Community Health Needs Assessment

Transcription

1 2015 Community Health Needs Assessment Tarzana Treatment Centers, Inc Oxnard Street, Tarzana, CA 91356

2 2015 Community Health Needs Assessment ACUTE PSYCHIATRIC HOSPITAL SPA 2

3 Prepared by Program Development Department CHNA Planning Team José C. Salazar, DrPH Clarita Lantican, PhD Acknowledgements Michael Gutierrez, MA Ronna Montgomery, MPH The Community Health Needs Assessment (CHNA) Team acknowledges the participation and support of the following TTC staff members in conducting the 2015 Community Health Needs Assessment: Alex Sandro Salazar, MA Dean Vitelli Desireé Arroyo-Espinet, CHES Garrett Lee Judy Lucks, CAADE Keith Star, LMFT, MBA Michele Comeaux Stan Galperson

4 Table of Contents Executive Summary.1 Introduction..5 Demographic, Social, Economic, Health, and Other Characteristics of the Population Served...7 Process and Methods..18 Findings.. 20 Prioritization of Health Needs Evaluation of the 2012 CHNA Implementation Plan Primary Health Care Facilities and Other Resources Available in Community Served 37 Agency Collaboration in SPA 2.42 List of Tables and Figures..43 References and Bibliography.43 List of Attachments 40

5 EXECUTIVE SUMMARY Tarzana Treatment Centers, Inc. (TTC) prepared the 2015 Community Health Needs Assessment (CHNA) for its Acute Psychiatric Hospital in compliance with the Patient Protection and Affordable Care Act enacted on March 23, 2010, section 501(r) requirement on 501(c) (3) tax- exempt hospitals to conduct CHNA every three years. The objectives of TTC s CHNA are to: 1) define the community TTC serves; 2) describe demographic, social, economic, health and other characteristics of the community served; 3) describe the process and methods used to conduct the assessment; 4) assess the health needs perceived by community members (including providers and clients); 5) assess existing primary health care facilities and other resources within the community available to meet the identified community health needs; and 6) describe how individual providers collaborate to deliver services. TTC established a CHNA planning team under the leadership of Dr. José C. Salazar, TTC s Director of Program Development and Contract Compliance, with Dr. Clarita Lantican as the lead Principal Investigator. Dr. Lantican s staff, Michael Gutierrez, MA, and Ronna Montgomery, MPH, formed the core team. This team worked collaboratively and engaged additional TTC employees and other community stakeholders. Three methods were used to address the objectives of the CHNA, including a patient survey, patient focus groups, and key informant interviews (KII) with community stakeholders. These methods of data collection allowed TTC to identify potential priority areas based on the current status of services available by TTC and other providers, and the potential service gaps in the communities TTC serves. Additionally, TTC s CHNA team reviewed existing secondary epidemiological and demographic data sources, past community needs assessment studies, and inventories of current health facilities and services in the community. Definition of Community TTC s Acute Psychiatric Hospital, referred to as the Inpatient Facility, is located in the city of Tarzana, California, in Los Angeles County (LAC). LAC is divided it into 8 Service Planning Areas (SPAs) based on geographic region for the purpose of development and coordination of public health and medical services within the County. TTC s Acute Psychiatric Hospital is located in SPA 2, which covers the San Fernando and Santa Clarita Valleys. SPA 2 is identified as the community of focus in preparing this year s CHNA. Clients receiving treatment in our Inpatient and Residential Facilities were chosen to represent the target population within the surrounding SPA 2 community. SPA 2 contains a large and diverse demographic, social, and economic population with a variety of health related characteristics. There are currently more than two million people living in SPA 2. The gender identification of SPA 2 residents is almost evenly split between female (50.5%) and male (49.5%). There are a higher percentage of people who identify as White, followed by Latinos, Asians, African Americans, and people who identify as Other (or multiple) races. The majority of people living in SPA 2 are adults age (29.9%), followed by older adults ages (25.7%), children ages 0-14 (19.2%), young adults ages (13.9%), seniors ages (9.9%) and the smallest percentage of people are 85 years or older in age (1.6%). The largest percentage of SPA 2 residents live in households that earn between $15,000 to less than $35,000 (18.8%), followed by residents in households who earn $50,000 to less than $75,000 a year 1

6 (16.5%). In terms of poverty, 15.0% of SPA 2 residents have a household income of less than 100% Federal Poverty level (FPL), compared to 18.0% in LAC overall. Eighty-one percent of the SPA 2 population have completed High School or achieved a level of educational attainment beyond High School. The most prevalent diseases in SPA 2 include cardiovascular diseases, especially hypertension, which affects the largest percentage of the population (30.9%), followed by asthma (8.7%), cardiovascular disease (8.0%), diabetes (6.7%), cancer (2.7%), and stroke (2.2%). The leading causes of death (in order of highest incidence) in SPA 2 are coronary heart disease (21.9% of all deaths), stroke (5.3%), and lung cancer (5.2%). The 2014 Annual Los Angeles County Department of Public Health (LAC-DPH) HIV/STD Surveillance Report shows that there were 6,861 people living with HIV/AIDS in SPA 2 at the end of By race, Whites and Latinos represent the largest percentage of people living with HIV/AIDS, at 32% and 42%, respectively. With an overall prevalence of 313 per 100,000, SPA 2 accounts for 14% of all people living with HIV/AIDS in LAC. There were an additional 2,846 people living with Non-AIDS HIV in SPA 2 at the end of 2013, which also accounted for 14% of all people living with Non-AIDS HIV in LAC. Process and Methods The process and methods to identify and prioritize the health needs of the community involved designing the assessment tools, collecting primary and secondary data, and then analyzing this data. A patient survey, interviews with community stakeholders, and focus groups with the target population were the methods used to collect primary data. These methods were the most appropriate to identify health needs based on the current status of services available by TTC and other providers, and to detect any service gaps in the communities TTC serves. The team conducted KIIs with key partners of TTC, surveyed available clients at the Inpatient Facility, and held focus group at TTC s Central residential facility. A total of 18 KIIs were conducted with community stakeholders, 127 surveys were collected, and 12 patients at TTC s Central residential facility participated in 2 focus groups. Based on consolidation of health needs identified by the patient survey, focus group participants, and key informants, TTC will focus on the following six (6) priorities during the implementation period. Priority 1. TTC will continue to provide the full continuum of SUD treatment services in the community with an emphasis on providing targeted outreach and engagement activities to TAY youth, homeless individuals and LGBTQ community. Priority 2. TTC will continue to provide the full continuum of MH treatment services to address stigma and serious mental illness (SMI) in the community with an emphasis on increasing community knowledge and access to underutilized programs for children and youth such as EPSDT, PEI and mild to moderate services. Priority 3. TTC s will assign to the existing CLAS Standards subcommittee the task of developing a plan to increase TTC s staff cultural competency via on-going CLAS standards staff training and development of a hiring and retention plan to increase TTC s staff bi-lingual (English/Spanish) language capability. 2

7 Priority 4. TTC will continue to implement its current patient tobacco cessation activities with an emphasis on impacting TAY youth and monitor adherence to TTC s tobacco written policy and procedure. Priority 5. TTC will continue focus on integrating behavioral health and medical care services by focusing on chronic diseases prevalent in the communities we serve (e.g. diabetes, obesity, asthma, high blood pressure, etc.) and it s interaction with SUD/MH. This includes addressing comorbidity and need to provide integrated and coordinated care via shared electronic charting and regular provider case communication and conferencing. Priority 6. TTC will continue to provide benefits assistance to patients including education to under insured and undocumented patients who may be able to access primary medical care and/or behavioral health services via State benefits and/or local benefits such as MyHealthLA. TTC will seek to expand the number of patients seen in SUD treatment services under MyHealthLA. Existing facilities and other resources within the community available to meet the identified community health needs Tarzana Treatment Centers, Inc. s (TTC) Central facility is located in Tarzana, California. It is licensed as an acute psychiatric hospital by the California Office of Statewide Health Planning and Development (OSHPD). Based on the 2014 OSPHD Hospital Utilization Data, LAC has a total of 11 facilities licensed as an acute psychiatric hospital and 2 facilities are located in SPA 2. TTC s Inpatient Facility is the one of the 2 licensed acute psychiatric hospitals in LAC and the only facility in SPA 2 that provides comprehensive services to individuals with mental and chemical dependency co-occurring disorders (COD). TTC offers 24-hour inpatient services for detoxification, residential treatment, and outpatient services. Throughout LAC, there are 4 OSHPD licensed hospitals and 2 community-based health facilities that provide similar services to individuals with COD. Collaboration of health providers to meet health needs TTC s key informants provided their insights and feedback concerning collaboration among healthrelated agencies in SPA 2. To summarize, the agencies collaborated to provide/receive referrals for clients, share data and information, enhance program implementation and provide technical assistance to other agencies. The agencies represented by the key informants have been collaborating with other agencies to address and/or resolve health issues. Key informants discussed the continued improvement in networking among community-based agencies in SPA 2, so that one agency s clients continue to receive a warm hand-off to others. For example, collaborative efforts in which comprehensive services are offered involve the placement of other agencies at a partner s site for seamless referrals. Some key informant have experienced difficulty in securing resources for areas that the County perceives to have less demand (such as peer mentoring and navigation), which makes collaborative efforts vital. Other suggestions for improving collaborations are the continued strategic development of various MOU s that need to be honored so that clients that are being referred out to other agencies will receive services sooner and not become discouraged. More community involvement is also an urgent need in some areas of SPA 2, in terms of starting or maintaining community groups, and welcoming the participation of local elected officials. There should be a strong push for meaningful opportunities for 3

8 involvement, such as community round-tables, with leading participants who will motivate the community around them and which the community can hold accountable. One informant also suggested the creation of community liaisons within public health agencies that assist clients with securing benefits, which would help ease the difficulty of navigating the local healthcare system options. Current collaborative efforts that have shown promise in meeting the health needs of the SPA 2 community include the SFV Providers Collaborative, and Valley Care Community Consortium (VCCC). A recent collaborative effort of note is the LAC-DMH Office of Integrated Care s Health Neighborhoods initiative. This effort was kicked off in the summer of 2014 to bring together mental health providers, public health, and SUD treatment providers, and other social service and community support agencies in the County. The focus of the initiative was to involve specific local regions/neighborhoods. This place-based approach would allow LAC residents to receive comprehensive, community-based care and prevention-oriented services to increase the overall health of the population, while decreasing health risks and trauma. Additionally, Northridge Hospital s Community Benefit Grants program, which TTC has actively been involved since 2004, is also an opportunity for community-based nonprofit agencies to collaborate with the Hospital on significant projects such as decreasing unnecessary Emergency Department utilization. Efforts such as these integrate health care services with large HMO and other providers so that smaller agencies can benefit from referrals to behavioral health, SUD treatment, and other services. Another example of a County-wide collaborative effort is LAC-DPH s Community Health Improvement Plan (CHIP), which is a collaborative effort to improve the health of all people living LAC. In November 2015, a representative of TTC and member of the CHNA staff attended the CHIP kick-off meeting. This meeting attempted to gather important feedback for LAC-DPH to amend or correct the particular goals set forth for three main priority areas. These priority areas are: Increasing prevention to Improve Health, Creating Healthy and Safe Communities, and Achieving Equity and Community Stability. The key priority areas and associated goals will be highlighted in this report to parallel the paths to improvement that will guide all partnering agencies in the County. In this year s CHNA report, 4 goals within the 3 CHIP priority areas will be highlighted in the following pages. These 4 goals include: prevent chronic disease, increase access to care, reduce transmission of infectious disease, and prevent and treat substance use disorder (SUD). 4

9 INTRODUCTION Tarzana Treatment Centers, Inc. (TTC) is a full-service behavioral healthcare organization that provides high quality, cost-effective substance use disorder (SUD) and mental health treatment to adults and youth. We are a non-profit, community-based organization that operates an acute psychiatric hospital, residential and outpatient alcohol and drug treatment centers, and family medical clinics. All facilities are licensed and certified by the State of California and the County of Los Angeles and are accredited by The Joint Commission. TTC prepared the 2015 Community Health Needs Assessment (CHNA) report for its Acute Psychiatric Hospital in compliance with the Patient Portability and Affordable Care Act, section 501(r) requirement on 501(c) (3) tax-exempt hospitals to conduct a CHNA every three years. The objectives of a CHNA are to: 1) define the community we serve; 2) describe demographic, social, economic, health and other characteristics of the community/populations served; 3) describe the process and methods used to conduct the assessment; 4) assess the health needs perceived by providers, clients, and members of the community; 5) assess existing primary health care facilities and other resources within the community available to meet the identified community health needs; and 6) describe how individual providers collaborate to deliver services. Definition of community served TTC s Acute Psychiatric Hospital, referred to as the Inpatient Facility, is located in Tarzana, California, in Los Angeles County (LAC), and within the boundaries of SPA 2. SPA 2 is identified as the community of focus in preparing this year s CHNA. LAC is divided it into 8 SPAs based on geographic region for the purpose of the development and coordination of public health and medical services within the County. SPA 2 includes the cities of Burbank, Calabasas, Canoga Park, Chatsworth, Encino, Glendale, Granada Hills, La Cañada Flintridge, La Cresenta, Mission Hills, North Hills, North Hollywood, Northridge, Pacoima, Panorama City, Porter Ranch, Reseda, San Fernando, Sherman Oaks, Studio City, Sunland, Sun Valley, Sylmar, Tarzana, Tujunga, Universal City, Van Nuys, Valley Village West Hills, Westlake Village, Winnetka, and Woodland Hills. The zip codes of these cities run from through a total of 63 zip codes. The Inpatient Facility also provides services to clients from other SPAs as well. However, more than half (54%) of clients that TTC served in 2015 resided in San Fernando Valley, while the remaining 46% resided outside of the San Fernando Valley and within LAC (Table 1). 5

10 Table 1: Patient Residence and Distance to TTC Inpatient Psychiatric Facility by SPA, 2015 Estimated Service Planning Area (SPA) Distance to Number of Inpatient Clients (n) SPA 1 Antelope Valley (AV) Facility (Miles) SPA 2 San Fernando & Santa Clarita Valleys (SFV SPA 3 & SCV) San Gabriel Valley (SGV) SPA 4 Metropolitan (Metro) SPA 5 West Los Angeles (West) SPA 6 South Los Angeles (South) SPA 7 East Los Angeles (East) SPA 8 South Bay (South Bay) The location of the Inpatient Facility is highlighted in Figure 1. Within SPA 2, the maximum distance to this facility is approximately 30 miles (from La Cañada Flintridge). Figure 1: Map of Los Angeles County SPA s and Location of TTC Inpatient Facility Inpatient Facility 6

11 DEMOGRAPHIC, SOCIAL, ECONOMIC, HEALTH, AND OTHER CHARACTERISTICS OF THE POPULATION SERVED The variation in demographic, socioeconomic characteristics and other social/physical determinants, can affect an individual s (or group s) quality of life, health, and health-related values/ priorities. 1 To understand the factors that may affect the health of those living in our community, it is necessary to first present the demographic and socioeconomic profile of SPA 2 residents as compared to LAC residents. The following subsections use the latest data available from a variety of secondary data sources. Population LAC will continue to experience slow but steady growth, with the total population projected to pass 10.5 million people by Currently, there are more than 2 million people living in SPA 2. In fact, the population of SPA 2 is approximately 22% of the total population of LAC (Table 2). A result of the implementation of the Patient Portability and Affordable Care Act (ACA) and the growing population of the San Fernando Valley, TTC anticipated that more consumers would be able to access care from a variety of providers within the San Fernando Valley and surrounding areas. This will allow TTC s Inpatient Facility to serve a larger proportion of clients from SPA 2, as well as from other SPAs of LAC. TTC s own plans of expansion are intended to meet the needs of the growing insured population as a result of healthcare expansion, not only on the national level, but also on the State and local level. Table 2: SPA 2 and L.A. County Population, 2014 SPA 2 L.A. County Population 2,190,319 10,069,036 Source: Los Angeles County Demographic Profile, LAC DPH, 2014 Population by Gender The population of SPA 2 is fairly evenly split, with 50.5% female and 49.5% male. This is consistent with the gender breakdown of LAC as a whole. Table 3: SPA 2 and L.A. County Population by Gender, 2014 SPA 2 L.A. County N % N % Male 1,084, % 4,966, % Female 1,105, % 5,102, % Total 2,190, % 10,069, % Source: Los Angeles County Demographic Profile, LAC DPH,

12 Population by Ethnicity The population of SPA 2 is racially and ethnically diverse with no clear majority population. Overall, in SPA 2 there is a higher percentage of people who identify as White, followed by Latinos, Asians, African Americans, and people who identify as Other. Furthermore, 18% of Latinos in LAC, and 34% of all non-hispanic whites in LAC live in SPA 2. 3 Table 4: SPA 2 and L.A. County Population by Race/Ethnicity, 2014 SPA 2 L.A. County N % N % Latino 872, % 4,854, % White 981, % 2,856, % Asian 251, % 1,445, % Black 78, % 867, % Other 6, % 44, % Total 2,190, % 10,069, % Source: Los Angeles County Demographic Profile, LAC DPH, 2014 The majority of people living in SPA 2 are between the ages 25 to 44 (29.6%), followed by older adults between the ages 45 to 64 (26.0%), children (18.8%) and seniors (10.1%). The smallest percentage of people is 85 years or older (1.7%). As expected, there is no significant difference in the age distribution of LAC residents. More than half of the SPA 2 and overall LAC population are between 25 and 64 years old. Approximately 20% are children (0-14 years) and 11% are seniors and elderly. The largest difference is that there seems to be a slightly higher percentage of older adults, and a slightly lower percentage of young adults, in SPA 2, as compared to LAC. Table 5: SPA 2 and L.A. County Population by Age, 2014 Estimates SPA 2* L.A. County N % N % Children (0-14) 389, % 1,924, % Young Adults (15-24) 285, % 1,491, % Adults (25-44) 613, % 2,941, % Older Adults (45-64) 537, % 2,466, % Seniors (65-84) 209, % 984, % Elderly (85+) 35, % 164, % Total 2,074, % 9,974, % Source: U.S. Census Bureau, 2014, American FactFinder *Combines San Fernando Valley CCD and Newhall CCD to approximate SPA 2 region

13 Language In SPA 2, the primary languages mostly spoken at home are English (66%), and Spanish (23.8%). In addition, 3.9% of households speak mostly Asian languages at home, and another 6.2% speak some other language. 4 These rates are somewhat different than LAC overall. Specifically, a lower percentage of people in LAC mostly speak English, and a higher percentage of people mostly speak Spanish than in SPA 2. Asian languages are reported more frequently in LAC, while other languages spoken at home are higher in SPA 2. This data is instructive to the continued work that TTC does to increase access to healthcare for those who have limited English proficiency (LEP), and to bridge this gap by providing culturally and linguistically appropriate services (CLAS) to all the clients TTC serves. 5 Population by Household Income The largest percentage of SPA 2 residents live in households that earn between $15,000 to less than $35,000 (18.8%), followed by residents in households who earn $50,000 to less than $75,000 a year (16.5%). Those two groups make up 35.4% of the total population of SPA 2, which is consistent with the large percentage (37.5%) of LAC population reported earning the same income. In terms of poverty, 15.0% of SPA 2 residents have a household income of less than 100% Federal Poverty level (FPL), compared to 18.0% in LAC overall. 6 Based on family size, FPL determines whether an individual or family is recognized as living in poverty. This is often used to determine eligibility for certain programs and benefits. Although the FPL in SPA 2 is not the highest of SPAs in LAC, it brings much needed attention to the connection between poverty and mental health issues, which is discussed later in this report. 7 Table 6: SPA 2 and L.A. County Population by Household Income, 2014 Estimates* SPA 2** L.A. County N % N % Less than (<) $15K 72, % 402, % $15K - <$35K 129, % 658, % $35K - <$50K 82, % 408, % $50K - <$75K 113, % 541, % $75K - <$100K 87, % 380, % $100K - <$150K 103, % 438, % More than(>) $150K 98, % 413, % Total 688, % 3,242, % *in 2014 Inflation-Adjusted Dollars Source: US Census Bureau, 2014 American FactFinder **Combines San Fernando Valley CCD and Newhall CCD to approximate SPA 2 region

14 Population by Level of Education According to US Census data, for the population 25 years and over, 11.1% of the population stopped going to school between Kindergarten and eighth grade, and 7.9% attended but have not completed High School. Eighty-one percent of the SPA 2 population have completed High School or achieved a level of educational attainment beyond High School. Additionally, a slightly higher percentage of the population in SPA 2 completed a Bachelor s and/or Graduate/Professional degree (32.6%) than residents of LAC overall (29.9%). Table 7: SPA 2 and L.A. County Population by Level of Education, 2014 Estimates SPA 2* L.A. County N % N % Left school K-8 155, % 891, % Some High School 110, % 629, % High School Graduate 284, % 1,344, % Some College 287, % 1,278, % AA Degree 103, % 445, % BA Degree 310, % 1,278, % Graduate/ Professional Degree 144, % 682, % Total 1,396, % 6,557, % Source: US Census Bureau, 2014 American FactFinder *Combines San Fernando Valley CCD and Newhall CCD to approximate SPA 2 region. Labor Force Out of over 1.6 million individuals 16 years and over in SPA 2, approximately 67% were gainfully employed, whereas a substantial 33% of population (16 years and over) were not in the labor force. Those who were not in the labor were students, retired individuals and the elderly. SPA 2 representative area has a slight higher percentage of population (16 years and over) in the labor force than L.A. County (64.7%). Otherwise, most indicators seem to show similar labor force participation. Table 8: SPA 2 and L.A. County Population by Labor Force, 2014 Estimates SPA 2* L.A. County N % N % Population 16 years & over 1,655, % 7,913, % In labor force 1,104, % 5,116, % Civilian labor force 1,104, % 5,113, % Employed 985, % 4,548, % Unemployed 119, % 564, % Armed Forces 569 <0.0% 3,680 <0.0% Not in Labor Force 550, % 2,796, % Source: US Census Bureau, 2014 American FactFinder *Combines San Fernando Valley CCD and Newhall CCD to approximate SPA 2 region. 10

15 These demographic summaries provided above illustrate that SPA 2 and the San Fernando Valley is a region that is not only racially/ethnically and culturally diverse, but also varies in socioeconomic status. Disease Estimates In terms of key diseases, Cardiovascular Diseases (especially hypertension) affects the largest percentage of the population (30.9%), followed by Asthma (8.7%), Cardiovascular Disease (8.0%), Diabetes (6.7%), Cancer (2.7%), and Stroke (2.2%). Table 9: Estimated Cases of Key Diseases in SPA 2 SPA 2 Affected Population % of Total Population Cardiovascular Diseases 654, % Hypertension 442, % Angina 33, % Congestive Heart Failure 25, % Coronary Heart Disease 63, % Heart Attack 49, % Stroke 40, % Asthma 185, % Cancer 57, % Diabetes 143, % Source: Valley Care Community Consortium (VCCC), 2013 Estimates of Cancer Incidence There were 57,738 incidences of cancer in SPA 2 reported in The types of cancer people are most likely to have in SPA 2 are Breast Cancer (1% of total population), prostate cancer (0.6%), cervical cancer (0.4%), colorectal cancer (0.3%), and uterine cancer (0.3%). Table 10: Estimated Incidence of Cancer in SPA 2 SPA 2 Affected Pop % of Total Pop Breast Cancer 20, % Prostate Cancer 13, % Cervical Cancer 8, % Colorectal Cancer 7, % Uterine Cancer 5, % Total Cancer Estimate 57, % Source: Valley Care Community Consortium (VCCC),

16 HIV/AIDS Prevalence According to the most recent LAC-DPH HIV Annual Surveillance Report, there were 6,861 people living with HIV/AIDS in SPA 2 at the end of Furthermore, SPA 2 has seen a decrease in HIV diagnoses since At the County level, Whites and Latinos represent the largest percentage of people living with HIV/AIDS (PLWH), at 32% and 42%, respectively. With an overall prevalence of 313 per 100,000, SPA 2 accounts for 14% of all people living with HIV/AIDS in LAC. There were an additional 2,846 people living with Non-AIDS HIV in SPA 2 at the end of It is significant to note that the racial/ethnic distribution of PLWH differs between genders in LAC. For instance, among female PLWH, 45% are Latina and 35% are African American, whereas for male PLWH, 41% are Latino and 35% are White. Table 11: HIV/ AIDS Prevalence SPA 2 % of Population Total People living with HIV/AIDS 6,861 14% Whites living with HIV/AIDS (County) 2,734 41% Hispanic/Latinos living with HIV/AIDS (Count) 2,684 41% Source: 2014 HIV Annual Surveillance Report In 2014, there were 246 new cases of HIV/AIDS diagnosed in SPA 2, which represented 14% of all new cases in LAC. The rate of new diagnoses for 2013 was 11 per 100,000 population, which decreased from a rate of 18/100,000 (388 new cases) in Leading Causes of Death The latest LAC-DPH Mortality Report indicates that there were a total of 12,731 deaths recorded in SPA 2 in As expected, this this is the highest number of deaths by SPA in LAC, since SPA 2 is also the largest SPA by area in LAC. The leading causes of death (in order of highest incidence) across SPA 2 are coronary heart disease (20.9% of all deaths), stroke (5.5%), and lung cancer (5.2%), Alzheimer s disease (5.2%), and COPD (Chronic Obstructive Pulmonary Disease) (4.4%). 9 The leading causes of premature death (death before 75 years of age) are also of great concern to TTC and the work the agency engages in with the SPA 2 community. Specifically, the leading causes of premature death are coronary heart disease, suicide, motor vehicle crashes, drug overdoses and lung cancer. TTC provides services that directly address suicide and other mental health issues, as well as address drug overdoses through SUD treatment and education. Table 12: Top 5 Leading Causes of Death in SPA 2, 2012 Cause of Death # of Deaths Rate* Number of Deaths in SPA 2 12,

17 Coronary Heart Disease 2, Stroke Lung Cancer Alzheimer s disease COPD (Chronic Obstructive Pulmonary Disease) *per 100,000 Source: L.A. Department of Public Health, Mortality Report 2012 Incidence of Serious Emotional Disturbance (SED) or Serious Mental Illness (SMI), by Gender, Race, and Age According to LAC-DMH estimates, more than 173,000 people in SPA 2 suffered from Serious Emotional Disturbance (SED) and Serious Mental Illness (SMI) in FY Meanwhile, a total of 30,593 consumers were served by LAC-DMH in Short Doyle/Medi-Cal Facilities. This would result in a penetration rate of 17.6%. Penetration rate is the ratio of total consumer served to the number of consumers estimated to have SED or SMI. LAC-DMH also measures the estimates of the SPA 2 population who are living at or below the 200% Federal Poverty Level (FPL) with SED/SMI. As stated previously, there is a recognized connection between mental health issues and the experiences of poverty. 10 This is due to the tremendous effect that the experiences of poverty (such as neighborhood violence, unstable housing conditions, and financial issues) has on cognitive functioning. The breakdown by gender, race/ethnicity and age for SED/SMI prevalence and penetration rates can be found in the Table 14, 15, and 16, below. Although more females were served in , males had a higher penetration rate (39.7%) among those who were at or below 200% FPL. The African American and Latino population in SPA 2 had the highest penetration rates in the total population estimated with SED/SMI. For African Americans and Native Americans in poverty (<200% FPL), higher penetration rates are estimated (85.6% and 60.6%, respectively). The lowest penetration rates were found for Asian/Pacific Islanders, at 6.5%, for the total SPA 2 population; for Asian/Pacific Islanders in poverty, the penetration rate rises to 42.7%. This clearly shows that while these three subpopulations are estimated to have SED/SMI in varying degrees, the experience of poverty significantly affects the mental health of these populations in SPA 2. Youth in SPA 2 appear to be highly affected with SED/SMI. For the estimated total population of SPA 2 with SED/SMI, youth age 0-15 years had the highest penetration at 24.9%, and adults years had the lowest, at 14.9%. This indicates that SPA 2 residents are connected more frequently to mental health providers than the other age groups. Still, the overall penetration rate for SPA 2 was 17.7%, which was the lowest in the County, suggesting that local mental health resources may have a smaller reach into the SED/SMI population than in other parts of the County. This result should emphasize that mental health promotion and education continue to be a major focus of TTC in SPA 2 through its various contracts with LAC-DMH and collaborating agencies

18 Table 13: SED or SMI Estimates by Gender in SPA 2 Consumers Served SPA 2* Penetration Rate* Male 15,051 37, % Female 15,542 45, % Total 30,593 83, % *Penetration rates for population living at or below 200% FPL with SED/SMI Source: Penetration Rates for SMI SED, LAC DMH Table 14: SED or SMI Estimates by Race in SPA 2 Consumers Served Estimated Total Pop. with SED/SMI Penetration Rate <200% FPL Pop. <200% FPL Penetration Rate* White 9,614 75, % 28, % Latino 16,423 74, % 49, % Asian/Pacific Islander 1,118 17, % 2, % African American 3,307 5, % 3, % Native American % % Total 30, , % 84, % *Penetration rates for population living at or below 200% FPL with SED/SMI Source: Penetration Rates for SMI SED, LAC DMH Table 15: SED or SMI Estimates by Age in SPA 2 Consumers Estimated Total Pop. Served with SED/SMI Estimated Total Pop. with SED/SMI <200% FPL Pop. 200% FPL Penetration Rate* 0-15 years 10,245 41, % % years 5,263 30, % 12, % years 12,877 86, % % 60 + years 2, , % 6, % Total 30, , % 83, % *Penetration rates for population living at or below 200% FPL with SED/SMI Source: Penetration Rates for SMI SED, LAC DMH Furthermore, the 2013 LAC-DPH Key Indicators of Health report shows 13.9% of adults in SPA 2 had been diagnosed with depression at least once in their lives, which was slightly higher than the County (12.2%). Meanwhile, 8.9% of adults indicated they were currently suffering from depression, slightly higher than the countywide rate of 8.3%. The suicide rate in SPA 2 was 8.3/100,000, which was higher than the Countywide rate of 7.5/100,000. These rates also parallel recent mortality statistics, with suicide as the second leading cause of premature death in SPA 2. 14

19 Substance Use No federal reporting agencies separate demographic characteristics of individuals in treatment facilities by SPA. However, the Substance Abuse and Mental Health Services Administration s (SAMHSA) Treatment Episodes Data for Admissions (TEDS-A) does provide epidemiological data related to substance use in LAC treatment facilities. This is relevant to the population TTC s Inpatient Facility serves because they can come from all over LAC. A snapshot of particular demographic and epidemiological data is shown below for 2012, the most current year data is available. Table 16: SUD Treatment Admissions, Los Angeles County (LAC), 2012 LAC % Total number of admissions to substance treatment 41,229 - Substance Abuse Type Drugs Only 25, % Alcohol and Other Drugs 10, % Alcohol Only 5, % Primary Substance of Choice Marijuana/Hashish 10, % Alcohol 9, % Heroin 8, % Methamphetamine 7, % Cocaine/Crack 2, % Other Opiates and Synthetics % Other Stimulants % Other Amphetamines % PCP (Phencyclidine)/Angel Dust % Other % Benzodiazepines % Non-Prescription Methadone % Other Hallucinogens % Barbiturates 8 0.0% Other Non-Barbiturate Sedative or Hypnotics % Inhalants % Over-The-Counter Medications % Other Non-Benzodiazepine Tranquilizers 8 0.0% Frequency of Use No Use in the Past Month 11, % 1-3 Times in the Past Month 5, % 1-2 Times in the Past Week 5, % 3-6 Times in the Past Week 7, % Daily 11, % Unknown/Unreported 5 - Age at First Use 15

20 11 years and under 2, % years 10, % years 10, % years 6, % years 4, % years % years % years % years % years % years % 50 years and over % Source: 2012 Treatment Episode Data Set-Admission (TEDS-A), SAMHSA In short, more than half of clients admitted for SUD treatment reported that they require services exclusively for drug use issues (61.2%), followed by alcohol and drugs (25.6%), or only alcohol (13.2%). Marijuana is reported to be the drug of choice by the highest percentage of people entering SUD treatment (26.2%) followed by alcohol (22.0%), heroin (21.6%), and methamphetamine (17.2%). Most of the clients entering treatment (27.3%) reported no drug use in the last 30 days followed by clients reporting daily use (27.5%). More than half of clients entering treatment (59.5%) reported first using drugs before the age of 17. Table 17: Demographics of SUD Treatment admissions, Los Angeles County (LAC), 2012 Demographic Characteristics SUD COD N % N % Total number of admissions to substance treatment 41,229-6,507 - Gender Female 15, % 2, % Male 25, % 3, % Age years old 1, % % years old 6, % % years old 2, % % years old 3, % % years old 4, % % years old 4, % % years old 3, % % years old 3, % % years old 3, % % years old 3, % % 55 years and older 3, % 1, % Race/Ethnicity Alaska Native 7 0.0% 1 0.0% American Indian % % 16

21 Asian % % Black/African American 9, % 2, % Latino/Hispanic American 17, % 1, % White 18, % 2, % Native Hawaiian/Other Pacific Islander % 2 0.3% Two or more races % % Other single race 11, % 1, % Education % 8 years or less 4, % % 9-11 years 16, % 1, % 12 years 15, % 3, % years 4, % % 16 years or more 1, % % Employment Full Time 1, % % Part Time 1, % % Unemployed 10, % % Not in Labor Force 27, % 5, % Living Arrangement Homeless 7, % 1, % Dependent Living 19, % 2, % Independent Living 13, % 2, % Prior Treatment Episodes None % 2, % 1 prior episode % 1, % 2 prior episodes % % 3 prior episodes % % 4 prior episodes % % 5 prior episodes % % Source: 2012 Treatment Episode Data Set-Admission (TEDS-A), SAMHSA Individuals who had received SUD treatment also self-reported having psychiatric problems in addition to substance use. While there was a total of 41,229 admissions to SUD treatment, 15.7% (6,507) of those admitted individuals reported having psychiatric problem in addition to an alcohol or drug problem. Of those individuals with CODs, 56.2% had one or more prior episodes, which may indicate the occurrence of relapse. In regard to age, older individuals are more likely to report having a psychiatric problem. A very small percentage of individuals were employed either full-time or part-time among those with SUDs and CODs yet, COD individuals were employed the least (4.4%). Furthermore, participation in the labor force is significantly limited for individuals with CODs (80.8%), than those with SUDs only (66.9%). Many more COD individuals are completely removed from the labor force rather than unemployed. As many SUD treatment providers can attest to, the percentage of homelessness among those with CODs is higher (23.0%) than those with SUD, whereas SUD individuals have a higher rate of dependent living (48.5%). This data was explored to a greater extent in the patient survey as well as the focus groups that were conducted as part of this CHNA report. 17

22 PROCESS AND METHODS Prior to beginning the process to complete the 2015 CHNA report, some preparation was required to ensure that an accurate portrayal of the community s health needs would be presented. The process to identify and prioritize the health needs of the community involved designing the assessment tools, collecting primary and secondary data, and then analyzing this data. First, it was necessary to review the previous CHNA and determine outcomes of the Implementation Plan. The 2012 CHNA was TTC s first IRS-mandated needs assessment, so lessons learned were communicated to the CHNA team in order to change some processes and procedures going forward. The team identified and reviewed studies of the SPA 2 community that already existed, in addition to information that needed to be collected from primary and secondary sources. The methods included (a) a thorough review of epidemiological and demographic data, (b) a survey of patients of mental health and addiction services, (c) patient focus group of mental health and addiction services, and (d) key informant interviews (KII) with stakeholders that are engaged in addressing health needs in SPA 2. From May to June 2015, the CHNA team collected epidemiological and demographic data from with local, state, and national mental health and addiction resources. Epidemiological data refer to the incidence of health related issues and the factors that contribute to those issues. Demographic data refer to detailed information about the LAC population by racial/ethnic, gender, sexual identity, socioeconomic, and other significant characteristics. Secondary data analysis was performed using a comprehensive internet search to identify organizations, studies, surveys, and reports that contained public health, morbidity, mental health, and addiction and treatment data. Examples of organizations cited include Valley Care Community Consortium (VCCC), LAC-DPH, LAC-DMH, the Office of Statewide Health Planning and Development (OSHPD), Healthy People 2020, California Department of Finance, US Census Bureau, and Substance Abuse and Mental Health Services Administration (SAMHSA). Using TTC s Program Development Department s grant master contact list, the lead staff identified current and frequently contacted individuals in partner agencies who would best serve to represent the low-income and/or minority population in SPA 2 as key informants. Communication between Dr. Lantican, Data, Evaluation and Grants supervisor, and the Directors of TTC s Inpatient and Residential Facility allowed the CHNA team to have access to patients for both the patient survey and the focus groups. The 2015 CHNA follows an exploratory research design. This method was determined to be the best for evaluating the current state of health for TTC patients and surrounding communities. An exploratory design allowed the CHNA team to examine the data and search for patterns or similarities between identified health needs (and other variables) in the patient survey, focus groups, and KIIs. Data Collection The patient survey used in TTC s last CHNA was revised to improve the clarity and breadth of health related topics that are covered. In addition, multiple needs assessment surveys were reviewed from other health organizations in California and nationwide to gather ideas of additional questions to include. After multiple revisions and pilot testing, the final survey consisted of 59 questions focusing on 18

23 demographic characteristics, perceived health status of self, physical limitations, health insurance coverage, utilization of medical services, risk behaviors, and the perceived health needs of the community. The CHNA team, along with Program Development Department interns, distributed the patient survey in the Inpatient Facility from October to December With the assistance of the Inpatient Technicians and Facility Director, available patients were gathered together between periods of activity to fill out the voluntary self-administered survey. The survey took approximately 10 minutes to complete. A total of 127 surveys were collected. Participants for Key Informant Interviews were identified from list of key partners, collaborators, and service providers with a working relationship with TTC staff, and who were representative of the SPA 2 community. A master contact list was used to categorize contact information and any duplicate contacts at an agency. During November and December 2015, TTC s Director of Program Development and Contract Compliance sent out several s with a link to the CHNA survey on SurveyMonkey to solicit responses from the identified partners. The full list of key informants is provided in the Attachments. For the KIIs, the CHNA planning team reviewed the questions asked during the previous CHNA. Part of this review involved a comprehensive internet search to find any insightful additional questions. The purpose of the interview was to inquire about the health needs of the community from the perspective of each community partner. As per the CHNA requirements, each community partner who participated in the KIIs serves as a representative of the minority and/or low-income populations they serve in SPA 2. Specifically, the interview tool collected information from community-based agencies on the target populations served, services offered, and insights on the health needs and/or deficits in the community. The KII survey was launched online via SurveyMonkey in October The CHNA staff attempted to call key informants as well, but most responded via SurveyMonkey with the option to select whether they prefer to be contacted for a follow-up conversation. Consumer focus groups were held during January 2016 at TTC s Central Residential facility. Dr. Lantican, Data, Evaluation and Grants Supervisor, contacted the Residential Facility Director and Operation Supervisor to schedule the focus groups and to recruit residents who lived in the SPA 2 region before admission to residential treatment. Focus groups were included as part of the data collection in order for patients to provide other perspectives on health needs, or elaborate on the ones identified in the patient survey. Questions asked during the focus group sessions related to the perception of their overall health, describing health issues of the communities where they live, how community issues affect health, and possible solutions to these issues. The focus groups lasted approximately 1 hour, and were facilitated by two members of the CHNA staff, with one acting as the facilitator and the other as a recorder. The recorder was also responsible for writing ideas shared among the focus group participants onto poster sheets. Focus group sessions were recorded using an audio recorder with the consent of the participants. Data Analysis The CHNA patient survey primarily collected quantitative data on patient demographic characteristics and various potential indicators of health status (e.g., race/ethnicity, age, income, disability status). Survey data was manually entered using SurveyMonkey, and using SurveyMonkey the data was summarized using descriptive statistics. Tables and graphics were prepared using Microsoft Excel. 19

24 Sixteen total contacts at TTC community partner agencies responded to the KII survey, and one was interviewed over the phone, making a total of 17 key informants. Qualitative and quantitative data were gathered from the KII survey and interview. The survey was distributed using SurveyMonkey. Analysis tools provided by SurveyMonkey were used to summarize the qualitative data in the survey, and the open-ended qualitative answers were analyzed using summary word-cloud tools, and categorized by topic/theme. Tables and graphics were prepared using Microsoft Excel. The audio recording of each focus group session was later transcribed and entered into Microsoft Excel. The recorder s written notes and poster sheets were used to supplement the audio recordings. Demographic data was collected using a short paper survey given to the focus group participants. Qualitative data collected from the focus group was analyzed categorically for topics/themes and key health issues that were frequently discussed. A copy of the focus group transcript and questions can be found in the Attachments. Data Limitations Unfortunately, some local, state and federal data sources did not have more recent data than what was provided in the 2012 CHNA. In addition, this report highlights a number of health needs identified using data sources and a methodology that was defined by the CHNA team as fitting TTCs resources. However, the final list of needs summarized in the next section is not necessarily the only issues that individuals in the SPA 2 region experience. Much like any exploratory study done, these choices have an effect on sample size. 20

25 FINDINGS Assessment of the health needs of SPA 2 is based on data collected from a patient survey, focus groups, key informant interviews, and gathering primary and secondary epidemiological and demographic data. Findings based on the data are described in detail in the following section. Survey Respondents: How Do They Compare to the SPA 2 Population? One hundred twenty-seven clients completed the CHNA survey at TTC s Inpatient Facility. The racial/ethnic breakdown is as follows: 63.8% White, 22.3% Latino, 9.2% Black/African American, 1.5% American Indian, 0.8% Asian, and 0.8% Pacific Islander. Compared to the SPA 2 population in Table 5, these rates are similar. White and Latinos were the majority of survey respondents, but there were more Black respondents, and less Asian respondents, compared to the race-ethnicity percentages in the SPA 2 region. A majority (66.7%) identified as male, and 33.3% identified as female; no respondents identified as transgender. By percentage, there were less female respondents, compared to 50.7% of the overall population of SPA 2 (Table 4). This gender distribution in the Inpatient Facility supports numerous studies that confirm more males than females are admitted to SUD treatment. 11,12 The age range of the respondents was 18 to 64 years old the majority of whom were 21 to 40 (46.8%). This is slightly younger than the overall SPA 2 population (Table 6). In terms of educational background, approximately 26% of respondents indicated that they had graduated high school or earned an equivalent GED. Similarly, the 2013 LAC-DPH Key Indicators of Health report and US Census data (Table 8) show that approximately 20% of SPA 2 residents have graduated from high school. In terms of employment status, a large percentage was either unemployed, or disabled and unable to work (Table 9). Specifically, respondents were 10.3% employed part-time, 9.5% employed full-time, 7.9% self-employed, and 38.9% unemployed; in addition, 1.6% homemakers, 2.4% were student, 2.4% were retired, and 27.0% disabled/unable to work. These percentages are comparable to the TEDS-A report in Table 17. In a related way, respondents reported income provides evidence of low or little employment. The yearly household income of respondents are as follows: 38.1% earned less than $19,999, 10.3% earned from $20,000 to $29,999, 11.9% earned from $30,000 to $50,999, 10.3% earned from $51,000 and over, and the 29.4% declined or didn t know their income. Respondents reported earning less income compared to the SPA 2 population (Table 6). Approximately 30% of residents in SPA 2 reported earning less than $35,000 whereas over 50% of respondents reported similar earnings. As discussed in previous sections, FPL levels are instrumental in determining eligibility for various programs and benefits. A quick analysis of FPL level based on respondents reported family size (using the survey question: How many people live with you? and Do you children live with you?) shows that 21% were at or below 138% FPL, and approximately 30% were at or below 100% FPL

26 Survey Respondents: Access to Health Care When asked about access to health services, respondents claim they usually receive medical care via their private doctor (35.8%), followed by a Hospital (26.8%), Emergency Room (22.0%), and Urgent Care (12.2%). Others also responded that they receive care in another community health clinic (18.7%), through Veterans Affairs offices (7.3%), and TTC primary care clinics (8.9%). This data reiterates an important point that continues to be of central focus for TTC, as indicated in the 2012 CHNA Implementation Plan. Over 75% of respondents reported visiting an emergency room in the past year. Although the medical reason for visiting the emergency room is unknown, these rates are extremely high for emergency room utilization. Emergency rooms operate as frontline providers of the health care safety net in the United States, providing 24-hour health care access, serving as the only guaranteed source of healthcare for the uninsured and otherwise vulnerable populations. However, there is still concern that emergency rooms are being used to treat non-urgent and preventable conditions. This may be contributing to overcrowding in emergency rooms. Reducing over-utilization of emergency rooms is a critical assessment of patients ability to access primary care providers and urgent care centers in a timely fashion, and to receive appropriate care in those settings. Strategies such as extending business hours in primary care settings and expanding weekend access to services might be possible solutions to decrease the use of emergency rooms for non-urgent conditions and to improve continuity of patient-to-provider care. In regard to access to health care and insurance, responses were mixed. The 2013 LAC-DPH Key Indicators of Health shows that 27.0% of adults in SPA 2 were uninsured. Additionally, 28.9% of these adults reported difficulty accessing medical care. The impact of ER use by uninsured individuals and the high cost of health care are major reasons why the Affordable Care Act was passed. Over a third of survey respondents considered the cost of care a major contributor in accessing needed medical care (35.5%). In addition, 16.3% of respondents considered lack of insurance coverage a major contributor, followed by transportation (15.7%). Even so, 58% of respondents felt they had access to healthcare services when they were needed. These results may be influenced by the fact that those who are uninsured have the option to apply for presumptive eligibility for Medi-Cal during the intake process to receive services from TTC. Although these numbers show mixed responses, they illustrate that access to care and cost of care is still a substantial issue that plays a role in the health and wellbeing of the SPA 2 community, and for those who receive services at TTC and other similar facilities. Over two-thirds (63.2%) of respondents had a routine physical exam in the last 12 months, and 75.9% were able to visit a doctor when they needed to. Dental and eye health were less attended to, as many respondents claim they did not receive dental or eye examinations in the past 12 months. Similarly, 49% percent of adults residing in SPA 2 did not have dental insurance. 13 Less than half of the respondents received an annual flu shot as well. The low frequency of receiving medical care can be expected from a population with 33% of respondents identifying as homeless before admission to the Inpatient Facility. Lack of a stable living arrangement can be a significant factor in accessing regular medical care. Interestingly, approximately 68% claim to have had access to mental health services in the last 12 months another sign that illustrates the interaction of health issues related to homelessness, substance use, and mental health

27 Table 18: Experience Accessing Health Services in the last 12 months before coming to Inpatient Facility (n=118) Have you Yes No N.A./ Don t Recall Had a physical examination? 63.2% 31.6% 5.1% Had an eye examination? 41.0% 58.1% 0.9% Been able to visit a doctor when you needed to? 75.9% 22.4% 1.7% Been able to afford all medications prescribed to you? 66.7% 31.6% 1.7% Had access to all the health services you needed? 59.0% 33.3% 7.7% Had access to all the health services your family needed? 58.0% 27.7% 14.3% Visited an Emergency Room? 76.1% 21.4% 2.6% Stayed in a hospital overnight? 53.0% 44.3% 2.6% Had any problem getting transportation to and from your health appointments? 41.9% 56.4% 1.7% Received a flu shot? 44.0% 54.3% 1.7% Always had access to healthy foods? 65.0% 31.6% 3.4% Seen a dentist? 54.7% 42.7% 2.6% Had access to mental health services? 67.8% 26.1% 6.1% Had access to services in the language you usually speak? 81.0% 10.3% 8.6% Survey Respondents: Health Status The self-reported health status of the respondents was of central importance in this CHNA process. Overall, respondents rated their health as 31.2% good, 52.8% fair, and 16.0% poor. Approximately 70% consider their health to be either fair or poor. These percentages confirm the expectation that they would indeed consider themselves to be in poor health while receiving services at the Inpatient Facility. In contrast, the LAC-DPH 2013 Key Indicators of Health shows that 18.5% of SPA 2 residents report their health to be fair or poor. 14 Although this measure is subjective to each individual, it is clear that the respondents rate their health worse than SPA 2 residents. In addition, 65.6% of respondents indicated they are limited in activities due to an impairment or health problem. Table 19: Self-rated overall health (n=125) N % Good % Fair % Poor % 14 Ibid 23

28 Survey Respondents: Behavioral Risk Factors Analysis of the patient survey revealed some significant behavioral risk factors that are linked to poor health outcomes. For example, approximately 65% of respondents claim to smoke cigarettes every day, and 26% claim to be exposed to second hand smoke on a daily basis. In contrast, only 13.8% of SPA 2 residents claim to smoke cigarettes. 15 A fifth of respondents (23%) have ever attempted to quit smoking. Electronic cigarettes (e.g., vape pens) have also become a controversial topic, as studies have shown a substantial increase in e-cigarette use, especially among young adults, as traditional cigarette use has declined. 16 A small percentage of respondents use e-cigarettes, but most do not. In terms of mental health, 38% claim they have been bothered by the way they have been thinking, acting or feeling in the past 30 days. Although subjective, this measure illustrates the need for addressing the mental health needs of TTC s service population. In fact, this is stressed by survey respondents and focus group participants as one of the top health priorities. Other items of concern in the patient survey have to do with nutrition and diet, which is shown to significantly affect physical health conditions at many levels. Questions on diet and food choices show that 72% eat fast food on at least a weekly basis; 74% drink sodas and sugary drinks on at least weekly basis; and close to 40% did not eat 5 servings of fruits or vegetables (the USDA recommended amount) in the past 30 days. As expected, for those who seek services at TTCs Inpatient Facility, a healthy and nutritious diet is clearly not a significant priority. Access to healthy foods, whether due to financial hardship or as a result of other issues, appears to be a persistent health need as well. Furthermore, LAC- DPH Key Indicators of Health show that 30% of households in SPA 2 (with incomes <300% FPL) are food insecure. Table 20: Survey Respondents Risk Behaviors in the last 30 Days (n=125) How many days did you Yes, or Weekly Once or No/Never Every Day Twice Have Unprotected Sex (n=113) 46% 54% Smoke cigarettes (n=116) 80 (69%) 7 (6.0%) 0 (0%) 29 (25.0%) Smoke e-cigarettes (n=117) 11 (9.4%) 8 (6.8%) 4 (3.4%) 94 (80.3%) Breath second-hand smoke (n=117) 42 (35.9%) 6 (5.1%) 1 (0.9%) 68 (58.1%) Feel bothered by the way you were thinking, 55 (47.8%) 19 (16.5%) 1 (0.9%) 40 (34.8%) acting or feeling, (n=115) Eat Fast Food (n=118) 46 (39.0%) 39 (33.1%) 6 (5.1%) 27 (22.9%) Drink Sodas or other sugar drinks/beverages 50 (42.4%) 37 (31.4%) 2 (1.7%) 29 (24.6%) (n=118) Eat at least 5 servings of fruit and/or vegetables (n=116) 28 (24.1%) 37 (31.9%) 5 (4.3%) 46 (39.7%) Additionally, 46% of respondents report having unprotected sex in the past 30 days before admission to the Inpatient Facility. Although there are no indicators of unprotected sex at the SPA 2 or County level, 15 Ibid

29 the most recent data from the National Survey on Drug Use and Health (NSDUH) illustrates that people with SUD are certainly at a greater risk for contracting and/or transmitting HIV and other STIs. This is primarily because of the misuse of drugs and/or alcohol which can affect judgment and lead to poor decision making. 17 These risky behaviors include sex without a condom or unprotected sex with multiple partners. The most frequent issues respondents have that are addressed by a doctor or health professional are depression/other mood disorders (60.7%), and high blood pressure (34.8%). Once again, mental health issues are shown to be highly represented within this population, and illustrate the high prevalence of comorbidity. Table 21: Survey Respondents Health Issues (n=125) Have you ever been told by a doctor, nurse, or other health professional EVER that you have, or are at risk for: Yes No At Risk Arthritis 27.7% 69.6% 2.7% Asthma 21.8% 77.3% 0.9% Cancer 10.0% 86.4% 3.6% COPD (Chronic Obstructive Pulmonary Disease) or emphysema 12.7% 84.5% 2.7% Depression or other mood disorder 60.7% 36.6% 2.7% Diabetes 10.9% 85.5% 3.6% Heart problems/heart disease 13.4% 83.0% 3.6% High blood pressure 34.8% 64.3% 0.9% High cholesterol 30.6% 65.8% 3.6% HIV/AIDS 7.3% 91.8% 0.9% Obesity 9.9% 89.2% 0.9% Stroke 4.5% 92.0% 3.6% Vision problems or blindness (uncorrectable) 20.9% 78.2% 0.9% Other 20.4% 77.8% 1.9% Overall, 69.5% of the respondents claim to have one or more disabilities (Table 22). In contrast, approximately 20% of adults in SPA 2 reported that they had a disability, contributing to 20% of all adults in LA County who have a disability. Of the respondents who have disability, 36% claim to have a mental disability

30 Table 22: Disability Status (n=115) Count % Yes % Hearing 7 4.9% Visual % Speech 3 2.1% Mobility % Mental % Developmental 1 0.7% Other 6 4.2% No % Declined 3 2.1% Don t Know 3 2.1% *Respondents may select more than one disability. Focus Groups Focus group sessions were vital for the lead CHNA team to investigate these health issues further and in more detail. Two focus groups were held in the TTC s Central residential facility through coordination with the Residential Facility Director and Operation Supervisor. Participants were residents who lived in the SPA 2 region before admission to treatment. Demographics of the focus group participants are similar to the data gathered in the patient survey, with a majority identifying as Latino or White. Additionally, focus group participants were largely unemployed and homeless before admission to treatment, and reported an annual income of less than $19,000. Self-reported health status of the focus group participants varied. Most experienced some severe mental and physical health issues as a result of substance use. A majority of participants asserted that their chronic/persistent health problems improved while receiving services in residential treatment. In fact, a significant amount of discussion time focused on numerous issues related to homelessness. Primarily, the experience of homelessness and substance use, or continued substance use, was a common one, especially methamphetamine use. Many locations in the San Fernando Valley and in LAC were described to be popular to homeless individuals, such as the Sunland-Tujunga Wash in the San Fernando Valley, and Skid Row in downtown Los Angeles. These tent cities are locations where the participants witnessed the interaction of homelessness, substance abuse, and criminal activity. Criminal activity and jail/prison experience also occupied a large part of the discussions. A majority of participants agreed that while jails/prisons are seen by the public as rehabilitative, for those who had jail/prison experience this is not the case. Participants who were incarcerated at some point in the past year agreed that criminal justice system often led to a cycle of substance use, crime or gang violence. Focus group participants also added valuable insight to this discussion of community issues. Participants first began by thinking of the community issues they see as connected to healthy outcomes. From this initial inquiry, most agreed that a lack of jobs in the community, and lack of job training for prisoners/paroles, has an impact on them due to discrimination of the previously incarcerated or prior substance use. In fact, some assert that the stigma of being formerly incarcerated can follow an individual and affect their opportunities, which can also affect their health and well-being, as some have 26

31 become depressed and start using drugs again. Job security is of the utmost importance when they are released from residential treatment. Job security was considered a significant contributor to their health and wellbeing, as learning and being self-sufficient would allow them to separate from drugs, crime, and homelessness. A few participants believe that there a lack of support services for paroles, or even educational opportunities while receiving treatment. Focus group participants echoed some of health issues present in the patient surveys; of note, there were instances of COPD, Hepatitis C, substance abuse-related dental issues, disability due to amputation of limbs cause by substance abuse, mental illness, and anxiety/stress issues. Focus group participants understand the issue of program funding and often feel it in their experiences of accessing various services such as Section 8 housing and treatment, or sober living facilities where both treatment and housing needs are met. Without the provision of these vital services, there are limited affordable options for housing in SPA 2, and years long waiting lists before securing housing. Part of the discussion time was spent brainstorming possible solutions to those health concerns. Solutions that received agreement among the participants included an increase in homeless outreach and services, including mobile shower and bathroom units in strategic locations in the SPA 2 region with a high degree of homelessness. Job training and placement (either associated with the facility or otherwise), and bringing more services within one location through collaborative efforts and thus increase linkages to care (such as food/transportation vouchers, referrals, temporary housing, etc.). Focus group participants tied their discussion of community issues with environmental issues. To them, having income and job security was linked to secure stable housing, which remains difficult to secure due to prior criminal records or evictions. Participants felt that there has been a decrease in affordable housing available, as many neighborhoods in the San Fernando Valley have become more expensive to live in. The issue is compounded when being released from prison or residential treatment and not having a place to start out at due to limited money. Additionally, the benefits of programs for the previously incarcerated on probation or parole focused was acknowledged, but there was a desire for more training opportunities at TTCs residential facility while in treatment. Following this line of thinking, participants believed/felt there was limited education or guidance for parolees or those released from treatment on what to do, who to see after being released. This eventually leads to cyclical behavior of recidivism and/or relapse. In essence, more hand-holding is needed for these individuals to achieve better health and positive results from their time in treatment. However, to try to solve the issue of substance use in the community, a focus on early intervention, prevention and education about the dangers early substance use and of getting in to early relationships, teaching life skills, and mental/emotional education and support to maintain emotional balance during vulnerable times, are all essential to lessen the incidence of risky behavior that leads to SUD or mental health treatment. 27

32 Key Informants Finally, the key informant responses were summarized to determine if representatives of community partner agencies expressed similar concerns as the focus group and survey participants. Seventeen key informants ranked what they consider to be the top three health needs of SPA 2. Most key informants agreed that SUD treatment services are vital. They believe that some populations specifically unsheltered/homeless transitional age youth (TAY) and transgender individuals are in greatest need for SUD treatment services at this time. Housing and supportive services for these populations were also considered to be lacking. Without these types of services, these vulnerable populations continue abusing substances and become exploited sexually. 18 Mental health issues, especially depression, were identified as having a tremendous impact on the development and management of chronic diseases. The informants describe how these comorbidities, when left untreated and/or unmanaged are a barrier to improving one s overall health. In addition, there still appears to be a stigma associated with seeking and receiving treatment from a mental health provider. This perceived stigma, cultural or otherwise, may continue to prevent seeking treatment for those who need it. Similar to SUD treatment services, mental health service provision for young children appears to be lacking. There is also a desire to have more qualified and culturally competent mental health professionals overall. In SPA 2, there is limited access to qualified professionals that continue to be in demand within the key informant agencies. Housing was another issue mentioned by some informants that also appears significant. As it stands, key informants state that there is still a limited supply of affordable housing in SPA 2. Furthermore, housing that is available is considered by some informants to be of poor quality. Many people seeking services in key informant agencies are already living in poverty or have low-wage occupations. In terms of access to food and diet, there was a desire to establish culturally competent collaborative programs and community education on health foods and food access in SPA 2. This issue has been a persistent one in the past few years, and is still a need as many healthy foods remain costly without the assistance of these programs. Chronic diseases are widespread and affect the already vulnerable populations in SPA 2 as well. One key informant expressed concern over the issue of prescription drug abuse and how this addiction interacts with the experience of chronic disease. 19 Moreover, obesity can lead to metabolic diseases and other diseases that have a negative impact on health outcomes. Access to care is also a top health need that is identified by most of the informants. What they have seen in the past few years is that there are still high prices to receive dental and medical care. This makes it prohibitive to see professionals and can also lead to avoidance of necessary care. Furthermore, the perception of regular dental care as not important to overall health is also misleading and can certainly lead to serious future health issues, and even low self-esteem

33 Some key informant agencies also serve the undocumented population in SPA 2. In this regard, there continues to be concern about the reluctance of undocumented individuals living in SPA 2 (and LAC) to seek health care. There are approximately 890,000 undocumented adults living in LAC. 20 These individuals and their families experience barriers to accessing care through a variety of ways, including language and culture differences, and lack of culturally competent care and services. For example, one informant mentioned socio-cultural factors that can affect the health of their primary Latino patients in terms of diet, lifestyle, and common health practices. Two other issues that were briefly mentioned by the key informants are the necessity for more cohesive peer support service for clients at key informant agencies in SPA 2, and transportation. These two concerns were expressed by the focus group participants as well. Peer support is a particularly urgent need for parolees and probationers to obtain basic necessities after release from jail or prison, such as finding a job, continuing education, securing shelter, or finding legal resources. Some key informants stated that they felt there was just not enough funding at the local, state or federal level to provide these essential peer support programs in order to develop relationships with clients and establish linkages for those who need it the most. In the same way, the availability of transportation services is a vital resource for clients to secure the services they need after being released from jail, prison, or SUD treatment. Without vouchers or passes for transportation, many clients would not be able to meet requirements mandated by the courts, or even follow-up appointments for other necessary services. Summary of Key Informant View of Needs at the Agency, Community and Environmental Level To obtain a more nuanced explanation of why informant health needs continue to be present in the community, the informants were asked to address barriers/challenges in three key areas: the agency level, the community/neighborhood level, and the environmental level (air/water/noise pollution, neighborhood safety, etc.). Altogether, these three elements play a significant role in defining the social determinants of health for the SPA 2 community. The purpose behind this form of questioning was to investigate any persistent macro-level factors that contribute to community health needs not being addressed adequately. At the agency level, lack of funding frequently determines what services an informant s agency is able to provide. In addition, the competitiveness of funding was also a challenge that many agencies face. Funding challenges are among the most obvious reasons for limiting the capacity of informant agencies to serve their target populations. This is especially concerning when there are services that are vital, such as peer mentoring for at-risk youth and previously incarcerated individuals. At the community/neighborhood level, informants listed factors that have an impact on healthy outcomes in their community. Factors include: community violence & unsafe neighborhoods; low community participation/motivation; lack of free/low-cost health education, information, and outreach; stigmatization of SUD/MH issues, homelessness/poverty, and the previously incarcerated. The environmental surroundings of a community can also directly impact the chances of healthy outcomes for a community. Informants state that healthy outcomes are hampered by: the persistent

34 availability of drugs and fast food in the communities served; poor/low-quality housing; lack of affordable housing; lack of transportation options; poor air quality; and lead exposure. Housing, availability of healthy food options, and transportation appear to be the most frequently mentioned challenges. PRIORITIZATION OF HEALTH NEEDS A multi-step process was used to arrive at a final list of health needs for this CHNA, and to inform the development of the 2015 CHNA Implementation Plan. First, a consolidation table was created to summarize the topics and themes that were covered in each primary data source (see Table 23). A check-mark denotes a topic/theme that was covered for that specific data source. Other notes indicate whether the topic/theme was not addressed in a particular data source, or if a topic/theme was addressed in another way but not specifically asked through a question, prompt, or discussion. The second step was to add more detailed descriptions of the context in which each topic/theme was covered or discussed. This step was essential in order to provide a thorough summary of all topics/themes and compare and contrast the data to determine similarities between each data source (see Attachments). This detailed table was created to show the final list of priority health needs for TTC. The process involved reviewing each topic/theme according to the data sources, and including 1) common needs identified between all data sources, and 2) unique needs that TTC may be able to address given its current capacity. For some of the priority needs, TTC may already be providing similar services. Needs that TTC will not addressed were included as priority needs to be met through referrals with community partner agencies. This final list of priority health needs was presented to the Chief Executive Officer, who then discussed the priorities with the Board of Directors. Each governing body of TTC gave their final approval in September Table 23. Health Priorities Identified by Data Sources Patient Survey (N=125) Key Informants (N=16) Focus Groups Substance Use Disorder Mental Health Services Tobacco Use/Control Housing Access to food/food security Dental health Gang violence/unsafe neighborhoods Chronic Disease Prevention & Management Access to Health Care/inability to get health coverage for Not addressed in focus group discussion. Not addressed in focus group discussion. 30

35 undocumented/health insurance Homeless services & outreach Lack of jobs/job training services Not directly asked in survey. -33% were homeless at some point before admission Not directly asked in survey -66% of survey were either disabled/unable to work or unemployed Obesity, diabetes, hypertension Not addressed in focus group discussion. Transportation Peer support Not directly asked in survey. No survey questions referenced peer support. Based on consolidation of health needs identified by the patient survey, focus group participants, and key informants, TTC will focus on the following six (6) priorities during the implementation period. Some of the priorities defined below are consistent with the Health People 2020 Leading Health Indicators, 21 and various goals in the LAC Community Health Improvement Plan (CHIP). 22 Priority 1. TTC will continue to provide the full continuum of SUD treatment services in the community with an emphasis on providing targeted outreach and engagement activities to TAY youth, homeless individuals and LGBTQ community. Although focus group participants (who are TTC residential patients) expressed gratefulness for the SUD services TTC provides, they suggest that SUD services are still a significant need in SPA 2, particularly for specific target populations (listed above) and areas of the San Fernando Valley. SUD programs and services are also a Leading Health Indicators in the national Healthy People 2020 campaign, 23 and one of the goals in the LAC CHIP. 24 Although progress is being made to lower rates of substance use in the United States, the use of mind and behavior-altering substances continues to take a major toll on the health of individuals, families, and communities nationwide. According to the 2014 NSDUH, approximately 21.5 million people (age 12 or older) had a substance use disorder in the past year, including 17 million people with an alcohol use disorder, 7.1 million with an illicit drug use disorder, and 2.6 million who had both an alcohol use and an illicit drug use disorder. 25 Substance abuse involving drugs, alcohol or both is associated with a range of destructive social

36 conditions, including family disruptions, financial problems, lost productivity, and failure in school, domestic violence, child abuse and crime. Moreover, both social attitudes and legal responses to the consumption of alcohol and illicit drugs make substance abuse one of the most complex public health issues. Estimates of the total overall costs of substance abuse in the United States, including lost productivity and health- and crime-related costs exceed $700 billion annually. 26 Priority 2. TTC will continue to provide the full continuum of MH treatment services to address stigma and serious mental illness (SMI) in the community with an emphasis on increasing community knowledge and access to underutilized programs for children and youth such as EPSDT, PEI and mild to moderate services. The provision of mental health treatment services in SPA 2 remains a vital service, especially in concurrence with SUD treatment. Almost half of survey respondents agree that mental health services are a high priority issue. In addition, Key informants observe that there are limited specialty youth mental health services available, and as a result they believe children and youth are an underserved population in mental health treatment services. Not only do mental health issues affect people of all ages, but all race/ethnicities. It is crucial that mental health professionals are expertly trained in cultural competence in order to treat mental health issues in a culturally-framed context. Therefore, TTC chose to address this need in Priority 3, as listed above. Priority 3. TTC s will assign to the existing CLAS Standards subcommittee the task of developing a plan to increase TTC s staff cultural competency via on-going CLAS standards staff training and development of a hiring and retention plan to increase TTC s staff bi-lingual (English/Spanish) language capability. Increasing access to mental health care is represented as a Leading Health Indicator in the national Healthy People 2020 campaign, and also a goal in the LAC CHIP. In fact, the burden of mental illness in the United States is among the highest of all diseases, and mental disorders are among the most common causes of disability. Data shows that, in 2014, approximately 1 in 5 adults (age 18 or older) in the United States (43.6 million) experienced a mental health issue most commonly anxiety or depression. An estimated 9.8 million adults experience a serious mental illness, including schizophrenia, bipolar disorder, or major depression. In addition, mental health disorders also affect children and adolescents at an increasingly alarming rate. In 2015, 1 in 5 youth, age (21.4%) experiences a severe mental disorder at some point during their life. It is not unusual for either adults or children to have more than one mental health disorder. 27 Furthermore, mental health and physical health are inextricably linked. Individuals with untreated mental health disorders are at high risk for many unhealthy and unsafe behaviors, including alcohol or drug abuse, violent or self-destructive behavior and suicide the 10 th leading cause of death in the United States, and 2 nd leading cause of death among people age 15 to 24. Priority 4. TTC will continue to implement its current patient tobacco cessation activities with an emphasis on impacting TAY youth and monitor adherence to TTC s tobacco written policy and procedure

37 Half of all survey respondents agreed that tobacco use is an important health issue in their community. The same sentiment was shared by key informants who saw it as a persistent health issue for their target populations. Focus group participants also shared numerous personal health issues caused or exacerbated by smoking in combination with other substance use. Reducing tobacco use, particularly reducing the rate of smoking, is a Leading Health Indicator in the Healthy People 2020 campaign, and a goal in the LAC CHIP. In 2014, an estimated 16.8% of all American adults (40.0 million people) identified as cigarette smokers; of these, 76.8% (30.7 million) were daily smokers. As a results of widespread tobacco use, more than 480,000 Americans die from tobacco-related illnesses, such as cancer and heart disease, each year. An estimated 41,000 of these deaths are the result of secondhand smoke exposure. For every person who dies from tobacco use, another 20 suffer at least one serious tobacco-related illness. Tobacco use poses a heavy burden on the United States economy and medical care system. Each year, smoking-related illnesses cost more than $300 billion, including nearly $170 in direct medical care for adults. 28 Priority 5. TTC will continue focus on integrating behavioral health and medical care services by focusing on chronic diseases prevalent in the communities we serve (e.g. diabetes, obesity, asthma, high blood pressure, etc.) and it s interaction with SUD/MH. This includes addressing comorbidity and need to provide integrated and coordinated care via shared electronic charting and regular provider case communication and conferencing. Similar to the 2012 CHNA findings, the data shows that chronic diseases are still a concern for the community TTC serves and for those who are served by key informant agencies. Survey respondents agreed that asthma, cancer, Hepatitis C, obesity, and diabetes were a community health issue. Key informants note that these chronic diseases are highly prevalent in their target populations, who are already vulnerable in terms of their socio-economic status. Comorbidity has also been an increasing concern for key informants as well. Aside from the persisting concerns of comorbidity, obesity and diabetes were the next two most concerning chronic health issues for key informants, who express concern about the costliness and availability of healthy foods, as well as the need to recognize the role socio-cultural factors play in food choice and diet (Priority 3 above also addresses these concerns). Care coordination and integration shall remain a high priority in order to improve the health and wellbeing of the communities TTC serves. Priority 6. TTC will continue to provide benefits assistance to patients including education to under insured and undocumented patients who may be able to access primary medical care and/or behavioral health services via State benefits and/or local benefits such as MyHealthLA. TTC will seek to expand the number of patients seen in SUD treatment services under MyHealthLA. A third of survey respondents agreed that access to health care and insurance was a community health need. A third of the key informants also mentioned the need for increased access to care or health insurance. Specifically, clients served by key informant agencies share that there are still high prices of medication or for accessing health care. This makes it prohibitive to see doctors for check-ups for other visits. Key informants also know that some of their under insured and undocumented clients slip through the cracks of healthcare reform, which can limit their eligibility to apply for health care

38 coverage. Recently, State insurance coverage began expanding to cover SUD treatment for more people. TTC hopes to provide benefits assistance to these people as well. A person s ability to access health services has a profound effect on every aspect of his or her health. People without medical insurance are more likely to lack a usual source of medical care, such as a primary care provider and are more likely to skip routine medical care due to costs, increasing their risk for serious and disabling health conditions. Increasing access to both routine medical care and medical insurance are vital steps in improving the health of the communities TTC serves. Providing access to health services is a Leading Health Indicator in the Health People 2020 campaign, and a goal in the LAC CHIP. Since the implementation of the Affordable Care Act (ACA) there are now significant reductions in uninsured rates. 29,30 Locally, residents of Los Angeles County are generally eligible for Medi-Cal, California health exchange marketplace Covered CA, or My Health LA. At the start of ACA, 21% of LAC residents were uninsured, whereas in 2015 that rate was reduced to 12%. 31 Health Priorities in Other Areas There were other health needs identified by the survey respondents, key informants and focus group participants were determined to be out of TTC s primary scope of services. Even those, these needs will be addressed by TTC by referring to community partners. These needs include the following topics/themes (see Attachments): Housing stock in SPA 2 region remains limited and in poor quality. TTC will continue to work collaboratively with community partners and refer patients to community partners that provide housing services not provided by TTC such as permanent supportive housing. Access to food/food security, which significantly impacts the health outcomes for those living in poverty. TTC will continue to work collaboratively with community partners and refer patients to available low cost and free food services, such as food pantries. Dental health is an often forgotten aspect of health care that can affect many other areas of health. TTC will continue to refer TTC patients to available dental care services in the community. Gang violence, unsafe neighborhoods and the involvement of crime and drugs. TTC will continue to work collaboratively with community agencies that provide gang involvement services and continue to refer patients to needed services. Lack of jobs/job training services, which leads to cyclical involvement in crime/substance abuse and selling drugs. TTC will continue to work collaboratively with community partners who provide vocational training services either on-site at TTC and/or via referral. Limited and unreliable transportation options. TTC will continue to provide patient transportation assistance via existing van fleet and ability to leverage use of bus tokens, bus/metro passes and taxi vouchers in certain service contracts

39 EVALUATION OF THE 2012 CHNA IMPLEMENTATION PLAN The 2012 CHNA Implementation Plan defines/identifies five (5) goals that were tracked annually from 2013 to Each goal had specific objectives and indicators to track progress: Goal: Improved physical and mental health conditions of COD individuals in the community Indicators: COD Patients served, and demographics of these patients. Table 24: Demographics of Unduplicated COD Patients Served*, Number of COD Patients 1,273 1, Gender Male 61.8% 62.6% 66.2% Female 38.2% 37.4% 33.8% Race/Ethnicity (if provided)** White 62.6% 62.6% 69.1% Black/African American 11.0% 11.1% 9.0% Hispanic 20.3% 23.8% 22.7% Asian or Pacific Islander 1.9% 1.6% 1.3% Native American 1.1% 1.0% 0.4% Mixed 3.0% 2.0% 1.2% Other 3.1% 6.0% 7.3% Age Group 17 and under 3.7% 1.6% 1.5% % 14.5% 14.5% % 27.9% 21.7% % 20.6% 19.4% % 21.9% 22.9% % 11.5% 14.4% % 1.8% 5.3% 75 and Over 0% 0.3% 0.4% Sexual Preference (if provided) Heterosexual 60.6% 60.7% 59.9% Gay/Lesbian 7.1% 6.3% 5.0% Bisexual 2.2% 3.4% 3.4% Unsure/Questioning/Don t Know 1.0% 0.9% 0.6% Treatment Complete, COD Patients 51.9% 51.3% 51.8% Treatment Complete, COD specific programming 64.8% 71.9% 80.5% *COD in primary care, mental health and SUD treatment services **Total may not be 100%; Hispanic ethnicity percentage is not mutually exclusive. 35

40 Perceptions of COD patients: TTC continues to monitor the perceptions of COD patients by using perception of care surveys in all SUD treatment modalities. Table 25 summarizes data from perception of care surveys for TTC s Inpatient Facility. The percentages below represent the aggregate percentage of Excellent and Very Good rating for each measure. This percentage illustrates positive perceptions of care. Most measures have achieved the 80% positive benchmark established by TTC. Table 25: Perception of Care for TTC s Inpatient Facility 2013 N= N= N= Overall structure of the program. 92% 85% 82% 2. Overall quality of care and services. 91% 90% 83% 3. Quality of dietary/food services. 91% 76% 73% 4. Quality of the housing & facilities. 89% 84% 80% 5. Quality of group counseling sessions. 94% 76% 75% 6. Quality of individual counseling sessions. 86% 72% 73% 7. Quality of nursing services. 87% 84% 84% 8. Quality of medical services. 82% 81% 78% 9. Quality of Psychological services you received 84% 71% 76% from an Intern, Post-doc, or Psychologist. 10. Quality of Psychiatric services. 75% 63% 69% 11. I have been treated with respect and dignity. 85% 89% 84% 12. I feel confidence and trust towards the staff. 86% 89% 83% 13. I feel the staff are courteous and friendly. 87% 92% 85% 14. The staff are respectful of my cultural 82% 92% 89% background. 15. Treatment has helped me deal with my addiction 75% 84% 76% problem. 16. Treatment has improved my overall health condition. 92% 81% 80% Goal: Improved smoking behavior of patients. Indicators: Number of patients screened for smoking: From , TTC admission staff have screened 100% of all patients for smoking behavior at admission to treatment. Patients who screen positive for smoking referred to NO-BUTTS hotline: 100% of patients who acknowledged smoking behavior at admission to treatment were referred to the hotline. This is a standard that continues to be implemented at all admissions to treatment. Number of patients receiving intervention services: TTC data for is shown below: Table 26: Patients Receiving Tobacco Intervention Services, Patients Admitting Tobacco Use at 2,703 2,859 2,928 Admission: Number and % of Patients Receiving 28% 18% 25% Assistance Quitting Tobacco: (759) (521) (733) 36

41 Goal: Prevention and treatment of infectious diseases. Indicator: Number of patient s screened: 100% of patients admitted to primary care, mental health and SUD treatment services are screened as part of intake protocol. This is a company standard that continues to be implemented at all admissions to treatment episodes. Goal: Improved access to health benefits. Indicator: Patients screened: 100% of patients admitted to primary care, mental health and SUD treatment services are screened for benefits they may be eligible for at time of admission, as part of intake protocol. This is a standard that continues to be implemented at all admissions to treatment. Goal: Improved Access to HIV/AIDS services. Indicator: TTC began implementation of SAMHSA s Getting Off! program in 2012, which provides linkages to HIV-related services and testing for HIV and Hepatitis B and C. During Fiscal Year , 96 patients have been enrolled and screened for HIV, and 82 (85%) have been tested for HIV. 37

42 PRIMARY HEALTH CARE FACILITIES AND OTHER RESOURCES AVAILABLE IN THE COMMUNITY SERVED The facility of Tarzana Treatment Centers, Inc. (TTC) located in Tarzana is licensed as an acute psychiatric hospital by California Office of Statewide Health Planning and Development (OSHPD). According to the Subdivision (b) of Section 1250 of the California Health and Safety Code, an acute psychiatric hospital is defined as a health facility having duly constituted governing body with overall administrative and professional responsibility and an organized medical staff that provides 24-hour inpatient care for mentally disordered, incompetent, or other referred patients for basic services including medical, nursing, rehabilitative, pharmacy, and dietary service. Based on the 2014 OSPHD Hospital Utilization Data, Los Angeles County (LAC) has a total of 11 facilities licensed as an acute psychiatric hospital and 2 facilities are located in SPA 2. The Tarzana facility of TTC is the one of the 2 licensed acute psychiatric hospitals in LAC, and the only one in SPA 2 that provides services to population with mental and chemical dependency co-occurring disorders. Other than licensed acute psychiatric hospitals, there are two (2) licensed chemical dependency recovery hospitals, one in SPA 3 and another in SPA 8, and three (3) licensed psychiatric health facilities in SPA 8. OSHPD defines a chemical dependency recovery hospital as a health facility that provides 24-hour inpatient care for persons who have a dependency on alcohol or drugs, including patient counseling, group and family therapy, physical conditioning, outpatient, and dietetic services (OSHPD). A psychiatric health facility (PHF), defined by Section of the California Health and Safety Code, is licensed by the State of Mental Health that provides 24-hour inpatient care for mentally disordered, incompetent, or other persons for psychiatry, clinical psychology, psychiatric nursing, social work, rehabilitation, drug administration, and appropriate food services for those persons whose physical health needs can be met in an affiliated hospital or in outpatient settings. 32 There are a total of 252 facilities throughout LAC and 57 facilities located in SPA 2 that provide services to population with mental health and substance use co- occurring disorder according to the SAMHSA Behavioral Health Treatment Services Locator. 33 All these facilities provide services to the co-occurring population at different levels of care, including inpatient, outpatient, and residential rehabilitation. Of all substance abuse treatment facilities in SPA 2, 8 facilities provide hospital inpatient services, 16 offer residential rehabilitation, 49 offer outpatient services, and 8 offers partial hospitalization/day treatment. In general, treatment in an outpatient setting involves clients in a variety of group modalities, such as chemical dependency education, relapse prevention, recovery process, family involvement and support, 12-step education, and aftercare, in addition to individual counseling sessions. A residential rehabilitation program is usually designed to create a therapeutic community geared to addressing all aspects of addiction- and mental health-related issues in a safe, supportive and structured environment for either short-term (within 30 days) or long-term (more than 30 days). A day treatment program generally offers partial hospitalization services during the day to address the unique needs of individuals struggling with addiction and/or mental health problems. Eight out of 57 facilities in SPA 2 offer detoxification to individuals struggling with a variety of 32 California Health and Safety Code

43 substance abuse addictions, including: alcohol, cocaine, crack, ecstasy, marijuana, inhalants, methamphetamines, opiates, stimulants, narcotics, hypnotics, muscle relaxers, and hallucinogens, as well as co-occurring mental issues, chemical dependencies and other illegal drugs. The aim of detoxification treatment is on early recovery, identifying relapse, and educating addictive individuals to cope with the triggers. Eight (8) facilities in SPA 2 have both methadone maintenance and methadone detoxification program available to individuals who are addicted to opioids where detoxification has not been successful and/or admittance to a substance abuse treatment facility requires complete abstinence. Methadone maintenance is the use of methadone administered over a period of time as treatment for opioid addicts whereas methadone detoxification is a mean of gradual and safe methadone withdrawal process in preparing clients to get clean and sober. Additionally, there are four (4) facilities in SPA 2 that provide Buprenorphine services for the treatment of opioid addiction, which is an alternative option to reduce risk potential for abuse, diversion and overdose of opioids. Considering the spectrum of services, TTC is the only licensed facility in SPA 2 that provides comprehensive mental health services and chemical dependency treatment to dual-diagnosed individuals, offering 24-hour inpatient services for detoxification and residential treatment and outpatient services. Throughout Los Angeles County, there are four (4) OSHPD licensed facilities and 2 community-based health facilities that provide similar services to individuals with mental health and substance abuse co-occurring disorders. A list of licensed acute psychiatric hospitals, dependence recovery hospitals, psychiatric health, and other licensed facilities providing services to people with mental health and substance use co-occurring disorder in LAC by SPA is included in the attachments. Description of Service Capacity and Utilization by Population with Co-Occurring Disorders (COD) in Los Angeles County using 2014 OSHPD data and 2012 TEDS-A Data Epidemiologic data are fundamental to planning services that are responsive to the needs of our service population. Individuals with co-occurring disorders (COD) are our main target population; thus, we determined to explore the capacity of and services provided by existing licensed acute psychiatric hospitals as well as chemical dependency recovery hospitals and psychiatric health facilities demonstrated in Table 28, 29, and 31. In this preliminary finding based on the available secondary data extracted from OSHPD, only two licensed acute psychiatric hospitals that provide services to individuals with mental and chemical dependency co-occurring disorders (COD). Due to the target population that our Inpatient Facility serves, this report only focuses on the COD population served by these two licensed acute psychiatric hospitals, one located in Tarzana that falls within the boundaries of SPA 2 and another one in Pasadena within SPA 3. By the end of 2014, these two licensed acute psychiatric hospitals had a total of 82 beds licensed for the treatment of co-occurring disorders. In 2014, a total of 2,689 COD patients were discharged with a total of 16,195 discharge days. Each discharged patient stayed in the facility at an average of 5.9 days. Looking at demographic characteristics of discharged patients, 100% of them age between 18 and 64 years old. Approximately 65% of these discharged patients identified themselves as White and 19% were Latino/Hispanic. In terms of payers, 16% were covered by traditional Medicare, 22% by traditional Medi-Cal, 28% by Managed Care third parties, 18% by other third parties, and 16% other payers. 39

44 SPA 1 SPA 2 SPA 3 SPA 4 SPA 5 SPA 6 SPA 7 SPA 8 However, many individuals with COD are either undiagnosed or cannot overcome the stigma associated with mental and/or behavioral health difficulties to seek out for help or to navigate the complicated service systems. According to Substance Abuse and Mental Health Services Administration (SAMHSA), among the 8.9 million adults with co-occurring disorders (COD), only 7.4% of individuals receive treatment for both conditions, and 55.8% did not receive treatment at all (SAMHSA). Table 27: Service Capacity and Utilization in Los Angeles County by SPA, 2013 Total number of licensed facilities Acute psychiatric hospitals Chemical dependency recovery hospitals Psychiatric health facilities Total number of licensed beds , Acute psychiatric , Skilled nursing Chemical dependency Intermediate care Total number of discharges N/A 2,580 16,941 1,005 1,983 1,022 7,500 6,510 Acute psychiatric ,365 1,005 1,983 1,022 7,488 5,952 Acute psychiatricchemical recovery N/A 2, Chemical dependency N/A recovery Skilled nursing N/A Intermediate care N/A Total number of patient days N/A 105, ,065 13,742 24,839 25, ,317 72,221 Acute psychiatric 0 3,387 94,813 13,742 24,839 25, ,129 55,164 Acute psychiatricchemical N/A 14,882 2, dependency Skilled nursing N/A 86, ,

45 Chemical dependency N/A 0 6, ,057 Intermediate care N/A Source: 2014 Hospital Annual Utilization Data, OSHPD TTC Primary Care Clinics As an integrated healthcare organization, TTC has a total of six satellite facilities licensed by Office of Statewide Health Planning and Development (OSHPD) of California Department of Health that provide primary medical care and other health care services to the communities in SPA 1 and SPA 2. These clinics serve as support and fill in some of the gaps in services identified by clients of the Inpatient Facility. Tarzana Primary Care Clinic In 2015, the Tarzana primary care clinic in SPA 2 had 0.80 Full-Time Equivalent (FTE) primary care providers along with 1.5 FTE clinical support staff. The Tarzana clinic served 599 patients with a total of 1,291 encounters. A majority (90.1%) who received primary medical care at the Tarzana clinic were between 100 to 138% FPL, with the rest under 100% FPL. A majority of these clients were covered by other payers (52.2%), followed by Medi-Cal/Medi-Cal Managed Care (37.3%), Medicare/Medicare Managed Care (4.7%), free service (3.7%), self-pay (1.1%), and others (e.g., private insurance and Covered California). Northridge Primary Care Clinic In 2015, the Northridge primary care clinic in SPA 2 had a total of 1.90 FTE primary care providers along with 4.50 FTE clinical staff, including registered nurse and medical assistants. The clinic served 1,562 patients with a total of 9,762 encounters. A majority (88.6%) who received primary medical care at the Northridge clinic were between 100% to 138% FPL, with the rest (11.4%) under the 100% FPL. A majority of these clients were covered by Medi-Cal/Medi-Cal Managed Care (74.8%), followed by free (8.8%), Medicare/Medicare Managed Care (6.9%), self-pay (6.3%), Covered California (2.1%), and others (e.g., all other payers and private insurance). Lancaster Primary Care Clinic In 2015, the Lancaster primary care clinic in SPA 1 had a total of 1.2 FTE primary care providers along with 7 FTE clinical staff, including medical assistants, billing and other administrative staff. The clinic served 1,650 patients with a total of 7,821 encounters. A majority (89.6%) who received primary medical care at the Lancaster clinic were between the 100% and 138% FPL, with the rest (10.3%) under the 100% FPL. A majority of these clients were covered by Medi-Cal/Medi-Cal Managed Care (80.4%), followed by self-pay (9.8%), all other payers (4.3%), Free (2.9%), Medicare/Medicare Managed Care (2%), and private insurance (<1%). Palmdale Primary Care Clinic In 2015, the Palmdale primary care clinic in SPA 1 had a total of 1.4 FTE primary care providers along with 3.2 FTE clinical support staff, including a marriage and family therapist, and medical assistants. The clinic served 491 patients with a total of 2,264 visits.a majority (89.6%) who received primary medical care at the Palmdale clinic were between the 100% to138% Federal Poverty Level (FPL), with 41

46 the rest (10.3%) falling under the 100% FPL. A majority of these clients were covered by Medi- Cal/Medi-Cal Managed Care (82.6%), followed by all other payers (5.2%), Medicare/Medicare Managed Care (5%), self-pay (4.4%), free (1.4%), and others (e.g., Covered California and private insurance). Reseda Primary Care Clinic In 2015, the Reseda primary care clinic in SPA 2 had a total of 1.8 FTE primary care providers along with 3 FTE clinical support staff, including medical assistants. The clinic served 418 patients with a total of 1,334 visits. A majority (89.9%) who received primary medical care at the Reseda clinic were between 100% to 138% Federal Poverty Level (FPL), with the rest (10%) falling under the 100% FPL. A majority of these clients (84.4%) were covered by Medi-Cal/Medi-Cal Managed Care, followed by Medicare/Medicare Managed Care (4.5%), Covered California (3.1%), self-pay (3.1%), free (2.8%), private insurance (1.4%), and all other payers (.4%). Granada Hills Primary Care Clinic In 2015, the Granada Hills primary care clinic in SPA 2 had a total of 0.15 FTE primary care providers along with 0.90 FTE clinical support staff, including a registered nurse and medical assistants. The clinic served 19 patients with a total of 29 visits. All clients who received primary medical care at the Granada Hills clinic were under 100% FPL. A majority of these clients (84.2%) were covered for free, and followed by Medi-Cal/Medi-Cal Managed Care (15.7%). 42

47 AGENCY COLLABORATION IN SPA 2 Key informants provided insights and feedback concerning collaboration among health-related agencies in SPA 2. To summarize, the agencies collaborated to provide/receive referrals for patients, share data and information, and enhance program implementation. The agencies represented by the key informants have been collaborating with other agencies to address and/or resolve health issues. For instance, since 2004, TTC has worked in collaboration with Northridge Hospital Medical Center s Emergency Department (NHMC ED) and Behavioral Services, to address the health needs of patients that utilize the ED. TTC s expertise in providing comprehensive case management services in NHMC s ED has continued to improve the access to appropriate levels of health care services for uninsured, underinsured and underserved residents of the SPA 2 ED users. Also, TTC has been receiving funding assistance from Kaiser Permanente Medical Center to serve individuals who are uninsured, living below the federal poverty level, and/or homeless with a chronic condition (i.e., diabetes and hypertension). If these individuals do not have continued access to appropriate medical care they will lose any health benefits gained while insured and ultimately cost the community more because of unnecessary and costly services at local emergency rooms (ER). LAC-DPH has provided TTC funding assistance to provide services mental health services to individuals served by TTC s Northridge primary care clinic. TTC also continues to work with collaborative partners including faith-based organizations and non-profit organizations (Mission City Community Network (MCCN), BIENESTAR, Providence Center for Community Health Improvement (PCCHI), and Vision y Compromiso (VyC) in SPA 2 to recruit Latino client and their families who are indigent/uninsured. TTC has also initiated collaboration with partner agencies to train Youth Mental Health First Aid (YMHFA) instructors and First Aiders through SAMHSA grant award. Eight agencies working with youth in SPA 2 pledged their commitment and support to the project (Project FAIR). Twenty-five agency staff were certified as YMHFA instructors. These instructors will train a total of 750 First Aiders for three years ( ). These local agencies include the Child and Family Center, Child and Family Guidance Center, El Centro de Amistad, Friends of the Family, Penny Lane Centers, Providence, ACE, and the Village Family Services. Collaboration is an effective way to pool and/or match existing health-related resources in addressing the health needs in SPA 2. It is important however that collaboration must be maintained and/or expanded to meet the identified health needs. As discussed above, collaboration was identified as one of gaps in health resources to adequately meet priority health needs. With the Affordable Care Act providing uninsured and underinsured population access to medical care, collaboration among health agencies in SPA 2 will be instrumental in maximizing and organizing funding resources for health care services in the community. 43

48 III. List of Tables and Figures Table 1: Patient Residence and Distance to TTC Inpatient Psychiatric Facility by SPA, Figure 1: Map of Los Angeles County SPA s and Location of TTC Inpatient Facility... 6 Table 2: SPA 2 and L.A. County Population, Table 3: SPA 2 and L.A. County Population by Gender, Table 4: SPA 2 and L.A. County Population by Race/ Ethnicity, Table 5: SPA 2 vs L.A. County Population by Age, 2014 Estimates... 8 Table 6: SPA 2 and L.A. County Population by Household Income, 2014 Estimates... 9 Table 7: SPA 2 and L.A. County Population by Level of Education, 2014 Estimates Table 8: SPA 2 vs L.A. County Population by Labor Force, 2014 Estimates Table 9: Estimated Cases of Key Diseases in SPA Table 10: Estimated Incidence of Cancer in SPA Table 11: HIV/ AIDS Prevalence in SPA Table 12: Leading Causes of Death in SPA Table 13: SED or SMI by Gender in SPA Table 14: SED or SMI by Race in SPA Table 15: SED or SMI by Age in SPA Table 16: SUD Treatment Admissions, Los Angeles County (LAC), Table 17: Demographics of SUD Treatment Admissions, Los Angeles County (LAC), Table 18: Experience Accessing Health Services in the last 12 months before coming to Inpatient Facility (n=118) Table 19: Self-rated Overall Health (n=125) Table 20: Survey Respondents Risk Behaviors in the last 30 Days (n=125) Table 21: Survey Respondents Health Issues (n=125) Table 22: Disability Status (n=115) Table 23: Health Priorities Identified by Data Sources Table 24: Demographics of Unduplicated COD Patients Served, Table 25: Perception of Care for TTC s Inpatient Facility, Table 26: Patients Receiving Tobacco Intervention Services, Table 27: Service Capacity and Utilization in Los Angeles County by SPA, IV. References and Bibliography 2013 Assessing the Community s Needs: A Triennial Report on San Fernando and Santa Clarita Valleys, Valley Care Community Consortium (VCCC), San Fernando Valley Economic Alliance Key Indicators of Health by Service Planning Area, Los Angeles County Department of Public Health, June & 2014 Hospital Annual Utilization Data, Office of Statewide Health Planning and 44

49 Development (OSHPD) Glossary of Terms and Abbreviations, Office of Statewide Health Planning and Development (OSHPD) ALIRTS Primary Care Clinic Data, Office of Statewide Health Planning and Development (OSHPD) Healthy People Treatment Episode Data Set-Admissions (TEDS-A), Survey Documentation and Analysis (SDA), Substance Abuse and Mental Health Services Administration (SAMHSA) California Health and Safety Code, Section 1250 & Co-Occurring Disorders, Substance Abuse and Mental Health Services Administration (SAMHSA) V. List of Attachments Patient Survey Key Informant Interview Focus Group Script and Questions List of Key Informants for SPA 2 List of facilities providing services to population with mental health and substance use cooccurring disorder in Los Angeles County by SPA 45

50 COMMUNITY HEALTH NEEDS ASSESSMENT SURVEY The purpose of this survey is to gather information about health-related needs in the community. Results from this survey will help Tarzana Treatment Centers, Inc. (TTC) plan and/or improve health services that meet your needs. The survey takes minutes to complete. Your participation in this survey is 100% voluntary. There are no negative consequences if you choose not to participate. We will not ask you for any information that could be used to identify you. You can refuse to answer any individual question, or stop the survey completely if it makes you uncomfortable. Your individual responses will not be shared with anyone other than the Evaluation Team of TTC, and will remain strictly confidential. **Please answer each question in terms of BEFORE you came to Inpatient Detox, unless otherwise noted.** Part I. Your Personal Information 1. What is the City and Zip Code where you live? 2. What is your date of birth? / / 4. Which of the following racial/ethnic groups do you 3. What is your gender? identify as? (Select all that apply.) Male White/Caucasian (non-hispanic) Female Black/African American Transgender Hispanic or Latino/a, specify: Other, specify: Native American/American Indian Declined Alaskan Native 5. Do you identify as Asian Straight Pacific Islander Lesbian or Gay Other, specify: Bisexual Declined Other, specify: 6. Is English your first language? Declined Yes Don't Know No 7. What is your employment status? (Select only one.) If No, what is? Employed part-time 8. What is your yearly household income, from all sources? Employed full-time Less than $19,999 Self Employed $20,000 $29,999 Unemployed $30,000 $50,999 Homemaker $51,000 Over Student Declined Retired Don t Know Disabled 10. Before coming to inpatient detox, what was your living Declined arrangement? (Select only one.) 9. What is your marriage status? Living Alone Single (never married) Living with family Married Living with roommates/friends Separated Living with spouse/partner and children Divorced Living with spouse/partner only 46

51 Widowed Living with children only Declined Homeless/No stable arrangement How long have you currently been homeless? 11. What is the highest level of education you have completed? 12. How many people live with you? 13. Do you have children under the age of 18? Less than high school Yes (How many? ) Some high school Do they live with you? High school graduate/ged Yes Some college No College graduate (A.A.,B.A.) Vocational school No Graduate degree or professional degree Declined Declined Don t Know Don t Know Part II. Health Status 14. Would you say your overall health is: 15. Do you exercise? Good Yes Fair How many days do you exercise each week? Poor How many hours do you exercise each day? Declined No 16. If you have a disability, which disability best describes you? (Select all that apply.) Hearing Visual Speech Mobility Mental Developmentally Disabled Other, specify: I do not have any disabilities Declined Don t Know 17. Are you eligible for benefits because of your disability? Yes No/Not Applicable Part III. Access to Medical Care 18. Have you ever felt discriminated against when getting 19. If you have children: Does your child/children have medical care/services? Yes No health insurance? If Yes, you feel you were discriminated because of your: Yes Declined (Select all that apply.) No Don t Know Age Sexuality If Yes, what kind: Race/ethnicity Disability status How long have they had insurance? Gender Other, specify: 21. Where do you usually receive medical care/services? (Select all that apply.) 20. I have difficulty getting the medical care I need because of (Select all that apply.) TTC primary care clinic Other community health clinic Cost of care Hospital Lack of transportation Emergency room Lack of insurance coverage Urgent care Language problems/ communication issues Private doctor The location(s) is/are too far from me Out of state/country No, I do not have difficulties getting care I do not receive medical care 47

52 Other, specify: Other, specify: Declined Declined Don t Know Don t Know Please select the answer which best describes your experience in accessing health services: NA/DON T YES NO RECALL In the LAST 12 MONTHS, have you 22. Had a physical examination? 23. Had an eye examination? 24. Been able to visit a doctor when you needed to? 25. Been able to afford all medications prescribed to you? 26. Had access to all the health services you needed? 27. Had access to all the health services your family needed? 28. Visited an Emergency Room? 29. Stayed in a hospital overnight? 30. Had any problem getting transportation to and from your health appointments? 31. Received a flu shot? 32. Always had access to healthy foods? 33. Seen a dentist? 34. Had access to mental health services? 35. Had access to services in the language you usually speak? Part IV. Risk Factors Please select the answer which best describes you: In the MONTH (30 days) before you were admitted to Inpatient Detox, how many days did you DAYS 36. Smoke cigarettes? 37. Smoke e-cigarettes (or vaporizers)? 38. Breathe second-hand smoke in your home or at work? 39. Feel bothered by how you were thinking, acting or feeling? 40. Eat fast food 41. Drink sodas or other sugary drinks/beverages 42. Eat at least 5 servings fruits and/or vegetables In the MONTH (30 days) before you were admitted to Inpatient Detox, did you 43. Have unprotected sex? YES NO XXXXXXXX 44. Try to quit smoking? YES NO XXXXXXXX 48

53 Part V. Your Health Needs & Community Health Priorities Have you EVER been told by a doctor, nurse, or other health professional that you have, or are at risk for: Yes No At Risk 45. Arthritis 46. Asthma 47. Cancer 48. COPD (Chronic Obstructive Pulmonary Disease) or emphysema 49. Depression or other mood disorder 50. Diabetes 51. Heart problems/heart disease 52. High blood pressure 53. High cholesterol 54. HIV/AIDS 55. Obesity 56. Stroke 57. Vision problems or blindness (uncorrectable) 58. Other, specify: What do you believe are the TOP 5 health issues in your community? CHECK 59. Access to healthy food/food security/frequent hunger 60. Asthma 61. Cancer 62. Dental health 63. Diabetes 64. Health insurance 65. Heart Disease 66. Health disparities (in the LGBT, minority, or low-income community, etc.) 67. Hepatitis C 68. High Blood Pressure 69. HIV/AIDS services 70. Housing 71. Infectious Diseases (TB, Measles, Hepatitis, etc.) 72. Joint Pain or Back Pain 73. Lung Disease 74. Mental Health services 75. Obesity 76. Reentry Services 77. Stroke 78. Sexually Transmitted Infections (STIs) 79. Substance Abuse Disorder 80. Tobacco Use 81. Violence (domestic violence, gang involvement or presence in neighborhood, bullying, etc.) 82. Don t Know 83. Other, specify: 49

54 Focus Group Script: **Pass out demographic survey at sign in.** Ask participants to please complete while we wait to start focus group. Hello everyone, my name is [name] and I will be your focus group facilitator today. (Extra introductions as needed.) Thank you for participating in this Focus Group, which is part of the Community Health Needs Assessment for Tarzana Treatment Centers. This assessment is completed every 3 years and determines the needs of the community and helps improve or expand the services Tarzana Treatment Centers offers. Your participation today is very important and we thank you for being here. I anticipate that this session will last about an hour to an hour and a half. Your identity and your comments will be kept strictly confidential and anonymous, so I ask that you be honest with your responses and sharing your opinions. With that being said, we will be recording this session, just to make sure we report everyone s opinions accurately and not identify anyone specifically. This group is structured like a conversation. I will start the conversation out with a question, which each of you can answer; after that, I will only jump in to get us back on topic, or to follow up on specific points. Feel free to disagree with what others have said or give another opinion: the more different ideas we hear, the more information we will have to work with. Please keep in mind that we are not going to evaluate or judge anyone s opinions or experiences, and our only interest is to listen and learn from your thoughts. Before we get started, does anyone have any questions? Introductions: Let s start by going around the table and introducing yourselves. If you could tell us your name, your age, and a little bit about the neighborhood or community where you most recently lived before coming to TTC. Okay, so we re here to learn about health issues or needs that you see in your neighborhood or community, but let s begin by talking a little bit more about you. 1. How would you describe your own overall health? a. Probe: Do you think of yourself as healthy? If so, why or why not? b. Probe: What sort of things on a personal level affect your health? (lack of exercise, poor diet, smoking, drug/alcohol use, etc.) 2. Now think of the neighborhood or community where you live. What are some things at the community level that affect your health and the health of people living around you? [There are clients that live outside SPA 2? Based on the survey, are clients residing in SPA 2 or elsewhere? We must make sure what is the community they are referring to. More than half of those who filled in a city and zip code were from zips within SPA 2 (56%), with also some from SPA 4 (30%)] a. Probe: Do any of these issues (lack of health/mental health services, homelessness, substance abuse, HIV/AIDS, gang/domestic violence, obesity/diabetes, hunger, unemployment, etc.) exist in your community? If so, how do they affect your health? b. Probe for homeless experience, how easy is it to exercise or eat healthy foods in your community? 3. Of these issues or concerns that we have discussed, what are the most important ones to you? Which ones do you think are affecting your health and the health of your community the most?

55 a. Probe for: issues mentioned above as well as ER use, SUD, STDs, tobacco use, mental health (depression & mood disorders) 4. How do you think we could best address these issues? What do you think needs to be done to improve your own health and your community s health? a. Probe: What sort of services or programs would help tackle these problems? 5. Let s talk specifically about health care. Have you ever had any problems getting medical care or mental health services? Do you have health insurance? a. What kind of problems have you had getting health care or insurance? (e.g., cost/lack of insurance, no transportation, language barriers, negative attitudes of providers, etc.) b. What could help you with these challenges? 6. Has there ever been a time where you felt discriminated against when getting health care? If so, tell us about your experience and why you think you were being discriminated against? a. What do you think needs to be done to prevent this from happening again to you or anyone else? 7. Of all the issues (give some examples) we discussed today, what is the most important to you? a. What should our priorities as a community be? b. What sort of programs or services would help you or people in your community the most? 8. Is there anything else you d like to add or any questions? We d like to thank you for being a part of this focus group. If there is anything that comes up for you that d you d like to add please contact me at (give contact information). Thank you.

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