participants, almst 66.5 percent f children ages 2 thrugh 5 had ever been breastfed cmpared t 73.7 percent in Minnesta and 80.3 percent in Dakta Cunty. Hennepin and Ramsey cunties als had higher percentages f bese children than the Minnesta average. 48

58 Exhibit 40: Minnesta Wmen, Infants and Children (WIC) Selected Indicatrs frm CDC s Pediatric and Pregnancy Nutritin Surveillance System in the Brader Cmmunity, * Children 2-5 years Wmen (Prepregnancy) Cunty 2010 WIC Participants** Overweight Obese Ever Breastfed Overweight r Obese Anka 10, % 11.5% 71.2% 52.3% Carver 1, % 9.3% 78.9% 53.4% Dakta 10, % 12.9% 80.3% 53.4% Hennepin 47, % 14.2% 77.3% 54.1% Ramsey 31, % 14.6% 66.5% 50.8% Sctt 3, % 11.8% 79.9% 52.4% Washingtn 5, % 10.8% 77.2% 52.6% Minnesta 230, % 13.1% 73.7% 54.2% Surce: Pediatric Nutritin Surveillance System and Pregnancy Nutritin Surveillance System via Minnesta Department f Health, *WIC participants are nt a representative sample f the ttal ppulatin **The ttal number f pregnant, pst-partum and nursing wmen, infants and children less than 5 years f age wh received WIC vuchers. Cunty level data are determined by cmbining unduplicated participants f all clinics within a cunty's bundaries. State ttal des nt equal the sum f the cunties because participants may mve cunties during the year. Minnesta Student Survey A survey f students in 6 th, 9 th, and 12 th grades, administered by the Minnesta Department f Educatin, gathers data n demgraphics, family and relatinships, health status issues, mental health indicatrs, and varius health risk behavirs including substance abuse, diet and exercise, and sexual activity. Eighty-eight percent f the schl districts in the state participated in the 2010 survey. Exhibits 41A-41C cmpare varius indicatrs fr the seven cunties in the cmmunity served by Children s t state averages at each grade level. Indicatrs are shaded light grey if they are 0-25 percent wrse than the state, medium grey if percent wrse, and dark grey if greater than 50 percent wrse than Minnesta. On average, students frm Anka and Ramsey cunties reprted the greatest number f unfavrable indicatrs. Fur indicatrs were greater than 50 percent wrse than the Minnesta average; the percent f 9 th and 12 th grade students in Ramsey Cunty eligible fr free and reduced-price lunch and the percent f 9 th grade students in Anka Cunty and 12 th grade students in Sctt Cunty that reprted using drugs ther than marijuana in the past mnth. Reprted drug use fr lder students was cmparatively high acrss several cunties. Amng 6 th grade students, screen time and asthma were issues in fur r mre cunties. These issues carry ver int 9 th and 12 th grade as well. Mental and behaviral health prblems as well as drug use becme mre prevalent in lder age grups. In 12 th grade, binge drinking and dmestic physical abuse cmpared unfavrably t Minnesta in five f the seven cunties. 49

59 Exhibit 41A: 6 th Grade Indicatrs and Variatin frm Minnesta, 2010 Categry Indicatr Anka Carver Dakta Hennepin Ramsay Sctt Washingtn Minnesta Participants Ttal Participants(N) 3,745 1,006 4,733 8,383 3,904 1,430 2,359 46,7 Access t Care Physical Exam in Past Year 64.5% 61.0% 62.5% 66.5% 61.0% 60.0% 57.0% 58.0 Health Behavirs 11+ Hurs TV Time per Week 20.0% 18.5% 17.0% 16.5% 16.5% 13.5% 15.0% Hurs Vide Game Time Per Week 12.5% 8.5% 11.0% 14.0% 11.5% 8.5% 9.0% Hurs Internet Time per Week 11.0% 7.5% 9.5% 10.0% 10.5% 8.0% 8.0% 9.0 Exercise 30 Minutes 5+ Days Per Week 40.0% 56.0% 49.0% 46.0% 43.0% 54.0% 52.5% Servings f Fruits and Vegetables Yesterday 37.5% 39.5% 40.0% 42.5% 39.0% 35.0% 42.5% 39.0 Always Wear Seatbelt 73.0% 77.0% 75.0% 75.0% 71.0% 74.5% 76.0% 72.0 Tbacc Use in Past Mnth 2.5% 1.0% 1.5% 2.5% 3.0% 1.0% 2.0% 2.5 Binge Drinking in Past Year* 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0 Alchl Use in Past Year 9.0% 5.0% 6.0% 7.5% 8.5% 4.5% 8.0% 8.0 Driving While Impaired in Past Year N/A N/A N/A N/A N/A N/A N/A N/A Ever Ride With Impaired Driver N/A N/A N/A N/A N/A N/A N/A N/A Marijuana Use in Past Mnth 1.0% 0.0% 0.0% 1.0% 1.0% 0.0% 0.5% 1.0 Use f Drugs Other Than Marijuana in Past Mnth 1.0% 1.0% 0.5% 1.0% 1.0% 0.5% 1.0% 1.0 % Ever Had Sex N/A N/A N/A N/A N/A N/A N/A N/A % D Nt "Always" Use Any Birth Cntrl Methd N/A N/A N/A N/A N/A N/A N/A N/A Health Asthma 16.0% 16.0% 15.5% 17.5% 17.0% 13.5% 14.0% 15.0 Status Overweight r Obese N/A N/A N/A N/A N/A N/A N/A N/A % Mental/Emtinal Prblem Lasting 12+ Mnths 8.5% 5.5% 7.0% 7.0% 7.5% 6.5% 7.0% 7.5 Mental and Often Unhappy, Depressed, r Tearful 7.0% 6.0% 6.0% 7.5% 9.0% 7.5% 6.5% 8.0 % Behaviral Depressin** 11.0% 6.5% 10.0% 12.0% 13.0% 10.5% 10.5% 11.5 % Health Ever Hurt Oneself On Purpse 14.5% 9.0% 11.5% 13.5% 15.5% 10.0% 13.0% 13.0 % Attempted Suicide 3.5% 1.0% 3.0% 4.5% 4.5% 2.5% 3.5% 3.5 % Free r Reduced Lunch 30.0% 22.5% 26.5% 35.0% 47.5% 22.5% 20.0% 32.5 % Scial and Feel Safe in Neighbrhd 92.0% 96.0% 92.5% 90.5% 92.5% 94.5% 84.0% 91.0 % Ecnmic Bullied in Last Mnth 49.5% 52.0% 52.5% 52.5% 50.5% 55.0% 53.5% 53.5 % Factrs Suffered Dmestic Physical Abuse 13.0% 9.0% 12.0% 12.0% 14.0% 11.0% 12.0% 12.0 % Suffered Sexual Abuse 4.5% 3.0% 3.5% 4.0% 4.0% 3.5% 4.0% 4.0 % Surce: Minnesta Department f Health, % *Typically drank 5 r mre drinks at a time and drank n 10 r mre ccasins during the past year ** In last 30 days have yu felt s discuraged r hpeless that yu wndered if anything was wrthwhile? 50

60 Exhibit 41B: 9 th Grade Indicatrs and Variatin frm Minnesta, 2010 Categry Indicatr Anka Carver Dakta Hennepin Ramsay Sctt Washingtn Minnesta Participants Ttal Participants (N) 3,698 1,056 4,541 8,466 4,401 1,415 2,478 47,3 Access t Care Physical Exam in Past Year 55.5% 56.5% 56.0% 63.0% 57.0% 50.0% 48.0% 49.5 Health Behavirs Health Status Mental and Behaviral Health Scial and Ecnmic Factrs 11+ Hurs TV Time per Week 21.0% 20.0% 20.0% 19.0% 19.5% 18.5% 20.0% Hurs Vide Game Time Per Week 15.0% 11.5% 13.5% 17.0% 11.5% 14.0% 13.0% Hurs Internet Time per Week 16.5% 14.0% 14.5% 16.0% 17.0% 16.0% 15.5% 15.5 Exercise 30 Minutes 5+ Days Per Week 51.0% 61.0% 56.0% 56.0% 47.5% 62.0% 59.0% Servings f Fruits and Vegetables Yesterday 32.0% 42.5% 38.5% 38.5% 34.5% 34.0% 36.5% 36.0 Always Wear Seatbelt 68.0% 65.5% 71.0% 70.5% 65.5% 66.5% 71.0% 65.5 Tbacc Use in Past Mnth 13.5% 11.5% 11.5% 9.5% 13.5% 13.0% 12.5% 13.0 Binge Drinking in Past Year* 2.5% 2.5% 2.0% 2.0% 3.0% 3.5% 2.5% 2.5 Alchl Use in Past Year 33.5% 26.5% 30.0% 26.5% 32.5% 34.5% 33.5% 33.0 Driving While Impaired in Past Year 3.5% 2.5% 3.0% 2.0% 5.0% 3.5% 3.5% 4.0 Ever Ride With Impaired Driver 18.0% 14.0% 13.5% 14.0% 18.0% 18.5% 14.5% 16.5 Marijuana Use in Past Mnth 11.0% 10.0% 9.0% 10.5% 13.5% 11.5% 10.0% 10.0 % Use f Drugs Other Than Marijuana in Past Mnth 6.0% 5.0% 3.5% 3.5% 4.0% 4.0% 4.0% 3.5 % Ever Had Sex 21.5% 16.5% 17.5% 19.0% 21.5% 18.5% 18.0% 20.0 % D Nt "Always" Use Any Birth Cntrl Methd Asthma 68.0% 19.0% 66.0% 19.0% 62.5% 17.5% 61.5% 20.0% 64.5% 17.5% 60.5% 18.0% 60.5% 18.5% 63.5 % 17.5 % Overweight r Obese 23.5% 17.5% 19.0% 20.0% 24.5% 21.5% 17.5% 22.0 % Mental/Emtinal Prblem Lasting 12+ Mnths 11.5% 9.0% 11.0% 9.5% 11.5% 11.5% 10.0% 10.5 % Often Unhappy, Depressed, r Tearful 9.0% 6.0% 7.5% 7.5% 9.5% 8.0% 6.0% 8.0 % Depressin** 15.5% 10.5% 13.5% 13.5% 15.0% 13.0% 12.0% 13.5 % Ever Hurt Oneself On Purpse 19.0% 14.5% 18.5% 15.5% 19.5% 19.0% 15.5% 17.5 % Attempted Suicide 7.0% 5.5% 6.5% 5.5% 7.5% 6.0% 5.5% 6.5 % Free r Reduced Lunch 27.0% 13.5% 19.5% 29.5% 43.5% 16.0% 13.0% 27.5 % Feel Safe in Neighbrhd 93.0% 97.5% 95.0% 93.0% 91.0% 92.5% 87.5% 93.5 % Bullied in Last Mnth 35.0% 42.0% 37.0% 33.5% 35.0% 40.0% 32.5% 38.0 % Suffered Dmestic Physical Abuse 11.5% 9.5% 10.0% 10.0% 12.0% 9.0% 8.5% 10.0 % Suffered Sexual Abuse 6.5% 4.0% 5.0% 5.0% 5.5% 5.0% 4.0% 5.5 % Surce: Minnesta Department f Health, *Typically drank 5 r mre drinks at a time and drank n 10 r mre ccasins during the past year ** In last 30 days have yu felt s discuraged r hpeless that yu wndered if anything was wrthwhile? % 51

61 Exhibit 41C: 12 th Grade Indicatrs and Variatin frm Minnesta, 2010 Categry Indicatr Anka Carver Dakta Hennepin Ramsay Sctt Washingtn Minnesta Participants Ttal Participants(N) 2, ,541 7,088 3, ,714 36,7 Access t Care Physical Exam in Past Year 48.5% 46.5% 50.5% 54.5% 50.0% 45.0% 45.0% 46.0 Health Behavirs Health Status Mental and Behaviral Health Scial and Ecnmic Factrs 11+ Hurs TV Time per Week 18.5% 17.5% 18.0% 18.0% 17.5% 18.5% 14.5% Hurs Vide Game Time Per Week 11.5% 9.0% 10.0% 14.5% 10.0% 11.0% 10.5% Hurs Internet Time per Week 15.0% 17.0% 14.0% 15.5% 16.5% 13.5% 13.5% 14.5 Exercise 30 Minutes 5+ Days Per Week 38.5% 43.0% 46.5% 42.5% 41.5% 44.0% 48.5% Servings f Fruits and Vegetables Yesterday 32.0% 41.5% 36.5% 38.5% 35.0% 34.0% 38.0% 34.5 Always Wear Seatbelt 73.5% 71.0% 74.5% 77.0% 74.5% 70.0% 78.0% 69.0 Tbacc Use in Past Mnth 29.0% 36.5% 33.0% 27.0% 28.0% 36.0% 30.0% 31.5 Binge Drinking in Past Year** 11.0% 16.5% 14.5% 12.0% 10.0% 16.0% 14.5% 13.5 Alchl Use in Past Year 52.0% 54.0% 59.0% 54.0% 52.0% 61.5% 59.0% 56.5 Driving While Impaired in Past Year 17.0% 21.0% 19.5% 17.0% 17.0% 19.0% 18.5% 18.5 Ever Ride With Impaired Driver 29.5% 33.5% 35.0% 33.0% 34.0% 33.0% 33.5% 33.0 Marijuana Use in Past Mnth 21.0% 20.5% 23.5% 24.0% 21.0% 22.5% 23.0% 21.0 % Use f Drugs Other Than Marijuana in Past Mnth 7.0% 5.5% 7.5% 6.0% 7.5% 9.5% 5.5% 5.5 % Ever Had Sex 49.5% 46.5% 52.0% 46.0% 47.0% 50.0% 42.0% 50.5 % D Nt "Always" Use Any Birth Cntrl Methd Asthma 39.0% 18.5% 39.0% 20.0% 38.5% 19.0% 37.5% 21.0% 42.5% 17.0% 37.5% 16.0% 30.0% 19.0% 38.5 % 18.0 % Overweight r Obese 22.0% 15.5% 19.5% 19.0% 22.0% 20.5% 17.0% 21.0 % Mental/Emtinal Prblem Lasting 12+ Mnths 13.0% 11.0% 13.0% 11.5% 11.5% 12.0% 11.0% 11.5 % Often Unhappy, Depressed, r Tearful 6.0% 5.5% 5.0% 6.5% 6.5% 6.0% 4.5% 6.0 % Depressin* 13.0% 10.5% 11.0% 12.5% 14.0% 12.0% 9.0% 11.0 % Ever Hurt Oneself On Purpse 19.0% 14.5% 17.5% 15.5% 17.0% 20.0% 13.5% 17.5 % Attempted Suicide 7.5% 6.5% 6.5% 7.0% 7.0% 7.5% 6.0% 7.5 % Free r Reduced Lunch 21.5% 12.0% 13.5% 25.5% 36.0% 13.5% 9.5% 22.5 % Feel Safe in Neighbrhd 94.5% 95.5% 95.5% 93.5% 92.0% 94.0% 92.0% 95.0 % Bullied in Last Mnth 25.0% 27.5% 26.0% 23.5% 26.0% 30.5% 23.0% 25.0 % Suffered Dmestic Physical Abuse 9.0% 6.5% 8.5% 7.5% 9.5% 8.5% 8.5% 8.0 % Suffered Sexual Abuse 6.0% 5.5% 4.5% 5.0% 6.5% 6.0% 4.0% 5.5 % Surce: Minnesta Department f Health, *Typically drank 5 r mre drinks at a time and drank n 10 r mre ccasins during the past year ** In last 30 days have yu felt s discuraged r hpeless that yu wndered if anything was wrthwhile? % 52

62 Minnesta Department f Human Services Exhibits 42, 43, and 44 relate data frm the Minnesta Department f Human Services yearly child welfare reprt. Exhibit 42 shws the child maltreatment rate by cunty in The chart als shws the percent f child maltreatment cases in 2011 which recurred frm Hennepin and Ramsey cunties bth reprted higher rates f child maltreatment than the Minnesta average. Hennepin, Washingtn, and Carver cunties had higher percent recurrence f maltreatment in their ppulatins than the state average. Exhibit 42: Cnfirmed Child Maltreatment Rates in the Brader Cmmunity, 2011 Cunty Maltreatment Rate per 1,000 Children Percent f Maltreatment Cases Which Recurred in 12 Mnths Anka % Carver % Dakta % Hennepin % Ramsey % Sctt % Washingtn % Minnesta % Surce: Minnesta Department f Human Services 2011 Minnesta Child Welfare Reprt, Exhibit 43 demnstrates the rate f abuse per type in each cunty. A child may have been abused in multiple ways, which wuld result in each abuse being recrded separately in the chart. Hennepin Cunty reprted higher rates f nn-medical neglect and sexual abuse than the Minnesta average; Ramsey Cunty reprted higher rates f nn-medical neglect and physical abuse. Exhibit 43: Cnfirmed Child Maltreatment Rates by Type in the Brader Cmmunity, 2011 Rates per 1,000 Children Maltreatment Type Anka Carver Dakta Hennepin Ramsey Sctt Washingtn Minnesta Neglect (nnmedical) Physical abuse Sexual abuse Mental injury Medical neglect Ttal Surce: Minnesta Department f Human Services 2011 Minnesta Child Welfare Reprt and U.S. Census Bureau: American Cmmunity Survey 5 Year Estimates , Exhibit 44 displays the rate f children in ut-f-hme care by race in each lcality. Native American children experienced the greatest rate f ut-f-hme care in six f seven cunties. White children were the least likely t live in ut-f-hme care. Hennepin and Ramsey cunties had the greatest rates f children nt living at hme, and their rates were abve Minnesta s average. 53

63 Exhibit 44: Children in Out-Of-Hme Care by Race and Ethnicity in the Brader Cmmunity, 2011 Racial/Ethnic Rates per 1,000 Children Chrt Anka Carver Dakta Hennepin Ramsey Sctt Washingtn Minnesta Black Native American Asian/Pacific Islander White Tw r Mre Races Hispanic r Latin* Ttal Surce: Minnesta Department f Human Services 2012 Minnesta Child Welfare Reprt and U.S. Census Bureau: American Cmmunity Survey 5 Year Estimates , * Hispanic r Latin ethnicity is reprted separately frm race. Persns f Hispanic r Latin rigin may be frm any racial grup. 54

64 Ambulatry care sensitive cnditins This sectin examines the frequency f discharges fr ACSC thrughut the cmmunity and at the hspital. Key insights: Ambulatry Care Sensitive Cnditins» ACSCs are cnditins which might have been prevented if the patient had accessed primary care at ptimal rates. Uninsured patients have higher levels f these discharges. High numbers f ACSC discharges may indicate the lack f access t r utilizatin f primary care services.» Asthma, urinary tract infectin, perfrated appendix, and diabetes shrt-term cmplicatins are the mst frequent discharges fr ACSC frm Children s. The methdlgies fr quantifying discharges fr ACSC have been well-tested fr mre than a decade. The methdlgies quantify inpatient admissins fr diabetes, perfrated appendixes, chrnic bstructive pulmnary disease (COPD), hypertensin, cngestive heart failure, dehydratin, bacterial pneumnia, urinary tract infectin, asthma, and ther cnditins that, in thery, culd have been prevented if adequate ambulatry (primary) care resurces were available and accessed by thse patients.22 Disprprtinately large numbers f discharges fr ACSC indicate ptential prblems with the availability r accessibility f ambulatry care services. The Agency fr Healthcare Research and Quality (AHRQ), part f the U.S. Department f Health and Human Services, publishes sftware and methdlgies fr assessing discharges fr ACSC. The AHRQ sftware was applied t analyze the prevalence f discharges fr ACSC in gegraphic areas served by Children s. The ACSC analysis prvides a single indicatr f ptential health prblems - allwing cmparisns t be made reliably acrss gegraphic areas and hspital facilities. This analysis als allws demnstrating a pssible return n investment frm interventins that reduce admissins (fr example, fr uninsured r Medicaid patients) thrugh better access t ambulatry care resurces. 22 See: fr mre infrmatin n this methdlgy. 55

65 Cunty-level analysis Disprprtinately large numbers f discharges fr ACSC indicate ptential prblems with the availability r accessibility f ambulatry (primary) care services. Exhibit 45 indicates hw many hspital discharges frm the seven cunties in the Children s brader cmmunity were fund t be fr ACSCs by payer and by area. Exhibit 45: Children s Discharges fr ACSC in the Brader Cmmunity by Payer, 2011 Cunty Medicare* Private Cmmercial/Self-Pay* Medicaid/PMAP Other* Ttal Anka 100.0% 7.1% 0.0% 7.4% 14.3% 7.3% Carver 0.0% 5.7% 0.0% 5.8% 0.0% 5.4% Dakta 0.0% 6.7% 16.7% 8.0% 25.0% 7.5% Hennepin 0.0% 7.8% 12.5% 9.9% 5.6% 8.9% Ramsey 0.0% 6.0% 9.1% 9.8% 0.0% 8.2% Sctt 0.0% 3.7% 0.0% 6.1% 0.0% 4.3% Washingtn 0.0% 6.3% 16.7% 7.3% 25.0% 6.9% Ttal 5.9% 6.9% 10.5% 9.2% 12.7% 8.0% Surce: Verité analysis f data frm Children s, using AHRQ sftware, *Cautin shuld be used when interpreting these data due t small sample size (less than 20 ttal discharges). The table indicates that in 2011, 8.0 percent f discharges were fr ACSCs. Patients frm the ther payer grup (neither private, self-pay, Medicaid, Medicare, nr PMAP) had the highest prprtin f discharges fr ACSC, fllwed by cmmercial/self-pay patients. Hspital-level analysis In 2011, 6.9 percent f Children s ttal discharges were fr ACSCs. Exhibit 46 indicates that Children s discharges fr ACSC were mst cncentrated in fur cnditins: asthma, urinary tract infectin, perfrated appendix, and diabetes shrt-term cmplicatins. 56

66 Exhibit 46: Discharges fr ACSC by Cnditin, 2011 Cnditin Grand Ttal Pediatric asthma 41.8% 32.3% 19.5% 6.4% 0.0% 359 Pediatric urinary tract infectin 54.0% 27.0% 10.9% 8.0% 0.0% 174 Pediatric perfrated appendix 18.2% 31.1% 41.7% 9.1% 0.0% 132 Pediatric diabetes shrt-term cmplicatins 0.0% 17.9% 54.7% 27.4% 0.0% 106 Pediatric gastrenteritis 73.5% 23.5% 2.9% 0.0% 0.0% 34 Dehydratin 0.0% 0.0% 0.0% 0.0% 100.0% 10 Bacterial pneumnia 0.0% 0.0% 0.0% 0.0% 100.0% 9 Urinary tract infectin 0.0% 0.0% 0.0% 0.0% 100.0% 4 Hspital acquired vascular catheter related infectins 0.0% 0.0% 0.0% 0.0% 100.0% 3 Uncntrlled diabetes 0.0% 0.0% 0.0% 0.0% 100.0% 2 Accidental puncture r laceratin 0.0% 0.0% 0.0% 0.0% 100.0% 1 Asthma in yunger adults 0.0% 0.0% 0.0% 0.0% 100.0% 1 Cngestive heart failure 0.0% 0.0% 0.0% 0.0% 100.0% 1 Diabetes lng-term cmplicatin 0.0% 0.0% 0.0% 0.0% 100.0% 1 Diabetes shrt-term cmplicatin 0.0% 0.0% 0.0% 0.0% 100.0% 1 Iatrgenic pneumthrax 0.0% 0.0% 0.0% 0.0% 100.0% 1 Ttal 34.9% 27.5% 24.2% 9.3% 4.1% 839 Surce: Verité analysis f discharge data frm the Children s using AHRQ sftware,

67 ZIP cde and census tract-level health status and access indicatrs The fllwing secndary data surces have been used t examine ZIP cde and census tractlevel health status and access t care indicatrs in the Children s brader cmmunity: (1) Dignity Health s Cmmunity Need Index, and (2) U.S. Department f Agriculture. Key insights: ZIP Cde and Census Tract-Level Indicatrs» Based n a cmpsite measure f sci-ecnmic need (Dignity Health s Cmmunity Needs Index), the immediate cmmunity cntains ZIP cdes scring as medium-high r high need.» Eighty-six census tracts surrunding the Twin Cities area are classified as fd deserts, lw-incme areas with lw access t healthy fd. Dignity Health Cmmunity Needs Index Dignity Health, a hspital system based in Califrnia, develped the Cmmunity Needs Index, a standardized index that measures barriers t healthcare access by cunty and ZIP cde. The index is based n five scial and ecnmic indicatrs:» The percentage f elderly, children, and single parents living in pverty;» The percentage f adults ver the age f 25 with limited English prficiency, and the percentage f the ppulatin that is nn-white;» The percentage f the ppulatin withut high schl diplmas;» The percentage f uninsured and unemplyed residents, and;» The percentage f the ppulatin renting huses. The Cmmunity Needs Index represents a scre based n these indicatrs, assigned t each ZIP cde. Scres range frm Lwest Need ( ), t Highest Need ( ). Althugh nt all f the data measured by the Cmmunity Needs Index are specific t children, the selected indicatrs may affect the health and wellbeing f children either directly r indirectly. Exhibit 47 presents the Cmmunity Needs Index (CNI) scre f each ZIP cde in the Children s brader cmmunity. Minneaplis (ZIP cdes 55404, 55411, and 55454) and St. Paul (ZIP cde 55103) exhibit the highest need scre at

68 Exhibit 47: Cmmunity Needs Index Scre by ZIP Cde Surces: Micrsft MapPint and Dignity Health, Fd deserts The U.S. Department f Agriculture s Ecnmic Research Service estimates the number f peple in each census tract that live mre than 1 mile frm a supermarket r large grcery stre in urban areas and mre than 10 miles frm a supermarket r large grcery stre in rural areas. 23 Several gvernment-led initiatives aim t increase the availability f nutritius and affrdable fds t peple living in these fd deserts. Exhibit 48 indicates the lcatin f identified fd deserts in the Children s brader cmmunity. 23 Ecnmic Research Service (ERS). (n.d.). Fd Desert Lcatr. U.S. Department f Agriculture. Retrieved 2012, frm 59

69 Eighty-six census tracts in the brader cmmunity were determined t be fd deserts. The majrity f the fd deserts were lcated near Minneaplis and St. Paul. Exhibit 48: Fd Deserts by Census Tract Surce: Micrsft MapPint and the Ecnmic Research Service, U.S. Department f Agriculture, Althugh rates f fd insecurity are sme f the lwest in the U.S., 16.7 percent f Minnesta s children were fd insecure in Fd insecurity is nt directly related t pverty. In many cases, residents with incmes greater than 185 percent f FPL are fd insecure, especially in unemplyed r underemplyed husehlds, areas with a high cst f living, and in families with high medical bills Feeding America. (2012). Map the Meal Gap: Child Fd Insecurity Retrieved 2012, frm MMG-Child-Executive-Summary-FINAL.ashx 60

70 Overview f the health and scial services landscape This sectin first examines gegraphic areas and ppulatins in the cmmunity with barriers t accessing care due t medical underservice r a shrtage f health prfessinals as well as individual facilities similarly lacking sufficient health prfessinals. Secnd, this sectin summarizes the varius assets and resurces available t imprve and maintain the health f the cmmunity. Key insights: Health and Scial Services Landscape» The Twin Cities area faces barriers t accessing care as demnstrated by the presence f federally-designated Medically Underserved Areas r Ppulatins (MUA/MUPs) and Health Prfessinal Shrtage Areas (HPSAs).» Anka, Washingtn, and Sctt cunties als cntain facilities and areas with a shrtage f health prfessinals.» The Shakpee Mdewakantn Siux Cmmunity in Sctt Cunty is designated as a primary medical, dental, and mental health prfessinal shrtage area due t ecnmic and/r cultural/linguistic barriers t receiving primary care.» 39 FQHCs in Hennepin and Ramsey cunties and ne in Washingtn Cunty serve HPSAs, MUAs, and MUPs.» Each cunty cntains ne r mre hspitals, health and human services departments, and ther agencies striving t meet health needs. Medically Underserved Areas and Ppulatins The Health Resurces and Services Administratin (HRSA) has calculated an Index f Medical Underservice (IMU) scre fr cmmunities acrss the U.S. The IMU scre calculatin includes the rati f primary medical care physicians per 1,000 persns, the infant mrtality rate, the percentage f the ppulatin with incmes belw the pverty level, and the percentage f the ppulatin greater than age 64. IMU scres range frm zer t 100 where 100 represents the least underserved and zer represents the mst underserved. 25 Any area r ppulatin receiving an IMU scre f 62.0 r less qualifies fr Medically Underserved Area (MUA) r Medically Underserved Ppulatin (MUP) designatin. Federally Qualified Health Centers (FQHCs) may be established t serve MUAs and MUPs. Ppulatins receiving MUP designatin include grups within a gegraphic area with ecnmic barriers r cultural and/r linguistic access barriers t receiving primary care. When a ppulatin grup des nt qualify fr MUP status based n the IMU scre, Public Law allws MUP designatin if unusual lcal cnditins which are a barrier t access t r the availability f persnal health services exist 25 U.S. Health Resurces and Services Administratin. (n.d.) Guidelines fr Medically Underserved Area and Ppulatin Designatin. Retrieved 2012, frm 61

71 and are dcumented, and if such a designatin is recmmended by the chief executive fficer and lcal fficials f the State where the requested ppulatin resides. 26 Exhibit 49 shws areas designated by HRSA as medically underserved. Hennepin and Ramsey cunties bth cntain MUAs; Ramsey Cunty als cntains an MUP. 26 Ibid. 62

72 Insert Exhibit 49: Lcatin f Federally Designated Areas in the Brader Cmmunity, 2012 Surces: Micrsft MapPint and HRSA, The brader cmmunity cntains MUAs and MUPs as well as HPSA ppulatins and facilities The majrity f these designatins are lcated near Minneaplis and St. Paul 63

73 Health Prfessinal Shrtage Areas An area can receive a federal Health Prfessinal Shrtage Area (HPSA) designatin if a shrtage f primary care, dental care, r mental health care prfessinals is fund t be present. In additin t areas and ppulatins that can be designated as HPSAs, a facility can receive federal HPSA designatin and a resultant, additinal Medicare payment if it prvides primary medical care services t an area r ppulatin grup identified as having inadequate access t primary care, dental, r mental health prfessinals and service capacity. HPSAs can be: (1) An urban r rural area (which need nt cnfrm t the gegraphic bundaries f a plitical subdivisin and which is a ratinal area fr the delivery f health services); (2) a ppulatin grup; r (3) a public r nnprfit private medical facility. 27 Many ppulatins in the Children s brader cmmunity are designated as HPSAs (Exhibit 49). The Shakpee Mdewakantn Siux Cmmunity in Sctt Cunty is designated as a primary medical care, dental, and mental health HPSA. In Hennepin Cunty, the lw-incme ppulatins in Nrth and Nrtheast Minneaplis are designated as primary medical care and dental HPSAs. The lw-incme ppulatins f Central Minneaplis, Central St. Paul, and Riverview/St. Paul als are designated as dental HPSAs. Descriptin f ther facilities and resurces within the cmmunity The Children s brader cmmunity cntains a variety f resurces that are available t meet the health needs identified in this CHNA. These resurces include facilities designated as HPSAs, hspitals, FQHCs, health prfessinals, and ther agencies and rganizatins. In additin t the ppulatins designated as HPSAs, several facilities in the Children s brader cmmunity are designated as HPSAs (Exhibit 50). 27 U.S. Health Resurces and Services Administratin, Bureau f Health Prfessinals. (n.d.). Health Prfessinal Shrtage Area Designatin Criteria. Retrieved 2012, frm 64

74 Exhibit 50: HPSA Facilities in the Brader Cmmunity, 2012 Cunty Name Type f Facility Type f HPSA Anka Anka Metr Reginal State Mental Hspital Mental Health Treatment Center Minnesta Crrectinal Facility Primary Medical Care, Crrectinal Facility - Lin Lakes Dental, Mental Health Axis Cmmunity Health Federally Qualified Health Primary Medical Care, Center Lk A Like Dental, Mental Health Cedar Riverside Peple's Center Cmprehensive Health Center Primary Medical Care, Dental, Mental Health Cmmunity University Health Primary Medical Care, Cmprehensive Health Center Care Center Dental, Mental Health Fremnt Cmmunity Health Cmprehensive Health Center Primary Medical Care, Dental, Mental Health Hennepin Cunty Health Care Primary Medical Care, Cmprehensive Health Center fr the Hmeless Dental, Mental Health Hennepin Hennepin Cunty Medical Center Other Facility Primary Medical Care Indian Health Bard Cmprehensive Health Center Primary Medical Care, Dental, Mental Health Native American Cmmunity Primary Medical Care, Cmprehensive Health Center Clinic Dental, Mental Health Nrthpint Health and Primary Medical Care, Cmprehensive Health Center Wellness Center Dental, Mental Health Suthside Cmmunity Cmprehensive Health Center Primary Medical Care, Dental, Mental Health University f Minnesta Cmmunity Health Care Cmprehensive Health Center Dental Mdel Cities Health Center Cmprehensive Health Center Primary Medical Care, United Family Practice Health Ramsey Center Westside Cmmunity Health Center Minnesta Crrectinal Facility Sctt - Shakpee Minnesta Crrectinal Facility - Stillwater Washingtn Minnesta Crrectinal Facility Oak Park Heights Surce: HRSA, Federally Qualified Health Center Lk A Like Cmprehensive Health Center Crrectinal Facility Crrectinal Facility Crrectinal Facility Dental, Mental Health Primary Medical Care and Dental Primary Medical Care, Dental, Mental Health Primary Medical Care, Dental, Mental Health Primary Medical Care and Mental Health Mental Health 65

75 Each cunty cntains at least ne hspital facility (Exhibit 51). Exhibit 51: Infrmatin n Hspitals in the Brader Cmmunity, 2011 Cunty Facility Name ZIP Cde Anka Mercy Hspital Unity Hspital Carver Ridgeview Medical Center Fairview Ridges Hspital Dakta Nrthfield Hspital Regina Medical Center Abbtt Nrthwestern Hspital Children s Hspital & Clinics Minneaplis Fairview Suthdale Hspital Hennepin Cunty Medical Center Maple Grve Hspital Hennepin Nrth Memrial Medical Center Park Nicllet Methdist Hspital Phillips Eye Institute Regency Hspital Of Minneaplis LLC Shriners Hspital Fr Children University Of Minnesta Medical Center Children's Hspital & Clinics f Minnesta Gillette Children s Specialty Hspital HealthEast Bethesda Hspital Ramsey HealthEast St. Jhn's Hspital HealthEast St. Jseph's Hspital Regins Hspital United Hspital Inc Sctt MCHS - New Prague St Francis Reginal Medical Center HealthEast Wdwinds Hspital Washingtn Lakeview Memrial Hspital Surce: Minnesta Department f Human Services, 2012, and the CMS Impact File, Federally Qualified Health Centers (FQHCs) were created by Cngress t prmte access t ambulatry care in areas designated as medically underserved. These clinics receive cstbased reimbursement fr Medicare and many als receive grant funding under Sectin 330 f the Public Health Service Act. FQHCs als receive a prspective payment rate fr Medicaid services based n reasnable csts. There are 40 FQHCs lcated in the seven cunties within the cmmunity served by Children s; 27 in Hennepin Cunty, 12 in Ramsey Cunty, and ne in Washingtn Cunty (Exhibit 52). Seven f these FQHCs als are HPSAs. 66

76 Exhibit 52: FQHCs in the Brader Cmmunity, 2012 Cunty Facility Name ZIP Cde Branch III Health Care Fr Hmeless Cedar Riverside Peple's Center Central Avenue Clinic Cmmunity-University Health Care Center Family Dental Of Suth Minneaplis Fremnt Clinic Hennepin Cunty Public Health Clinic Heritage Senirs Clinic Indian Health Bard Of Minneaplis, Inc Mary's Place Native American Cmmunity Clinic Dental Services Native American Cmmunity Clinic Cunseling Services Nrthpint Health And Wellness Hennepin Our Savir's Shelter-Hmeless Shelter Peple Serving Peple Peple's Center Teenage Medical Services Plymuth Christian Yuth Center Salvatin Army Harbr Lights Secure Waiting Sharing & Caring Hands Sheridan Wmen & Children's Clinic Simpsn Shelter Suthside Dental Clinic & Mbile Dental Van St. Stephen's Shelter Universal Medical Services, Inc. / Axis Medical Center Visin Clinic Yuthlink Drthy Day Clinic East Side Family Clinic Family Services Center Helping Hand Dental Clinic McDnugh Hmes Clinic Ramsey Open Cities Health Center, Inc Open Cities Nrth End Clinic Unin Gspel Missin United Family Medicine United Family Medicine at Sibley Plaza West Side Dental Clinic Westside Cmmunity Health Services, Inc Washingtn St Crix Family Medical Clinic Surce: HRSA,

77 Exhibit 53 presents the rates f primary care physicians, mental health prviders, and dentists per 100,000 ppulatin. Prvider rates are rughly half the Minnesta average fr mental health prviders in Anka Cunty and fr dentists in Carver Cunty. Exhibit 53: Health Prfessinals Rates per 100,000 Ppulatin in the Brader Cmmunity Primary Care Physicians* Mental Health Prviders* Practicing Dentists* Cunty Rate per Rate per Rate per Number 100,000 Number 100,000 Number 100,000 Anka Carver Dakta Hennepin 1, , Ramsey Sctt Washingtn Minnesta 5,280** ,848** , Surce: HRSA s Area Resurce File, 2011, and Minnesta Department f Health, *Primary care physician data is frm 2011, dentist data is frm 2010, and mental health prvider data is frm **Numbers f health prfessinals in Minnesta calculated by Verité. As f 2012, a range f ther agencies and rganizatins are available in each cunty t assist in meeting health needs, including cunty health departments and human services departments. Sme f these include:» Lcal health departments and human and scial services departments, and related clinics: Anka Cunty Human Services Department Anka Cunty Department f Cmmunity Health and Envirnmental Services Carver Cunty Cmmunity Scial Services Department Carver Cunty Public Health and Envirnmental Divisin Dakta Cunty Health and Family Services: Hennepin Cunty Human Services and Public Health Department Ramsey Cunty Cmmunity Human Services Department St. Paul - Ramsey Cunty Public Health Department Sctt Cunty Public Health Department h.aspx Washingtn Cunty Cmmunity Services Department 68

78 Washingtn Cunty Public Health and Envirnment Department Schl districts in the seven-cunty cmmunity.» Free clinics in Hennepin, Ramsey, and Washingtn cunties.» Organizatins that fcus n mental health, including: Anka Cunty Children s Mental Health Unit Children s Mental Health Lcal Advisry Cuncil f Dakta Cunty Hennepin Cunty Children's Mental Health Cllabrative Hennepin Cunty Mental Health Advisry Cuncil (HCMHAC) Mental Health Assciatin f Minnesta Mental Health Cnsrtium f Carver Cunty Natinal Alliance n Mental Illness f Minnesta (NAMI Minnesta) Ramsey Cunty Children's Mental Health Cllabrative St. Paul-Ramsey Cunty Mental Health Bard Sctt Cunty Mental Health Advisry Cuncil Washingtn Cunty Mental Health and Advisry Recvery Bard» Organizatins that fcus n dental health, including: Neighbrhd Health Care Netwrk in St. Paul Children s Dental Clinics in Sctt Cunty Children s Dental Services Rnald McDnald Care Mbile Dental Clinic Dakta Smiles, a mbile dental prgram fr children. Additinally, lists f available resurces have been cmpiled by cmmunity fundatins, clinics, and health departments and can be fund at the fllwing websites:» 2012 Health Resurces Directry fr Diverse Cultural Cmmunities» Anka Cunty Resurces fr Building Better Lives Anka Cunty Resurce Guide fr Senirs» Dakta Cunty Resurce Guide» est/resurce_guides/dakta_cunty_resurce_guide.pdf» Dental Clinics in the Anka Cunty Area» 69

79 » Hennepin Cunty Directry f Free r Sliding Fee Mental Health Clinics ccf06498/?vgnextid=49e2e5d0820a3210vgnvcm rcrd» Sctt Cunty List f Lw-Cst Dental Clinics» ntal%20clinics%20website.pdf» Sctt Cunty List f Sliding Fee and Lw-Cst Medical Clinics nd%20lw%20cst%20medical%20clinics%20website.pdf 70

80 Findings f ther recent cmmunity health needs assessments Verité als cnsidered the findings f ther needs assessments published since Twenty such assessments have been cnducted in the Children s area and are publicly available. Summary findings frm these assessments are prvided belw, with the mst recent presented first. Key insights: Other Recent CHNAs» Cmmn themes amng ther recent needs assessments cnducted in the area include: - Abuse f alchl amng adults and lder children, - Pr mental health, - Insufficient exercise amng yuth, - Prevalence f chrnic diseases, particularly diabetes and besity amng adults, and asthma amng children, - Lw birth weight infants fr the nn-white ppulatin, and - Disparities in access t and affrdability f care.» Vulnerable ppulatins such as racial and ethnic minrities, lwincme and hmeless ppulatins, and thse with special needs generally face greater barriers t health cmpared t ther chrts. The abve assessments fund that these grups have greater difficulty accessing health care and insurance due t cst. The cst f child care is als mre f a burden fr these families. Increasingly, peple are being frced t chse between meeting basic needs, such as fd and husing, r btaining health care.» Lcal needs assessments als shw that scial and ecnmic disadvantages create disparities in health status fr vulnerable ppulatins in the cmmunity. Lw-incme families and children typically have prer diets, limited physical activity, and higher rates f smking and substance abuse resulting in higher rates f chrnic diseases like diabetes, besity, and cardivascular issues. Chrnic disease and mental illness are particularly prevalent amng hmeless yuth and adults. Nn-White ppulatins exhibit higher rates f lw birth weight infants. 71

81 Hennepin Cunty Human Services and Public Health Department, et al., 2012 Five lcal cmmunity health bards, tgether with cmmunity partners, cllabrated in the creatin f a Cmmunity Health Imprvement Plan fr Hennepin Cunty. Participating health bards represented the cities f Minneaplis, Richfield, Edina and Blmingtn, as well as Hennepin Cunty as a whle.28 The grup drew n varius secndary data surces, including the SHAPE survey (summarized belw), Minneaplis Department f Health and Family Supprt, Results Minneaplis, Blmingtn Public Health, Minnesta Department f Health, Minnesta Student Survey, Healthy Peple 2020, Minnesta Department f Educatin, Centers fr Disease Cntrl and the Census Bureau. Strategic health issues identified include:» Maternal and child health; nutritin, besity and physical activity; scial and emtinal wellbeing; health care access; and scial cnditins that impact health. Fairview Health Services, 2012 Fairview Health Services, a hspital system based in Minneaplis, cllabrated with each f their six facilities t cnduct a cmmunity health needs assessment and adpt implementatin strategies in Within the Fairview system, the University f Minnesta Amplatz Children s Hspital, lcated n the University f Minnesta Medical Center Fairview campus, prvides specialized pediatric care t the cmmunity. The hspital used discharge data frm , Dignity Health s Cmmunity Need Index, and data frm fcus grups, interviews, and surveys t assess needs fr the brader Minneaplis area. Findings include:» Mental health, heart disease, diabetes, lw birth weight infants and infant mrtality, and the need fr health infrmatin, educatin, and cultural cmpetency emerged as tp themes frm the assessment.» The facility s tp hspitalizatins fr the ttal ppulatin resulted frm pneumnia, bld pisning, and stearthritis.» The area s leading causes f death were fr cancer, heart diseases, and mental disrders. Hspitalizatins fr mental health and deaths related t mental disrders were bth higher than Minnesta averages.» Fr the pediatric ppulatin, tp hspitalizatins were fr pneumnia, dehydratin, and asthma. Leading causes f death fr this ppulatin include birth defects, SIDS, and hmicide, all f which cmpared prly t state averages. 28 Hennepin Cunty Human Services and Public Health Department, et al. (2012) Cmmunity Health Imprvement Plan fr Hennepin Cunty Residents. Retrieved 2013, frm b310VVgnVC fe4689RCRD 29 Fairview Health Services. (2012). University f Minnesta medical Center Cmmunity Health Needs Assessment (CHNA) Implementatin Plan. Retrieved 2012, frm 72

82 Kids Cunt Minnesta and Children s Defense Fund, 2012 The assessment cnducted by Children s Defense Fund and Kids Cunt Minnesta30 analyzed the health f children in the 11 Ecnmic Develpment Regins (EDRs r Regins) f Minnesta. Regin 11 represented the seven cunties in the Minneaplis-St. Paul metr area: Anka, Carver, Dakta, Hennepin, Ramsey, Sctt, and Washingtn. Findings were primarily frm years 2009 t Findings are as fllws:» Abut 22 percent f children in Regin 11 received SNAP assistance in 2011, ne f the highest percentages in the state.» The rate f children arrested fr a serius crime in 2010 was nearly fur times higher in Regin 11 than in the lwest rate in the state.» Eleven percent f children in Regin 11 had limited English prficiency skills, cmpared t seven percent in the whle state in 2011.» Abut 5.8 percent f children in Regin 11 did nt have health insurance, cmpared t a state average f 6.7 percent. The Minneaplis Fundatin and Wilder Research, 2012 The assessment 31 analyzes changes t the 25 scial, educatinal, and ecnmic indicatrs selected by The Minneaplis Fundatin and Wilder Research in 2010 fr the OneMinneaplis dashbard. The reprt prvides, fr each indicatr, the mst current available data and examines racial and ethnic differences, when available. Althugh many indicatrs imprved r remained the same, racial and ethnic disparities are still prevalent. Findings include: Educatin / Children and Yuth» The percent f students graduating n time wrsened; additinally, graduatin rates were highest fr White residents, at 68 percent, and lwest fr American Indian residents, at 17 percent.» Only 57 percent Hmng-speaking kindergarteners and 38 percent f Spanish-speaking kindergartners were ready fr schl cmpared t 83 percent f English-speaking kindergartners. White residents utperfrmed nn-white residents n kindergarten readiness, 3 rd grade reading prficiency, and 5 th grade math prficiency.» There are large gaps between enrllment f White and nn-white high schl students in pst-secndary educatin. While abut 68 percent f all students enrlled in pstsecndary educatin, 31 percent f American Indian residents enrlled cmpared t 77 percent f White residents. Ecnmic Vitality 30 Children s Defense Fund Minnesta. (2012). Minnesta Kids Cunt 2012: Children Acrss Minnesta. Retrieved 2012, frm 31 The Minneaplis Fundatin and Wilder Research. (2012). neminneaplis 2012 Cmmunity Indicatrs Reprt. Retrieved 2013, frm Research/Publicatins/Studies/neMinneaplis/neMinneaplis%202012%20Cmmunity%20Indicatrs%20Reprt.pdf 73

83 » The share f lw-incme husehlds with affrdable husing in was 21 percent, a 42 percent decrease frm Asian and Hispanic r Latin residents living in lw-incme husehlds are least likely t have affrdable husing.» A single female is the head f husehld in 68 percent f the Minneaplis families that face pverty.» Nn-White and freign-brn residents are mre likely t be in pverty than White residents. Justice and Equality» 27 percent f Minneaplis yuth were arrested fr a serius crime, a higher rate than in previus years. Black residents were mre ften arrested fr serius crimes than White and Asian residents. Black residents make up 29 percent f the Minneaplis ppulatin but 65 percent f the arrests.» Nn-White residents earning less than 200 percent f the federal pverty level reprted experiencing the mst situatins in which they felt unaccepted due t their race, ethnicity, r culture. St. Paul Ramsey Cunty Public Health, Family Health Sectin, 2012 The Family Health Sectin f St. Paul-Ramsey Cunty Public Health32 created and issued a teen survey n reasns fr and reasns deterring visits t the dctr, as well as general demgraphic trends in the data. Findings include:» In the last year, abut 81 percent f teens reprted visiting a dctr in a clinic.» Thirty-six percent f respndents stated lack f health insurance as the main reasn fr nt visiting a dctr in the last year. Anther predminant reasn fr nt visiting the dctr was feeling uncmfrtable with the dctr. Washingtn Cunty Cmmunity Services, 2011 Results frm a survey by Washingtn Cunty Cmmunity Services and Wilder Research33 demnstrated the need fr child care in Washingtn Cunty and the state. In the 2009 survey, 1,209 families with at least ne child under age 12 in their husehld were randmly selected t participate. Sme f the findings include:» Amng children that received child care, nly 25 percent attended child care full time, as cmpared t 75 percent wh received part time care.» Lw-incme families tended t pay abut 20 percent f their incme n child care, which was duble the prtin f what higher incme families paid. 32 St. Paul-Ramsey Cunty Public Health, Family Health Sectin. (2012, January). Access and Use f Medical Care: A Survey f Teen s Perspectives. Retrieved 2012, frm 33 Washingtn Cunty Cmmunity Services Child Care Licensing Prgram. (2011, September/Octber). Washingtn Cunty Child Care Statistics in Minnesta. Caring and Sharing Newsletter. Retrieved 2012, frm 74

84 » Abut every 1 in 5 children in Minnesta had a special need that impacted their quality f child care.» Nn-White parents, parents f children with special needs, and lw-incme parents were twice as likely t be affected by the cst f child care cmpared t parents nt in these categries. Wilder Research, 2011 Wilder Research cmpleted a study34 abut the hmeless ppulatin in the seven-cunty Minneaplis-St. Paul metr area and in Greater Minnesta in A ttal f 220 hmeless parents in the state (with 349 children) were interviewed, 66 f whm (with 109 children) were in the metr area. Findings are as fllws:» Single adult females were the head f nearly 80 percent f hmeless sheltered families and 62 percent f hmeless unsheltered families.» Similar t past rates, 13 percent f hmeless parents reprted that ne r mre f their children had a chrnic r severe illness.» Of the unsheltered hmeless parents: Nineteen percent reprted truble accessing needed dental care fr their children; Twenty percent said their children had skipped meals in the past mnth; and Furteen percent reprted they had been unable t btain needed health care fr children in the past year.» Abut 49 percent f hmeless parents stated that they (the parent) were tld by a health prvider r prfessinal that they had a serius mental health disrder.» Hmeless parents reprted an inability t btain needed health care: Three percent f parents were unable t prvide r btain mental health care fr their children; and Parents in the metr area had fewer difficulties btaining care, at nine percent, cmpared t parents in Greater Minnesta, at 17 percent. Hennepin Cunty Human Services and Public Health Department and Statewide Health Imprvement Prgram (SHIP), 2011 Hennepin Cunty Human Services and Public Health Department and Statewide Health Imprvement Prgram (SHIP) prduced a reprt titled SHAPE 2010-Child Data Bk,35 prtraying data frm the SHAPE 2010 Child Survey. 34 Wilder Research. (2011, May) Minnesta Hmeless Study: Hmeless Children and their Families. Retrieved 2012, frm Research/Publicatins/Studies/Hmelessness%20in%20Minnesta,%202009%20Study/Hmeless%20Children%20and%20Th eir%20families,%20full%20reprt.pdf 35Hennepin Cunty Human Services and Public Health Department. (2011, April). SHAPE 2010 Child Survey Data Bk. Retrieved 2012, frm k2010full_ pdf 75

85 Findings are as fllws:» Overall Health and Chrnic Cnditins: Abut tw percent f Hennepin Cunty parents stated their children had serius physical, behaviral, r develpmental cnditins that limited their ability t attend schl regularly. Abut 15 percent f Hennepin Cunty parents tk their children t the emergency rm due t an asthma attack. Of thse children (ld enugh t attend an educatinal institutin), 23 percent were in pre-kindergarten r kindergarten, 12 percent were in first thrugh third grades, 13 percent were in furth thrugh 6 th grades, and 14 percent were in 7 th thrugh 12 th grades. The rates f children with ADD/ADHD in Hennepin Cunty (10 percent) and depressin (nine percent) were lwer than the Minneaplis averages at 12 percent and 10 percent, respectively.» Weight, Nutritin, and Physical Activity: Abut 17.2 percent f children surveyed frm lw-incme husehlds did nt have any servings f vegetables daily, cmpared t 12.6 percent f children frm husehlds nt classified as lw-incme. Abut 73.5 percent f Hennepin Cunty s residents stated that the schls invlved children in enugh physical activity; lw-incme families felt less secure abut their children s physical activity levels than thse nt classified as lwincme. Regular smking arund children was present in 11 percent f lw-incme husehlds as cmpared t 2.5 percent f higher-incme husehlds in Hennepin Cunty. Drug use preventin was discussed by 65 percent f families wh were nt lwincme in Hennepin Cunty, as cmpared t nly 60 percent f lw-incme families. Abut 79.1 percent f Hennepin Cunty children ate the standard servings f fruit (2 r mre servings), cmpared t 74.9 percent f lw-incme children. Abut 48.1 percent f children in Hennepin Cunty had zer servings f sweetened drinks, cmpared t 34.5 percent f lw-incme children.» Child Care and Health Insurance Cverage: The percentage f families receiving childcare frm smene nt related t the child was much lwer fr lw-incme families, at 28 percent, than higher incme families, at 51 percent. Abut 88.8 percent f children aged 17 r yunger receive care frm a medical hme, cmpared t 80 percent f lw-incme children. Abut 60.6 percent f children in Hennepin Cunty saw the same dctr mre than nce, cmpared t 46.7 percent f lw-incme children. 76

86 Dakta Cunty Public Health Department, 2011 The Dakta Cunty Public Health Department cmpleted a set f cmmunity health prfiles36 f data frm 2000 t This analysis described health utcmes, changes, and behavirs in the ppulatin. The fllwing are findings frm the study:» Alchl and Drug Use by Yuth:» Chrnic Disease: Dakta Cunty experienced a decrease in frequent drinking amng 9 th and 12 th graders frm 2004 t Of all mtr vehicle injuries in Dakta Cunty, seven percent were alchlrelated, cmpared t 38.5 percent f mtr vehicle fatalities that were alchlrelated. There were steady decreases in alchl-related fatalities and injuries between 2000 and In 2009, the sale r pssessin f marijuana cmprised eighty-ne percent f narctics arrests. Between 2008 and 2009, the highest rate f asthma was amng children ages 0 t 4, cnsisting f 529 hspitalizatins and 1,925 emergency rm visits.» Maternal and Child Health: Abut six percent f mthers were smkers during pregnancy, an increase frm Unintended pregnancies were reprted amng 37 percent f wmen in 2008.» Mental Health: In 2010, 86 percent f mthers received prenatal care in their first trimester. Attempted suicide r premeditated feelings f suicide decreased fr students frm 2004 t 2010, but suicide and unintentinal injuries were still the leading causes f death, as their rates increased between 1998 and 2009.» Nutritin and Physical Activity:» Smking: The percent f six mnth ld babies in 2010 wh were still breastfed was similar t the state at 31 percent but lwer than the Healthy Peple 2010 gal f 50 percent. The percentage f 9 th grade students wh wanted t lse weight (59 percent in 2010) decreased 21 percentage pints, while the percentage f 12 th graders wh wanted t lse weight (62 percent in 2010) decreased 14 percentage pints between 2004 and Dakta Cunty 9 th graders reprted primarily accessing cigarettes frm friends, at a rate f 55 percent in Dakta Cunty Public Health Department. ( ). Dakta Cunty Cmmunity Health Assessment and Planning: Cmmunity Health Prfiles. Retrieved 2012, frm 77

87 The number f students in Dakta Cunty wh reprted smking decreased frm 1998 t Minnesta Department f Health Cmmunity and Family Health Divisin, 2010 The Minnesta Department f Health s Cmmunity and Family Health Divisin37 wrked n the Maternal and Child Health Services Title 5 Blck Grant, analyzing the past perfrmance f the state f Minnesta and creating pririties fr 2011 thrugh It als prvided trends and impacts n health utcmes f mthers, infants, children, and yuth with special healthcare needs. Findings fr Minnesta include:» Binge drinking was an issue fr 6.6 percent f mthers during their first trimester f pregnancy, and fr 5.6 percent during their last trimester.» Abut 16 percent f pregnant wmen in Minnesta reprted smking during their pregnancy.» Unintentinal pregnancies were highest amng Black (47.4 percent) and Hispanic r Latin ppulatins (45.9 percent). These pregnancies were lwest amng Whites (33.6 percent).» Immunizatin recrds in 2008 shwed that apprximately 91 percent f all children were prperly and age-apprpriately immunized, an increase frm the 2004 immunizatin rate f 85 percent.» The pregnancy rate and birth rate fr wmen between the ages f 15 and 19 decreased between 1997 and 2008.» In 2008, the ppulatin f children with special health care needs was abut 14.4 percent, slightly higher than the natinal average f 13.9 percent. Blue Crss and Blue Shield Fundatin f Minnesta and Wilder Research, 2010 Wilder Research and the Blue Crss and Blue Shield f Minnesta Fundatin cmmissined a reprt in Octber t examine links between sciecnmic status and health utcmes fr the Twin Cities seven cunty regin (Anka, Carver, Dakta, Hennepin, Ramsey, Sctt, and Washingtn). They als released a supplement t the reprt which prvided additinal data and analyses.39 Secndary data frm the Minnesta Department f Health and gegraphic mapping patterns were used t prvide analysis. Sme f the findings include: 37 Minnesta Department f Health, Cmmunity and Family Health Divisin. (2010, July). Minnesta 2010 Needs Assessment: Maternal and Child Health Services Title V Blck Grant. Retrieved 2012, frm 38Blue Crss and Blue Shield f Minnesta Fundatin and Wilder Research. (2010, Octber).The Unequal Distributin f Health in the Twin Cities. Retrieved 2012, frm 39Blue Crss and Blue Shield f Minnesta Fundatin and Wilder Research. (2010, Octber). Revealing Sciecnmic Factrs that Influence Yur Health: Supplement t the Unequal Distributin f Health in the Twin Cities Reprt. Retrieved 2012, frm %20Wilder%20cmpanin%20piece.pdf 78

88 » The mrtality rate fr the seven cunty area was highest fr American Indians (abut eight percent) and Blacks (abut seven percent). American Indians and Blacks als had the highest rates fr besity, diabetes, and infants with lw birth weights.» The mrtality rate fr nn-white residents was nearly 60 percent higher than fr thse wh were White.» While abut fur percent f Whites had babies with lw birth weights, seven percent f nn-whites had the same utcme.» Every additinal $10,000 f husehld incme earned in an area crrelated with a neyear increase in life expectancy fr that area s ppulatin. High incme areas had children with life expectancies that were up t eight years higher than children in lwerincme areas.» The reprt nted that mre than half f a persn s health utcmes were impacted by the fllwing factrs: incme, educatin, race, and residence. Wilder Research, 2010 Wilder Research prvided a reprt40 fr Hennepin Cunty Children s Research Cllabrative n health needs, particularly mental health needs, f children and teens in schls and cmmunity prgrams f Hennepin Cunty in The reprt used data cllected frm tw nline surveys with mental health service prviders and cllabrative stakehlders in Hennepin Cunty, interviews with mental health system leaders, and a 90-minute fcus grup with parents/caregivers in the cunty wh cared fr a child receiving mental health services. Findings include:» Nearly 70 percent f the Hennepin Cunty mental health unit was male, with the majrity f the ppulatin being Black (43 percent) and White (42 percent).» Mre than 80 percent f yuth receiving targeted case management help were cvered thrugh a public health insurance plan in 2008.» Student t schl cunselr ratis in Minnesta were sme f the lwest in the natin, at 800:1, cmpared t the natinal average f 488:1 students in 2007.» Abut 83 percent f survey respndents felt that the system serving yuth with mental health issues was smewhat effective. Wilder Research, 2010 Wilder Research analyzed the availability f mental health services fr the Hmng Cmmunity in Ramsey Cunty and assessed barriers t accessing these services. The reprt 41 is a cmpilatin f surveys, interviews, and secndary data cllectin frm U.S. Census data fr the years Wilder Research. (2010, January). Hennepin Cunty Children s Health Cllabrative: System f Care Assessment. Retrieved 2012, frm Research/Publicatins/Studies/Hennepin%20Cunty%20Children%27s%20Mental%20Health%20Cllabrative/System%20 f%20care%20assessment.pdf 41 Wilder Research. (2010, June). Hmng Mental Health Assessment- An Assessment f mental health needs and services in the Hmng Cmmunity in Ramsey Cunty. Retrieved 2013, frm Research/Publicatins/Studies/Hmng%20Mental%20Health%20- %20An%20Assessment%20f%20Mental%20Health%20Needs%20and%20Services%20fr%20the%20Hmng%20Cmmunity %20in%20Ramsey%20Cunty/Mental%20Health%20Needs%20and%20Services%20fr%20the%20Hmng%20Cmmunity%2 0in%20Ramsey%20Cunty,%20Full%20Reprt.pdf 79

89 Findings include:» The Hmng cmmunity accunted fr abut five percent f Ramsey Cunty s ppulatin, but nearly half f the Hmng ppulatin in Ramsey Cunty was under the age f 18 years.» In Ramsey Cunty, abut 40 percent f the Hmng cmmunity was nt in the labr frce, cmpared t 31 percent f the general ppulatin.» In St. Paul, the average husehld incme fr the Hmng cmmunity was $45,300, cmpared t the average husehld incme f $62,559.» In St. Paul, nearly 11 percent f the Hmng cmmunity was receiving gvernment assistance, cmpared t abut 5 percent f the verall ppulatin.» Between 2009 and 2010, abut 90 percent f students wh stated Hmng was their primary language were enrlled in the free r reduced-price lunch prgram althugh these students cmprised nly 25 percent f the entire student ppulatin.» Between 2009 and 2010, abut 12 percent f the Hmng cmmunity received special educatin classes.» Hmng cmmunity members expressed a preference fr traditinal practices and supprt services cmpared t mre Western frms f care.» Mre acculturated and educated Hmng members in the cmmunity were the mst likely t seek care fr mental health issues.» During 2008 and 2009, nearly half f the individuals using the Sutheast Asian Services within Wilder s Children and Family Services were frm the Hmng cmmunity. Carver Cunty Public Health Department Data Resurce Center, 2009 The Data Resurce Center f Carver Cunty Public Health Department cmpleted a data prfile42 f residents behavirs between 2003 and 2009 that discussed findings in multiple categries. Findings are as fllws:» Health Behavirs: In 2007, abut 13.7 percent f 9 th graders and 31.5 percent f 12 th graders reprted binge drinking. Between 2003 and 2006, the number f minr cnsumptin citatins increased frm abut 150 t 250. The percentage f physically inactive students (thse wh d nt exercise fr 30 minutes r mre a day, n five r mre days) increased 6.2 percent fr 9 th graders, 9.8 percent fr 6 th graders, and 13 percent fr 12 th graders between 1998 and 2007.» Overall Health: 42 Carver Cunty Public Health Department. (2009, July). Carver Cunty Public Health Data Prfile. Retrieved 2012, frm 80

90 Chrnic disease, pr ral health, lack f prenatal care, and mental health prblems were amng the majr health issues in Carver Cunty.» Infectius Disease: Between 2007 and 2008, cases f pertussis increased frm three t 36. Carver Cunty Public Health Department, 2009 Carver Cunty Public Health Department administered a biannual survey43 in Out f 42 public and private schls in the cmmunity, 32 schls respnded. By examining the services prvided by schl nurses t elementary, middle, and high schl students, health needs f students were identified. Survey findings are as fllws:» Amng students, the predminant health cnditin present was asthma, at a rate f 78.4 per 1,000 students (r 39 students per schl), fllwed by ADD/ADHD at a rate f 59.2 per 1,000 students (r 31 students per schl).» Hearing referral rates were highest amng high schl students at 13.9 per 1,000 children and lwest amng middle schl students at 8.7 per 1,000 children.» Visin referral rates were highest amng elementary schl students at a rate f 56.1 per 1,000 children and lwest amng high schl students at a rate f 25.8 per 1,000 children.» Regularly scheduled medicatins fr asthma r ther chrnic cnditins were prvided t eight students per day, n average, but sme schls had up t twenty-eight students per day receiving this treatment. Anka Cunty Gvernment Center and Cmmunity Health and Envirnmental Services Department, 2009 The Cmmunity Health and Envirnmental Services Department44 f the Anka Cunty Gvernment Center discussed findings and health trends in Anka Cunty frm 2000 t 2010, thugh findings cncerning children were primarily frm 2003 t Findings abut yuth include:» In 2007, 36 percent f children were cnsidered verweight, while 26 percent were classified as bese, cmparable t the statewide percentages.» An estimated 15 percent f adults exhibited binge drinking behavir in 2007, higher than state averages, but the behavir has trended dwnward since 1997.» Twenty-six percent f 12 th graders reprted binge drinking, cmpared t 12 percent f 9 th graders.» Eighty-five percent f Anka children received age-apprpriate immunizatins. 43 Carver Cunty Public Health Department. (2009, May). Survey f Nursing Services in Carver Cunty Schls. Retrieved 2012, frm 44 Anka Cunty Gvernment Center, Cmmunity Health & Envirnmental Services Department. (2009, Octber). Anka Cunty Cmmunity Health Assessment Reprt Retrieved 2012, frm 81

91 Dakta Cunty Human Services Advisry Cmmittee, 2008 Infrmatin n autism and its impact n children and adults in Dakta Cunty were prvided in a reprt45 by the Dakta Cunty Human Services Cmmittee in Data surces included schl districts and the Dakta Cunty Scial Services Department. Findings include:» Between 2002 and 2006, the number f autistic children (0 t 21 years ld) served thrugh Special Educatin departments increased by 117 percent, frm 514 t 1,117, acrss eight lcal schl districts within Dakta Cunty.» Schl districts saw increases in the detectin f children with autism by 116 percent between 1997 and 2006.» Within the Dakta Cunty Develpmental Disabilities (DD) Sectin, nly 17 percent f individuals with autism in this regin received services. Washingtn Cunty Department f Public Health and Envirnment, 2008 An assessment by the Washingtn Cunty Department f Public Health and Envirnment discussed trends46 in Washingtn Cunty between 2000 and Using an nline health survey, yuth envirnmental survey, senir citizens survey, fcus grups, and interviews, this reprt was cmpiled during Nvember 2007 and February 2008 and included respnses by mre than 1,370 individuals. Findings include:» The percent f premature births decreased frm 8.6 percent t 7.6 percent in the cunty between 2004 and 2006.» Births t unmarried wmen increased frm 20.2 percent in 2004 t 22.2 percent in 2006.» The number f cases f Lyme disease increased frm 51 in 2004 t 64 in 2007.» Lking at physicians per 10,000 peple, Washingtn Cunty had a greater number (14.9) than Sctt Cunty (8.8) and Dakta Cunty (10), while it had fewer physicians than Hennepin Cunty (37.6), Anka Cunty (16.2), and Ramsey Cunty (28.6).» The number f dentists per 10,000 ppulatin was higher fr Washingtn Cunty (6.6) than Sctt Cunty (3.3), Carver Cunty (2.9), Dakta Cunty (5.7), and Anka Cunty (4.9), while the number f dentists was lwer than in Ramsey Cunty (6.8) and Hennepin Cunty (7.5).» In Washingtn Cunty, 15 percent f children enrlled in the WIC prgram were at risk fr being verweight, cmpared t 13 percent statewide; hwever, the percent f verweight children enrlled in WIC decreased frm 12.2 percent t 9.3 percent between 2003 and 2007.» The percent f children in 6 th grade eating five r mre servings f vegetables decreased frm 1998 (23.2 percent) thrugh 2007 (21.1 percent). In cmparisn, the percent f 45 Dakta Human Services Advisry Cmmittee. (2008, Octber). Reprt n Autism Spectrum Disrder in Dakta Cunty. Retrieved 2012, frm 46 Washingtn Cunty Department f Public Health and Envirnment. (2008). Washingtn Cunty Cmmunity Health Assessment Retrieved 2012, frm 82

92 individuals cnsuming the dietary guideline in 9 th grade and 12 th grade increased frm 17.2 percent in 1998 t 20 percent in 2007 and 12.2 percent in 1998 t 15.7 percent in 2007, respectively.» The leading causes f hspitalizatins were as fllws: Injury and pisning (19.2 percent) fr ages 5 thrugh 14; and Mental disrders (25.9 percent) fr ages 15 thrugh 19.» In 2002, apprximately 22 percent f Washingtn Cunty s ppulatin reprted prblems with acute drinking, defined as drinking mre than 5 drinks n ne ccasin, cmpared t 18 percent in 2006.» Cigarette smking declined frm 2002 and 2006, decreasing frm 22.3 percent t 18.9 percent. Wilder Research, 2008 Wilder Research analyzed the availability f affrdable husing services in the East Metr Area, which includes: Anka, Dakta, Ramsey, and Washingtn cunties. Needs fr husing services are analyzed by jurisdictin, husehld size, senir husehlds, and incme level. Husehlds defined as lw-incme have incmes at r belw 60 percent f the regin s Median Family Incme (MFI), which is $80,900; whereas husehlds defined as very lw-incme have incmes at r belw 30 percent f the MFI. The reprt 47 uses secndary data frm the U.S. Census, the State Demgrapher, and the Metrplitan Cuncil t prvide prjectins and trends. Findings include:» St. Paul had the highest actual and prjected lw-incme and cst-burdened husehlds in 2000 and 2010, at 31 and 30 percent, respectively. Prjectins suggest a decrease in the percentage t 27 percent by Washingtn Cunty had the lwest percent f cst-burdened husehlds, at 11 percent, fr the years 2000 and 2010, but this is prjected t increase t 13 percent by 2020.» St. Paul was prjected t cnsist f 35 percent f very lw-incme husehlds by The twn is prjected t gain anther 16 percent f very lw-incme husehlds between 2010 and The greatest increase prjected in very lw-incme husehlds was in Dakta Cunty, at 29 percent between 2010 and 2020.» The greatest number f cst-burdened, very lw-incme senir husehlds was prjected t be in St. Paul (6,032 husehlds) cmpared t Washingtn Cunty, with the lwest prjected number (2,975 husehlds).» By 2020, Dakta Cunty is prjected t have the greatest number f cst-burdened, very lw-incme husehlds, r nearly 8,395 husehlds. Washingtn Cunty is prjected t have the least, at 4,665 husehlds.» The sheltered hmeless ppulatin increased arund 10 percent between 2000 and 2006 and the prevalence f mental illness in the hmeless ppulatin rse 16 percentage pints. The prprtin f hmeless that were ex-ffenders increased 11 percentage pints. 47 Wilder Research. (2008, July). East Metr Husing Need: Prjectins f lw-incme and cst-burdened husehlds by 2010 and Retrieved 2013, frm Research/Publicatins/Studies/East%20Metr%20Husing%20Needs/East%20Metr%20Husing%20Need%20- %20Prjectins%20f%20Lw-incme%20and%20Cstburdened%20Husehlds%20by%202010%20and%202020,%20Full%20Reprt.pdf 83

93 » Abut 25 percent f the hmeless ppulatin entering shelters in Ramsey Cunty were cnsidered lng term hmeless ppulatins. Of the nearly 2,000 shelters acrss the East Metr regin, 80 percent f the current capacity fr prviding shelter, transitinal husing, beds, and resurces was used in Ramsey Cunty in St. Paul-Ramsey Cunty Department f Public Health, 2007 This assessment48 began in the fall f 2007 by St. Paul-Ramsey Cunty Department f Public Health. The assessment presented respnses frm a survey f 575 participants, meetings with Cmmunity Health Advisry Cmmittee experts, and public health related secndary data. Findings include:» Alchl and Drug Use: Ramsey Cunty experienced 4.1 alchl related vehicle crashes fr every 100 mtr-vehicle crashes that ccurred in the cunty, dwn frm 5.1 in 2002, and lwer than the state average f 5.3 in Apprximately 5 percent f 9 th thrugh 12 th graders reprted using methamphetamines in the past year, a decrease frm Between 2003 and 2004, abut 18.8 percent f children between the ages f 6 and 11 were verweight. In cmparisn, 17.4 percent f adlescents between the ages f 12 and 19 were verweight.» Infectius Disease: The rate f new HIV diagnses was 10.8 per 100,000 individuals fr Ramsey Cunty in 2005, higher than that f the state, at 6.2 per 100,000 individuals. The rate f AIDS was higher fr males than females, thugh recently the male AIDS cases have trended dwn while female cases f AIDS have risen. The Black ppulatin has higher rates f HIV/AIDS than the White ppulatin.» Children, Yuth, and Families: The percent f lw birth weight babies in Ramsey Cunty, at 5.8 percent in 2005, was higher than the state average f 4.9 percent. The percent f mthers wh did nt smke during pregnancy increased frm 89.4 percent f mthers in 2001 t 92.5 percent in 2005, cmpared t the state figures f 88.8 and 90.5 percent, respectively.» Child Care: Rughly 12.4 percent f wmen wh had n prenatal care r had prenatal care nly during their third trimester had lw birth weight babies, as cmpared t 6.9 and 8.3 percent f thse wh received prenatal care in their first r secnd trimester, respectively. The Wmen, Infants, and Children Prgram (WIC) catered t a diverse ppulatin in Ramsey Cunty in 2006, with 28 percent f participants being Asian, 27 percent Black, 20 percent Hispanic r Latin, and 18 percent White. WIC children were mre likely t be verweight cmpared t children in the rest f the state in every year frm 2004 thrugh St. Paul-Ramsey Cunty Department f Public Health. (2007.) Cmmunity Health Assessment. Retrieved 2012, frm 84

94 The average cst f child care decreased as age increased; the cst fr children tw years f age and yunger was $5,700, cmpared t the cst f child care fr children between 10 and 12 years, which was nly $3,300. The percent f incme spent n child care was much higher fr thse f lwer incme brackets, as families earning under $20,000 paid 28 percent f their incme n child care, as cmpared t families earning $75,000 r mre, wh spent seven percent f incme n child care. 85

95 Secndary data indicatrs f cncern This assessment analyzed secndary data regarding demgraphics, scial and ecnmic factrs, health behavirs, physical envirnment, care delivery, mrbidity, and mrtality. Exhibits present the indicatrs that appeared mst unfavrable in the cmmunity served by Children s when cmpared t natinal, state, r lcal benchmarks. Further details and discussin regarding these indicatrs can be fund in previus sectins. 86

96 Exhibit 54A: Secndary Data Indicatrs f Cncern Categry Indicatr Lcatin Cmmunity Value Benchmark Data Frmat Benchmark Definitin Grwth in nn-white ppulatins Cmmunity 6.5%-17.5% 1.1% Percent White ppulatin Grwth in Hispanic ppulatin Cmmunity 18.9% 2.5% Percent Nn-Hispanic ppulatin Residents 5+ wh are linguistically islated Hennepin 6.9% 4.2% Percent MN average Residents 5+ wh are linguistically islated Ramsey 9.5% 4.2% Percent MN average Primary language f students: Hmng Ramsey 14.4% 2.4% Percent MN average Demgraphics Primary language f students: Russian Sctt 1.3% 0.3% Percent MN average Primary language f students: Smali Hennepin 3.8% 1.6% Percent MN average Primary language f students: Smali Ramsey 2.7% 1.6% Percent MN average Primary language f students: Spanish Dakta 5.3% 4.7% Percent MN average Primary language f students: Spanish Hennepin 8.4% 4.7% Percent MN average Primary language f students: Spanish Ramsey 6.8% 4.7% Percent MN average Educatinal achievement Ramsey Cunty rank Number f cunties Pverty rate: ttal ppulatin Hennepin 13.5% 11.9% Percent MN average Pverty rate: ttal ppulatin Ramsey 17.5% 11.9% Percent MN average Pverty rate: children Hennepin 17.9% 15.4% Percent MN average Pverty rate: children Ramsey 26.0% 15.4% Percent MN average Pverty Hennepin Cunty rank Number f cunties Pverty Ramsey Cunty rank Number f cunties Children enrlled in MFIP Hennepin 1.3% 0.8% Percent MN average Children enrlled in MFIP Ramsey 1.6% 0.8% Percent MN average Child hmelessness Hennepin Rate per 100,000 MN average Scial and Child hmelessness Ramsey Rate per 100,000 MN average Ecnmic Sectin 8 husing assistance wait time Anka Mnths MN average Factrs Sectin 8 husing assistance wait time Carver Mnths MN average Sectin 8 husing assistance wait time Hennepin Mnths MN average Sectin 8 husing assistance wait time Ramsey Mnths MN average Sectin 8 husing assistance wait time Washingtn Mnths MN average Students reprting free and reduced lunch (9 th ) Ramsey 43.5% 27.5% Percent MN average Students reprting free and reduced lunch (12 th ) Ramsey 36.0% 22.5% Percent MN average Family and scial supprt Hennepin Cunty rank Number f cunties Family and scial supprt Ramsey Cunty rank Number f cunties Teen pregnancy age Ramsey Rate per 100,000 MN average Births with n father n birth certificate Ramsey 15.4% 9.3% Percent MN average Surce: Verité analysis f secndary data,

97 Exhibit 54B: Secndary Data Indicatrs f Cncern Categry Indicatr Lcatin Cmmunity Value Benchmark Data Frmat Benchmark Definitin Student drug use ther than marijuana (9th) Anka 6.0% 3.5% Percent MN average Student drug use ther than marijuana (12 th ) Sctt 9.5% 5.5% Percent MN average Tbacc use Anka Cunty rank Number f cunties Health Unsafe sex Hennepin Cunty rank Number f cunties Behavirs Unsafe sex Ramsey Cunty rank Number f cunties Intermediate prenatal care Ramsey 26.1% 16.9% Percent MN average Inadequate r n prenatal care Ramsey 4.7% 3.1% Percent MN average Envirnmental quality Dakta Cunty rank Number f cunties Envirnmental quality Ramsey Cunty rank Number f cunties Envirnmental quality Washingtn Cunty rank Number f cunties Built envirnment Anka Cunty rank Number f cunties Physical Vilent crime Hennepin Rate per 100,000 MN average Envirnment Vilent crime Ramsey Rate per 100,000 MN average Cmmunity safety Anka Cunty rank Number f cunties Cmmunity safety Hennepin Cunty rank Number f cunties Cmmunity safety Ramsey Cunty rank Number f cunties Children arrested fr serius crimes Ramsey Rate per1,000 MN average Access t Care Insufficient mental health prviders Anka Rate per 100,000 MN average Mrbidity Mrbidity rate Hennepin Cunty rank Number f cunties Health Outcmes: Mrtality Mrbidity rate Ramsey Cunty rank Number f cunties Teen unbelted vehicle fatality percent f ttal Carver 20.0% 8.9% Percent MN average Teen unbelted vehicle fatality percent f ttal Ramsey 20.0% 8.9% Percent MN average Teen unbelted vehicle fatality percent f ttal Washingtn 33.3% 8.9% Percent MN average Child unintentinal injury percent f ttal injury Dakta 57.1% 47.8% Percent MN average Child unintentinal injury percent f ttal injury Hennepin 52.2% 47.8% Percent MN average Child hmicide percent f ttal injury Hennepin 23.9% 10.5% Percent MN average Child hmicide percent f ttal injury Ramsey 38.9% 10.5% Percent MN average Child suicide percent f ttal injury Anka 21.7% 16.3% Percent MN average Child suicide percent f ttal injury Carver 60.0% 16.3% Percent MN average Child suicide percent f ttal injury Ramsey 27.8% 16.3% Percent MN average Child suicide percent f ttal injury Sctt 60.0% 16.3% Percent MN average Child suicide percent f ttal injury Washingtn 55.6% 16.3% Percent MN average Child mtr vehicle fatality percent f ttal injury Dakta 28.6% 21.4% Percent MN average Surce: Verité analysis f secndary data,

98 Disparities f cncern Vulnerable ppulatins ften lack the resurces necessary t maintain ptimal health. Health indicatrs highlighting racial and ethnic disparities that appeared mst unfavrable in the cmmunity served by Children s are presented belw (Exhibit 55). Exhibit 55: Disparities f Cncern Categry Indicatr Lcatin Cmmunity Value Benchmark Data Frmat Benchmark Definitin Drput rate: White Ramsey 6.5% 3.3% Percent MN average Drput rate: American Indian/Alaska Native Anka 13.9% 3.0% Percent White ppulatin Drput rate: American Indian/Alaska Native Dakta 4.7% 2.2% Percent White ppulatin Drput rate: American Indian/Alaska Native Hennepin 16.7% 2.7% Percent White ppulatin Drput rate: American Indian/Alaska Native Ramsey 20.5% 6.5% Percent White ppulatin Scial and Drput rate: Asian Sctt 6.1% 2.6% Percent White ppulatin Ecnmic Drput rate: Asian Washingtn 2.5% 1.3% Percent White ppulatin Factrs Drput rate: Black Anka 7.0% 3.0% Percent White ppulatin Drput rate: Black Dakta 7.6% 2.2% Percent White ppulatin Drput rate: Black Hennepin 9.2% 2.7% Percent White ppulatin Drput rate: Black Ramsey 8.3% 6.5% Percent White ppulatin Drput rate: Hispanic r Latin Cmmunity 11.0% 3.0% Percent White ppulatin Access t Care Medically underserved ppulatins (MUPs) (Native American Ppulatin) St. Paul Present N/A N/A Present r nt present - n benchmark Health prfessinal shrtage areas (HPSAs) (Native American Ppulatin) Sctt Present N/A N/A Present r nt present - n benchmark Health Outcmes: Nn-White infant mrtality Ramsey Rate per 100,000 White ppulatin Mrtality Nn-White infant mrtality Hennepin Rate per 100,000 White ppulatin Surce: Verité analysis f secndary data,

99 Gegraphic areas f cncern Certain gegraphic areas within the cmmunity served by Children s exhibited higher levels f need when cmpared t the cmmunity as a whle. Secndary data shw that areas and ppulatins prximate t Minneaplis and St. Paul had particularly high levels f financial hardship, risk fr fd insecurity, and barriers t accessing care (Exhibit 56). Exhibit 56: Gegraphic Areas f Cncern Categry Indicatr Lcatin Cmmunity Value Benchmark Data Frmat Benchmark Definitin Minneaplis Lw-incme husehlds Schl Dist 25.7% 15.1% Percent Children's cmmunity ttal St. Paul Lw-incme husehlds Schl Dist 25.7% 15.1% Percent Children's cmmunity ttal Minneaplis Medicaid discharges Schl Dist 66.6% 44.8% Percent Children's cmmunity ttal Scial and Ecnmic Factrs Physical Envirnment Access t Care Medicaid discharges St. Paul Schl Dist 65.3% 44.8% Percent Children's cmmunity ttal Self-pay discharges Sctt 2.0% 1.0% Percent Children's cmmunity ttal High CNI scres Minneaplis CNI scre Wrst scre High CNI scres St. Paul CNI scre Wrst scre Fd deserts Minneaplis Present N/A N/A Present r nt present - n benchmark Fd deserts St. Paul Present N/A N/A Present r nt present - n benchmark Medically underserved areas (MUAs) Minneaplis Present N/A N/A Present r nt present - n benchmark Medically underserved areas (MUAs) St. Paul Present N/A N/A Present r nt present - n benchmark Health prfessinal shrtage areas (HPSAs) Hennepin Present N/A N/A Present r nt present - n benchmark Health prfessinal shrtage areas (HPSAs) Ramsey Present N/A N/A Present r nt present - n benchmark Surce: Verité analysis f secndary data,

100 Primary data assessment Cmmunity input was gathered thrugh interviews. Findings frm this primary data are presented belw. Key insights: Interviews» Pr mental health impacts the entire family and accessing treatment fr these issues is difficult.» Many parents thrughut the cmmunity need supprt in the frm f health educatin, basic life skills training, techniques fr prviding guidance and discipline t adlescents, and assistance translating health care knwledge int behaviral changes.» Language and cultural barriers, citizenship/residency cnditins, scial stigma, fear, cst, and a lack f prviders accepting Medicaid are majr barriers t accessing primary, mental health, and dental care.» Adlescents needs access t cnfidential sexual and reprductive medical services. Many in this ppulatin hesitate t seek care due t fear f scial repurcussins.» Diabetes, asthma, allergies, and besity are chrnic disease cncerns f the pediatric ppulatin.» Health risk behavirs such as substance abuse, pr diet, lack f exercise, and incmplete immunizatins are prevalent.» Families f children with cmplex needs require assistance with daily caregiving, scial and emtinal needs, and the lgistics f traveling t the hspital fr medical services.» Health system cmplexity, lack f integratin acrss prviders, regulatry and administrative burdens, and payment reductins result in frustratin fr bth patients and prviders.» Lack f insurance and lack f understanding f apprpriate use leads t insufficient primary care utilizatin and veruse f the emergency rm fr nn-emergent cnditins. 91

101 Summary f interview findings Interviews regarding health needs in the cmmunity served by Children s were cnducted with 63 key infrmants, including external stakehlders (thse nt affiliated with Children s) and internal staff. The interviews prvided input n a wide range f cmmunity health issues, including barriers t access t health services, changes in cmmunity ppulatin, prevalence f certain health cnditins, scial determinants f health, health disparities, and ther tpics. The interviews were guided by a structured interview guide, and interviewees were encuraged t identify and discuss all current and emerging issues affecting cmmunity health. Verité staff summarized all interview cmments and assessed the frequency with which cmmunity health issues were mentined and als assessed infrmant views regarding the severity f each cncern. The fllwing issues are cnsidered f greatest cncern t cmmunity health, based n that assessment. Issues are rdered based n the frequency and intensity f respnses: Pr Mental and Behaviral Health. Issues relating t pr mental health are prevalent and increasing thrughut the entire cmmunity, including depressin, bullying, child abuse, anger management, anrexia, and seasnal adjustment disrder. The impact f mental f illness f parents/caregivers n the develpment and mental health f infants, children, and adlescents is als a cncern. Other issues are mre cncentrated in subppulatins, ntably Psttraumatic Stress Disrder (PTSD) in refugee grups. These issues are exacerbated by a lack f integratin between medical and mental health, insufficient insurance access and cverage, inadequate payment rates t attract and retain prviders insufficient treatment capacity, insufficient language/culturally apprpriate care, lack f participatin in Medicaid/Medical Assistance by prviders, difficulty f effective drug management, and lack f free/lw-cst services, and travel fr treatment ut f the area. A fractin f referrals get treatment but even thse services that are prvided can be difficult t access. Skilled interpreters als may nt be readily accessible and ineffective interventins may be prescribed due t misdiagnses. Additinally, althugh a strng prvider-patient relatinship imprves health utcmes, relatinship strength varies between individual prvider-patient encunters. Effective treatment fr these issues is hindered by stigma assciated with diagnsis, cultural acceptance f symptms f mental illness as nrmal, and unrealistic expectatins fr quick treatment f lng-standing mental illnesses. Further, lack f frmal training fr first respnders increases the likelihd that the result f mental health crises will be incarceratin/detentin rather than treatment. Unsupprted Parenting. Lack f parenting knwledge negatively impacts children despite the best intentins f parents/caregivers. This lack f parenting knwledge ranges frm basic skills t mre specialized skills, such as cnflict reslutin and supervisin f lder children/adlescents. The reluctance fr parents/guardians t seek assistance due t perceptins f judgment, management f ther issues, wrk demands, and lack f awareness that prblems exist cmpunds this issue. In sme families, an inverted parent-child relatinship exists due t language r ther barriers. As a result, parents may wait t lng t seek parenting supprt. In sme cases that can result in child abuse and/r interventins frm the plice/curts. Parents/caregivers in the cmmunity may lack basic living skills, be unaware f available resurces, and be unable t translate health care knwledge int behaviral changes. Patients 92

102 may be mistrusting and/r intimidated by the size f institutinal facilities and cnfused by cnflicting messages, such as fd assistance ptins and nutritin cunseling. Finally, individuals may nt seek supprt due t misperceptins and fears, ntably fears f the unknwn, cncerns abut affrdability, reluctance t ask fr assistance, and fear fr physical safety in traveling t different facilities. Effective supprt fr parents needs t be prvided in a supprtive, culturally apprpriate manner which respects the rle f parents/caregivers. Parents need t be engaged in pen and hnest dialgue, and prvided materials that translate thery int readily applied practice, such as hw t pack a schl lunch. Lack f Access and Barriers t Care. Enhanced access t care is needed fr children/adlescents because f language, cultural and citizenship barriers, paperwrk/dcumentatin requirements, insufficient public transprtatin including fr suburban/exurban ppulatins, hurs f peratin, and the decreasing number f prviders wh accept Medical Assistance (MA). Interrupted insurance cverage is als a cncern due t MA s recertificatin requirements and changing cverage frm parents/caregivers. Lack f access t care is exacerbated by different cultural expectatins f care and the cmplexity f the medical system. Navigatin supprt is insufficient in the cmmunity. The lack f access and barriers t care is evidenced by the use f the ER fr nn-emergent cnditins and insufficient utilizatin f preventive care. Adlescent Needs. Adlescents have unmet needs fr cnfidential access t medical services, especially thse related t sexual and reprductive health, safety frm/alternatives t vilence, and interventins against substance abuse. Fr sme adlescents, the need fr cnfidentiality is significant due t ptential repercussins f sexual activity frm family members and vilence by gang members. Issues f cnfidentiality are impacted by lack f independent financial resurces, insurance dcuments that may disclse services received, misunderstandings cncerning prvider-patient cnfidentiality, and lack f available cmmunity services. Additinally, the transitin between pediatric and adult services needs t be imprved. Substance Abuse. Interventins are needed t respnd t abuse f alchl, prescriptin drugs, and illegal drugs. In additin t the persnal impact n users, prviders within the cmmunity are challenged t prvide services because f the mixing f different substances, varying strengths f illegal drugs, and the cntinual emergence f new substances. Prblems are increased in husehlds in which parents/caregivers d nt secure prescribed medicatins. Chrnic Disease. Imprved management f chrnic disease, including diabetes, asthma, and allergies is needed, especially given increases in the severity and number f impacted individuals. Integratin f services acrss the cmmunity, including schls, scial wrkers, and nutritinists is lacking, as evidenced by scpe f practice restrictins in schls that may delay treatment. Additinally, changes t the envirnmental factrs that impact chrnic disease, such as air particulates and parental stress levels, need t be addressed. Obesity, Insufficient Activity, and Pr Nutritin. Children and adlescents lack sufficient activity and apprpriate nutritin t maintain healthy bdy weights. The resulting besity is endemic acrss all grups and regins in the area. Many issues cmpund the need fr increased activity and imprved nutritin, including envirnmental factrs such as lack f access t healthy fds, ready access t unhealthy fd, and insufficient ptins fr safe, physical activity. Persnal factrs als increase besity, including lack f knwledge abut hw t prepare healthy fd ptin, verestimates f healthy prtin sizes, misperceptins f health fd ptins, and different cultural perceptins f healthy bdy weight. 93

103 Dental Needs. Mre access t dental services is needed by children and adlescents wh are uninsured r underinsured, especially thse individuals cvered by MA. Dental care needs have increased due t increased cnsumptin f nn-flurinated bttled water, limited MA acceptance by dentists, and resistance by sme parents/guardians t accept free services due t fear f judgment. Supprt fr Caregivers/Families f Children with Cmplex Needs. Children s is a key resurce fr children in need f specialized medical care, drawing patients frm the seven-cunty metr area and thrughut the state. Families and caregivers f children with special needs reprt that cnducting the activities f daily life can be verwhelming. These families require cmprehensive supprt fr daily caregiving and meeting the scial and emtinal needs f the entire family as well as greater awareness and empathy frm the wider cmmunity. Fr families wh live at distance frm Children s, the lgistics f recurring travel t the hspital fr medical services are daunting as well as ecnmically draining. ER Use. There are numerus reasns that parents/caregivers chse t use ER services fr nnemergency cnditins, including cncern fr the safety f children, lack f knwledge abut apprpriate ER use, ease f receiving services, and lack f health insurance. Use f the ER increases after the first visit, regardless f the emergent status f the patient. Prvider Expectatins. Prviders, as key members f and stakehlders in the Children s cmmunity, are perating in a system with enhanced expectatins fr services, changing regulatins, increased dcumentatin requirements, and reductins in payments. The result is verwrk, stress, and cmpassin fatigue by prviders as evidenced by reduced vlunteerism, lack f participatin in MA, and difficulty in recruiting new practitiners. The time demands frm high assigned caselads make it difficult fr prviders thrughut the cntinuum f care, including physicians, nurses, pharmacists, scial wrkers, and cmmunity health wrkers, t wrk cllabratively in the prvisin f care. Additinally, financial pressures necessitate cnslidatin f prviders int large systems yet sme in the cmmunity assign negative qualities t these entities due t the resulting scale and scpe. Patient Dissatisfactin. The delivery and financing f services by entities has yielded a system in which navigatin is difficult because f gegraphic distances and knwledge gaps. Patients are expected t manage their care yet lack system knwledge. Participants raised cncerns abut cnfrnting phne trees when calling prviders, interacting with stressed frnt line staff, and having t cmplete numerus detailed frms during perids f illness/injury. Further, patient ppulatins assess the degree t which the cmmunity is inclusive r exclusive by representatin f similar individuals n the entity bards, the lcal perspective f health services/insurance as a right r privilege, and the ease r difficulty in accessing services. Changing Ecnmy and Demgraphics. The ppulatin in the service area is becming mre diverse, with ntable increases in Latin, Sutheast Asian, and Smali ppulatins. Hwever, adjustments t prvide culturally apprpriate services lag behind and can result in misdiagnsis and ineffective treatment plans. Further, a set f cmmn, crss-cultural expectatins has nt been develped, leading t frictin frm unmet expectatins. Dwnturns in the ecnmy and a shift t service jbs increased unmet needs due t declines in incme and increases in uninsurance/underinsurance. Gegraphically, vulnerable ppulatins are becming mre cncentrated in Hennepin Cunty. Cmmunicable Diseases and Injuries. Incmplete immunizatins lead t preventable epidemics, such as whpping cugh and influenza. Similarly, preventable injuries result frm lack f r 94

104 misuse f safety equipment, such as absence f bicycle helmets, lack f car seats in taxis, and imprper installatin f car seats in private autmbiles. Infrmatin and Misinfrmatin. Prviding persnal and cmmunity health infrmatin t individuals is challenging because this infrmatin is ften cmplex. Simultaneusly, the benefits f interventins and preventive activities are difficult t measure and cmmunicate t the cmmunity and plicy makers. Misinfrmatin, such as the incrrect belief that vaccines cause disease, can be cmmunicated and accepted rapidly. 95

105 Individuals prviding cmmunity input The 63 stakehlders were cmprised f public health experts; individuals frm health r ther departments and agencies; leaders r representatives f medically underserved, lw-incme, and minrity ppulatins; and ther cmmunity members (Exhibits 57, 58, 59, and 60). Public health experts Individuals interviewed with special knwledge f r expertise in public health include (Exhibit 57): Exhibit 57A: Public Health Experts Interviewed Name Rina McManus SuzAnn Stens-Vel Bnnie Brueshff, RN, PHN, MSN Laurel Hff Marcee Shaugnessy Directr Title Planning Specialist Public Health Directr Directr f Cmmunity Health and Envirnmental Services Public Health Department Manager Affiliatin r Organizatin St. Paul Ramsey Cunty Public Health St. Paul Ramsey Cunty Public Health Dakta Cunty Public Health Department Anka Cunty Cmmunity Health and Envirnmental Services Department Carver Cunty Public Health Special Knwledge r Expertise Rina McManus has ver 40 years f experience in public health and safety issues. She led the Anka Cunty Cmmunity Health and Envirnmental Services Department fr 20 years and has als been the Deputy Cmmissiner f the Minnesta Department f Public Safety and as a Nursing Directr in St. Luis Cunty. SuzAnn Stens-Vel has wrked in Ramsey Cunty fr 10 years. She is respnsible fr cmmunity health imprvement plans and the accreditatin prcess, with expertise in public health. Bnnie Brueshff manages and prvides leadership fr the Public Health Department in Dakta Cunty. In the past, she has wrked as Public Health Deputy Directr and Supervisr fr Dakta Cunty and Apnea Hme Mnitring Crdinatr at Minneaplis Children s Medical Center. Laurel Hff has been the Directr f Cmmunity Health & Envirnmental Services and has served as Public Health Nursing Directr, with expertise in nursing and health issues. Marcee Shaugnessy is the Public Health Department Manager and Alternate Appintment t the State Cmmunity Health Services Advisry Cmmittee (SCHSAC) fr Carver Cunty. 96

106 Exhibit 57B: Public Health Experts Interviewed Name Ellen de Schwitzenberg Jennifer Deschaine Sue Hedlund Gretchen Musicant Karen Zeleznak, MPH Mlly Snuggerud, RN David Brummel Tdd Mnsn Cheryl Burke Title Family Health Directr Directr f Health and Public Services Deputy Directr Cmmissiner Directr and Public Health Administratr Family Health Prgram Manager Public Health Imprvement Crdinatr Public Health and Case Management Area Directr Cunty Crdinatr Affiliatin r Organizatin Sctt Cunty Public Health Sctt Cunty Public Health Washingtn Cunty Public Health and Envirnment Minneaplis Department f Health and Family Supprt Blmingtn Public Health Blmingtn Public Health Hennepin Cunty Human Services and Public Health Department Hennepin Cunty Human Services and Public Health Department St. Paul Ramsey Cunty Public Health Special Knwledge r Expertise Ellen de Schwitzenberg has public health expertise thrugh her jb as the Family Health Directr at Sctt Cunty Public Health. Jennifer Deschaine came t Sctt Cunty in June She has directed a number f initiatives, including leading Sctt Cunty s respnse t the 2009 H1N1 pandemic, assisting with the frmatin f the Meth Task Frce, and wrking with the Shakpee Mdewakantn Siux Cmmunity t establish the Mbile Health Clinics prgram. Sue Hedland is the Deputy Directr f Public Health and the Envirnment in Washingtn Cunty and is the Chair f the Health & Wellness Advisry Cmmittee. She has als served as Prgram Manager f Washingtn Cunty Public Health. Gretchen Musicant is the Cmmissiner f the Minneaplis Department f Health and Family Supprt and previusly has served as the Directr f Public Health Initiatives. Karen Zeleznak has public health expertise thrugh her rle at Blmingtn Public Health. Mlly Snuggerud is a Family Health Prgram Manager at Blmingtn. She als has public health experience wrking as a Prenatal Educatr at Ridgeview Medical Center, and has been the Prgram Directr f West Suburban Teen Clinic. David Brummel is the Public Health Imprvement Crdinatr with Hennepin Cunty Human Services and Public Health and als has served as the Cmmunity Health Prgram Supervisr. Tdd Mnsn has expertise n a variety f public health issues including disabilities and senir issues. Cheryl Burke wrks as the cunty crdinatr fr St. Paul Ramsey Cunty Public Health. 97

107 Health r ther departments r agencies Several interviewees were frm departments r agencies with current data r ther infrmatin relevant t the health needs f the Children s cmmunity (Exhibit 58). This list excludes the public health experts identified in Exhibit 57. Exhibit 58: Individuals frm Health Departments r Agencies Interviewed Name Title Affiliatin r Organizatin Sctt Leitz Assistant Cmmissiner Minnesta Department f Human Services Glenace Edwall, PhD, PsyD, LP, Directr f the Children s Minnesta Department f Human Services MPP Mental Health Divisin Cmmunity leaders and representatives The fllwing individuals were interviewed because they are leaders r representatives f medically underserved, lw-incme, and/r minrity ppulatins (Exhibit 59). This list excludes the public health experts identified in Exhibit 57. Exhibit 59A: Cmmunity Leaders r Representatives Interviewed Name Shirlynn LaChapelle, RN Title President Affiliatin r Organizatin Minnesta Black Nurses Assciatin Nature f Leadership Rle Shirlynn LaChapelle has experience with a minrity ppulatin as President f the Minnesta Black Nurses Assciatin. Kathleen Tmlin Vice President f Scial Justice Advcacy Cathlic Charities f St. Paul and Minneaplis Kathleen is the Vice President f Scial Justice Advcacy and supervises the Office fr Scial Justice at Cathlic Charities. Mary Ann Sullivan, MSW, LISW Vice President fr Prgram Operatins Cathlic Charities f St. Paul and Minneaplis Mary Ann Sullivan has 30 years f experience in a leadership rle with Cathlic Charities. She has held varius rles as a part f Family Services Divisin. She began her career as a psychiatric scial wrker at Middlesex State Hspital in Middletwn, Cnnecticut. Jse William Castellans, MD, PhD Senir Directr f the Cmmunity Health Wrker Services (at the time f interview) Cmunidades Latins Unids En Servici (CLUES) DREGAN Prject At the time f the interview, Dr. Castellans wrked fr CLUES, a culturally-sensitive research prgram fr the Latin Cmmunity in Minnesta. As an emergency medicine physician, Dr. Castellans has directed natinal and internatinal public health cmmunity-based initiatives in health prmtin and preventin. 98

108 Exhibit 59B: Cmmunity Leaders r Representatives Interviewed Name Patricia Harmn Wendy Ringer Nra Slawik, MPA Matthew Flry Gretchen Ambrsier Tm Steinmetz, MA Elaine Cunningham Crystal (Trutnau) Windschitl Kendall Munsn Title Executive Directr Family-t-Family Health Infrmatin Center Crdinatr Directr f Educatin at Autism Sciety f Minnesta (AuSM) Directr f Healthcare Partnerships Vice President f Prgrams Chief Operating Officer/Prgram Directr Outreach Directr Executive Directr Family Resurce Center Crdinatr Affiliatin r Organizatin Crner Huse PACER (Parent Advcacy Calitin fr Educatinal Rights) Autism Sciety American Cancer Sciety Rnald McDnald Huse Washburn Center fr Children Children s Defense Fund Phillips West Neighbrhd Organizatin Children s Nature f Leadership Rle Patricia Harmn has been respnsible fr the verall management f the Center and cntinued develpment f prgramming in rder t meet the missin f Crner Huse. Patricia has ver 20 years f experience wrking in nt-fr-prfit leadership, the majrity f which has been in the field f child welfare. Wendy Ringer is the Family-t-Family Health Infrmatin Center Crdinatr fr PACER, an rganizatin fcused n children with disabilities. Nra Slawik handles Autism Discvery prgrams, and grup-specific autism training; her area f expertise is in autism and early childhd plicy issues. As the Minnesta Directr f Healthcare Partnerships, Matthew Flry is respnsible fr increasing the rate f cancer screening thrugh strategic cllabratins and state and lcal agencies. Gretchen Ambrsier prvides marketing and cmmunity relatins supprt t the Rnald McDnald Care Mbile prgram. Gretchen has past wrk experience at the American Red Crss Twin Cities Chapter fr nearly 5 years in multiple rles, including Cmmunity Prgrams and Outreach Manager. She has als wrked as the Outreach Crdinatr fr Partners fr Vilence Preventin in St. Paul. Tm has presented natinally and lcally n treating child trauma and aggressin, develping and sustaining schl-based mental health services. Elaine Cunningham has been the Outreach Directr fr nearly 12 years at Children s Defense Fund. Crystal (Trutnau) Windschitl is the Executive Directr fr the Philips West Neighbrhd Organizatin, an rganizatin fcusing n develpment f the Phillips West neighbrhd. Kendall Munsn prvides supprt fr family planning prgrams and services t the cmmunity. 99

109 Exhibit 59C: Cmmunity Leaders r Representatives Interviewed Name Title Affiliatin r Organizatin Dealla Cahw WIC Supervisr Children s Lisa Buchal Tessa Billman David Teschler, RN Leah Hebert Clinical Scial Wrker Family Advisry Cuncil Family Crdinatr Clinic Manager Executive Directr Children s Children s Native American Cmmunity Clinic Open Arms f Minnesta Nature f Leadership Rle Dealla Cahw prvides training and supprt n breast feeding and nutritin educatin. Lisa Buchal prvides services t all inpatient units and several utpatient units/clinics in the hspital. The Family Advisry Cuncil represents inpatient and utpatient experiences wrking cllabratively with staff t prmte and enhance family-centered care and t imprve the family and patient experiences. Tessa prvides a supprting rle in establishing prgrams fr this bjective. David Teschler is the Clinic Manager at the Native American Cmmunity Clinic, which prvides medical, dental, cunseling, and supprt services fr the Native American Cmmunity, especially fr underserved and underrepresented grups. Leah Herbert is the Executive Directr f Open Arms f Minnesta, which prvides free meals t individuals in the cmmunity, especially thse with HIV/AIDS, MS, ALS, breast cancer and mre than 60 ther diseases. 100

110 Persns representing the brad interests f the cmmunity Exhibit 60: Other Interviewees Representing the Brad Interests f the Cmmunity Name Title Affiliatin r Organizatin Carmen Teskey, MA, BSN, RN Nursing Services Manager Minneaplis Public Schls Dn Greeley Officer Minneaplis Plice Department Lucy Gerld Officer Minneaplis Plice Department Mark Blumberg Officer St. Paul Plice Department Kevin Miller Medical Transprt Directr f Operatins Allina Dan DeSmet Reginal Manager Nrth Memrial Hspital Mary Yackley, RN, LSN, MA Supervisr, Student Health and Wellness St. Paul Public Schls Erin Petersen Crdinatr, Family Safety Prgrams Minnesta Safety Cuncil Luis Ramirez-Regalad Prgram Crdinatr, Strng, Fast, Fit YWCA Minneaplis Amy Ward Manager, Health Care Initiative Wilder Fundatin Elizabeth Petersn, PhD Directr f Research & Planning Greater Twin Cities United Way Stephanie Devitt Public Affairs Cnsultant The Bush Fundatin Gary Schiff Cuncilmember Minneaplis City Cuncil Gwen Riedl Manager Organizatinal Develpment Children s Dave Brumbaugh Vice President, Human Resurces Children s Jhn Chavers HR Business Partner Children s Bbbie Carrll Sr. Directr f Patient Safety and Infrmatics Children s Julie Bman, MD Staff Physician, Gen Pediatric Clinic Children s David Hirschman, MD Trauma C-Medical Directr Children s Tnet Barry, MSN, RN Patient Care Manager Children s Dnald Brunnquell, PhD, LP Directr, Ethics Children s Pamela Gigi Chawla, MD Medical Directr, General Pediatrics Clinic, St. Paul (At time f interview) Children s Sheldn T Berkwitz, MD Medical Directr, General Pediatrics Clinic, Minneaplis Children s Erik Bjerke Specialty Clinic Manager Children s Lisa Levy Specialty Clinic Manager Children s Kim Flaata, RN RN Clinic Supervisr Children s Dave Aughey, MD Medical Directr f Adlescent Health Children s Clark Smith, MD Chief f Pediatrics Children s Lisa Fray Assistant Clinical Manager Children s 101

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114 University f Wiscnsin Public Health Institute and Rbert Wd Jhnsn Fundatin. (2012.). Cunty Health Rankings: Mbilizing Actin Tward Cmmunity Health. Retrieved 2012, frm U.S. Bureau f Labr Statistics. (n.d.). Unemplyment Rates. Retrieved 2012, frm U.S. Census Bureau. (n.d.). Demgraphic Data. Retrieved 2012, frm U.S. Centers fr Disease Cntrl and Preventin. (2011). Behaviral Risk Factr Surveillance System. Retrieved 2012, frm U.S. Department f Health and Human Services. (2010). Cmmunity Health Status Indicatrs Prject. Retrieved 2012, frm U.S. Department f Husing and Urban Develpment. (2009). A Picture f Subsidized Husehlds fr Retrieved 2012, frm U.S. Health Resurces and Services Administratin. (n.d.) Area Resurce File. Retrieved 2012, frm U.S. Health Resurces and Services Administratin, Bureau f Health Prfessinals. (n.d.). Health Prfessinal Shrtage Area Designatin Criteria. Retrieved 2012, frm U.S. Health Resurces and Services Administratin. (n.d.) Guidelines fr Medically Underserved Area and Ppulatin Designatin. Retrieved 2012, frm U.S. Health Resurces and Services Administratin. (n.d.). Shrtage Areas. Retrieved 2012, frm Washingtn Cunty Cmmunity Services Child Care Licensing Prgram. (2011, September/Octber). Washingtn Cunty Child Care Statistics in Minnesta. Caring and Sharing Newsletter. Retrieved 2012, frm Washingtn Cunty Department f Public Health and Envirnment. (2008). Washingtn Cunty Cmmunity Health Assessment Retrieved 2012, frm Wessel, Christina. (2011, July 22). Health and Human Services Budget Asks Vulnerable Minnestans t Pay a Price. Retrieved 2012, frm Wilder Research. (2008, July). East Metr Husing Need: Prjectins f lw-incme and cstburdened husehlds by 2010 and Retrieved 2013, frm Research/Publicatins/Studies/East%20Metr%20Husing%20Needs/East%20Metr%20H using%20need%20-%20prjectins%20f%20lw-incme%20and%20cstburdened%20husehlds%20by%202010%20and%202020,%20full%20reprt.pdf Wilder Research. (2010, January). Hennepin Cunty Children s Health Cllabrative: System f Care Assessment. Retrieved 2012, frm Research/Publicatins/Studies/Hennepin%20Cunty%20Children%27s%20Mental%20Healt h%20cllabrative/system%20f%20care%20assessment.pdf Wilder Research. (2010, June). Hmng Mental Health Assessment- An Assessment f mental health needs and services in the Hmng Cmmunity in Ramsey Cunty. Retrieved 2013, 105

115 frm Research/Publicatins/Studies/Hmng%20Mental%20Health%20- %20An%20Assessment%20f%20Mental%20Health%20Needs%20and%20Services%20fr%2 0the%20Hmng%20Cmmunity%20in%20Ramsey%20Cunty/Mental%20Health%20Needs %20and%20Services%20fr%20the%20Hmng%20Cmmunity%20in%20Ramsey%20Cunty,%20Full%20Reprt.pdf Wilder Research. (2011). Hmelessness in Minnesta, 2009 Study. Retrieved 2012, frm Research/Publicatins/Studies/Frms/Study/dcsethmepage.aspx?ID=49&FlderCTID=0 x0120d52000f239ca0ed16f9a49b139aa a21dcc750948ad7da FC83C&List=5ffe87fb-8c cc-db1b1907fa0a&RtFlder=%2FWilder- Research%2FPublicatins%2FStudies%2FHmelessness%20in%20Minnesta%2C%202009%2 0Study Wilder Research. (2011, May) Minnesta Hmeless Study: Hmeless Children and their Families. Retrieved 2012, frm Research/Publicatins/Studies/Hmelessness%20in%20Minnesta,%202009%20Study/Hm eless%20children%20and%20their%20families,%20full%20reprt Yungerman, Anna. (2012). Special Needs Fcus Grup. Children s Hspitals and Clinics f Minnesta. 106

116 Abut Verité Healthcare Cnsulting Verité Healthcare Cnsulting, LLC (Verité) was funded in May 2006 and is lcated in Alexandria, Virginia. The firm serves as a natinal resurce that helps hspitals cnduct cmmunity health needs assessment and develp implementatin strategies that address pririty needs. The firm als helps hspital assciatins and plicy makers with cmmunity benefit reprting, planning, prgram assessment, and plicy and guidelines develpment. Verité is a recgnized, natinal thught leader in cmmunity benefit and in the evlving expectatins that tax-exempt healthcare rganizatins are being required t meet. The CHNA prepared fr Children s Hspitals and Clinics f Minnesta was directed by the firm s president and managed by a senir-level cnsultant. Assciates and research analysts supprted the wrk. The firm s president, as well as all senir-level cnsultants and assciates, hld graduate degrees in relevant fields. Verité Healthcare Cnsulting s wrk reflects fundamental cncerns regarding the health f vulnerable peple and the rganizatins that serve them Mre infrmatin n the firm and its qualificatins can be fund at 107

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