Maimonides Medical Center Community Health Needs Assessment and Community Service Plan

Transcription

1 Maimonides Medical Center Community Health Needs Assessment and Community Service Plan As Adopted and Submitted to the New York State Department of Health December 30, 2016 Service Area Covered Participating Hospitals Contact Primary and Secondary Service Areas of Maimonides Medical Center Maimonides Medical Center Adam Stolz VP & Chief of Staff

2 Contents Federal CHNA Section Page Cover Page Foreword 2 Executive Summary 3 X 1 Maimonides Medical Center (MMC) and its Community About MMC 5 MMC s Community: Definition and Characteristics 5 X X MMC s Engagement with its Community 8 Community Care of Brooklyn (CCB): Overview and Alignment with MMC s Community Health Program 8 2 Identification of Health Needs Quantitative Component: Health Indicators 10 X X Qualitative Component: Public Deliberations 19 X X Qualitative Component: Interviews 22 X X Qualitative Component: NYS DOHMH TCNY Community Consultations 23 X X 3 Prioritization of Community Health Needs Selected New York State Prevention Agenda Priorities 24 X X Selected New York State Prevention Agenda Disparities 25 X X Health Needs Not Addressed 25 X 4 Implementation Plan Identification of Resources to Address Community Health Needs 26 X Existing and Continuing Programs and Interventions 26 X Inventory of Community Health Activities Completed, Ongoing, and Planned 27 X Work Plan for Addressing New York State Prevention Agenda Priorities 34 X 5 Ongoing Engagement with Partners and Communities Served 43 X X 6 Dissemination and Awareness of the CHNA/CSP 43 X X Appendices A: Data Sources 44 B: Maimonides Community Health Internal Coordinating Committee Roster 45 NY CSP X 1

3 Foreword This document serves several functions and meets legal and regulatory requirements for Maimonides Medical Center (Maimonides, or MMC). In its entirety, it is referred to throughout as a Community Health Needs Assessment and Community Service Plan or CHNA/CSP. The document contains component material which may separately be referred to, in the document or elsewhere, by the following terms: Community Health Needs Assessment (CHNA) as defined by the Federal Government Implementation Plan (IP) as defined by the Federal Government Community Service Plan (CSP) as defined by the State of New York Community Health Implementation Plan (CHIP) as defined by the State of New York This document describes: Activities Maimonides undertook during and prior to 2016 to assess the health needs of its community in partnership with other organizations and members of the community Findings from those activities about the health needs of its community Activities Maimonides conducted during and/or prior to 2016 that address those findings and/or the findings contained in its prior CHNA approved in 2013 Activities Maimonides will conduct in to address the findings in this CHNA Maimonides wishes to acknowledge the work of Sylvie Doppelt and Kalpana Bhandarkar in the creation of this report, along with members of the Maimonides Community Health Internal Coordinating Committee, a roster of which is found in Appendix B. 2

4 Executive Summary Maimonides Medical Center (Maimonides or MMC) is a 711-bed specialty care teaching hospital in Borough Park, Brooklyn that treats over 43,000 inpatients per year more than any other hospital in Brooklyn. MMC serves patients from all over the borough and beyond. Its primary and secondary service areas cover most of Southern Brooklyn, and for this document are defined as including the following New York City Community Districts: Borough Park, Sunset Park, Bensonhurst, Bay Ridge/Dyker Heights, Coney Island, Sheepshead Bay, and Flatbush/Midwood (collectively referred to as MMC s service area). The service area s communities are incredibly diverse and include large immigrant populations; 45% of residents were born outside the United States. In 2016 Maimonides undertook a process to assess the health needs of these communities, drawing on direct input from local residents and from information generated by other organizations that serve these communities. The assessment revealed various degrees of healthcare access, healthy behaviors, health conditions, and health outcomes across the service area, including many instances of unmet needs and cases where the service area community, in whole or part, fares worse than New Yorkers on average with respect to health. Based on the community s measurable health needs, Maimonides distinct competencies and resources, and the direct input of community members and partners, Maimonides has elected to focus on the following New York State Department of Health Prevention Agenda priorities ( Prevention Agenda priorities ): Prevent Chronic Diseases Promote Healthy Women, Infants and Children Promote Mental Health and Prevent Substance Abuse Within the framework of the Prevention Agenda priority to prevent chronic diseases, Maimonides has identified diabetes and obesity in the Hispanic community as a health disparity to address. 17% of the residents of MMC s service area are Hispanic, including 44% of Sunset Park residents. Hispanics experience much greater rates of childhood obesity, diabetes incidence, and diabetes-related mortality than do non-hispanic Whites. In addition, MMC continues to identify low rates of vaccination in particular flu vaccination as a disparity affecting multiple communities within its service area. These priorities remain consistent with those previously selected by MMC and reported in its 2013 Comprehensive Community Service Plan (CCSP). To confirm these priorities MMC reviewed health and related data from several sources including: New York City Department of Health and Mental Hygiene (DOHMH) Community Health Profiles Take Care New York 2020 Community Consultations Conducted by DOHMH New York City Health Provider Partnership Brooklyn Community Needs Assessment U.S. Census Bureau American Community Survey (ACS) New York State Cancer Registry MMC Finance Department / Patient Registration Data To more deeply understand the health challenges facing its communities, Maimonides sought input from members of the community through multiple mechanisms including: Convening a series of public deliberation sessions involving community members Interviewing leadership of community-based organizations Convening a meeting of the MMC Council of Community Organizations (COCO) to gain feedback from community and faith-based leaders, elected officials, healthcare providers and public health specialists 3

5 Maimonides works closely with a large number of partner organizations in assessing its community s health needs and in implementing programs that are responsive to those needs. For the qualitative portion of the needs assessment MMC partnered with the New York Academy of Medicine (NYAM) to conduct the public deliberations and stakeholder interviews referenced above, an endeavor that was funded by the Agency for Healthcare Research and Quality (AHRQ). On an ongoing basis MMC works with the following types of organizations both to understand the health needs of the people it serves and to conduct programming: Faith-based organizations Public and non-profit social services providers e.g. senior centers, recreation centers Public schools Community associations & boards Elected officials Public health officials These organizations often provide space, event promotion, cultural and linguistic expertise, and other assets. Maimonides engages its broader community through events held with organizations like those described above, stakeholder interviews, structured deliberations like the one which was conducted as an input to this assessment, COCO meetings, and other forums. Maimonides has undertaken in 2016, and will implement in , a range of interventions to address the three priorities and one health disparity that it is highlighting in this report, as well as many other initiatives that are inventoried in Section 4 below. These initiatives were selected based on MMC s institutional competencies and capacity; input from community members and partner organizations; and ability to deliver meaningful, measurable interventions. They include: Priority Area or Disparity Examples of Interventions & Strategies Prevent Chronic Diseases Lung and colon cancer screening programs Family Health Challenge Disparity: Prevent Diabetes Symposia led by dietician or physician in community settings & Obesity in the Hispanic " Vida SI, Diabetes NO!" initiative Community Promote Healthy Women, Pursue baby-friendly practice and hospital designations Infants and Children Provide volunteer doulas to pregnant women and families Promote Mental Health and Prevent Substance Abuse Participate in DSRIP-funded 100 Schools Initiative to make mental health services more accessible to children Provide LCSWs to operate in primary care practices To measure the progress associated with each of these initiatives, the lead organization or MMC department tracks event frequency, participation, and, where applicable, measures of comprehension, awareness, attitudes toward health, or behavior modification. MMC will continue to engage closely with the people it serves, directly and through community representatives, to evaluate the effectiveness of its programs and continue to develop new ways to positively impact health in Southern Brooklyn. 4

6 1. Maimonides Medical Center and its Community About Maimonides Medical Center Maimonides Medical Center (Maimonides or MMC) is a 711-bed specialty care teaching hospital in Borough Park, Brooklyn, the most populous borough in New York City. Maimonides offers a number of nationally-recognized and accredited centers of excellence including a Heart and Vascular Center, Brooklyn s largest and only full-service outpatient Breast Center and Cancer Center, and a Stroke Care Center. MMC has the borough s only fully accredited children s hospital, a Regional Perinatal Center serving high risk neonates, and the State s largest Obstetrics program, delivering more than 8,600 babies each year. In August 2016, MMC received provisional status as an Adult and Pediatric Trauma Center, becoming Brooklyn s only Pediatric Trauma Center. On an annual basis, the Medical Center has more than 43,000 inpatient discharges more than any other hospital in Brooklyn as well as 120,000 Emergency Department visits and 300,000 outpatient visits. Maimonides has 10 hospital-based outpatient centers, delivering primary and specialty care, dental services, and behavioral health care services. Over 80% of inpatients are covered through government insurance programs Medicaid or Medicare and Maimonides treats all patients, regardless of ability to pay. Maimonides is also one of the largest independent teaching hospitals in the country, with 23 accredited residency programs across all major services lines, training 480 interns, residents, and fellows each year. MMC s Community: Definition and Characteristics Maimonides catchment area goes well beyond its immediate neighborhood. It treats a large number of patients from all parts of Southern Brooklyn, and serves patients from across the borough, Staten Island, and beyond. The neighborhoods in which the majority of Maimonides patients collectively live, and which compose Maimonides primary and secondary service areas include Borough Park, Sunset Park, Bensonhurst, Bay Ridge, Dyker Heights, Bath Beach, Gravesend, Coney Island, Brighton Beach, and Midwood. Zip MMC Inpatient Origin by Zip, 2015 % of Total MMC 2015 Discharges United Hospital Fund Neighborhood Name , % Borough Park , % Sunset Park , % Borough Park , % Borough Park , % Borough Park , % Bay Ridge & Bensonhurst , % Coney Island , % Coney Island , % Coney Island , % Coney Island , % Flatbush , % Bay Ridge & Bensonhurst , % Bay Ridge & Bensonhurst All Other 10, % Total 43, % 5

7 Map of MMC Inpatient Origin by Zip, 2015 Source: AHS Patient Registration Data for CY15, MMC Finance The Medical Center s service area is one of the most racially and ethnically diverse in New York City. Maimonides patient population includes large numbers of Orthodox Jews, Chinese, Latino, Russian, Caribbean, and South and Southeast Asian (primarily Pakistani, Bangladeshi, Indian, Laotian, Filipino, and Indonesian) residents. The borough s rich diversity is reflected in Maimonides inpatient and outpatient populations. Maimonides Inpatient Demographic Breakdown, 2015 Race/Ethnicity Count % White 20,943 59% Black / African American 4,008 11% Asian 6,791 19% American Indian/Alaska Native 19 0% Other/Unknown 3,747 10% Race/Ethnicity Count % Hispanic or Latino (any race) 4,120 11% Not Hispanic or Latino 27,005 75% Unknown 4,887 14% Source: Demographic Data from AHS/MMC MIS 6

8 The quantitative component of this assessment draws on the New York City Department of Health and Mental Hygiene s (DOHMH) Community Health Profiles published in October The DOHMH profiles define communities based on the same boundaries used by New York City Community Board Districts; there is one profile for each community district. This document uses data for seven Brooklyn community boards that roughly correspond to its primary and secondary services areas, as depicted below. NYC Community Districts Included in this Needs Assessment Neighborhoods Included in Community Districts (CDs) Used in this Assessment CD # CD Name Neighborhoods Partially or Wholly Contained Within the CD 7 Sunset Park Sunset Park, Windsor Terrace 10 Bay Ridge & Dyker Heights Bay Ridge, Dyker Heights, Fort Hamilton 11 Bensonhurst Bensonhurst, Bath Beath, Gravesend, Mapleton 12 Borough Park Borough Park, Kensington, Ocean Parkwwy 13 Coney Island Coney Island, Gravesend, Homecrest, Sea Gate, West Brighton 14 Flatbush & Midwood Flatbush, Midwood, Ditmas Park, Manhattan Terrace, Ocean Parkway, Prospect Park South 15 Sheepshead Bay Sheepshead Bay, Gerritsen Beach, Gravesend, Homecrest, Kings Highway, Manhattan Beach, Plumb Beach Over 1.1 million people live in these seven communities. Nearly half (approx. 45%) of the population is foreignborn, including many undocumented immigrants. 52% are white, 21% are Asian, 17% are Hispanic, and 8% are black. The areas Maimonides serves rank consistently high in rates of household poverty and lower levels of education. 37% of the residents in these communities have limited English proficiency. 7

9 MMC Service Area Population Snapshot Foreign-Born, Limited English Proficiency, Age 65+, Race/Ethnicity % Foreign % Ltd Racial/Ethnic Breakdown* Neighborhood Born English White Asian Hispanic Black Other % Over 65 New York City 37% 23% 33% 14% 29% 23% 2% 14% Brooklyn 38% 24% 36% 11% 20% 31% 2% 12% Borough Park 32% 32% 64% 19% 13% 2% 2% 10% Sunset Park 47% 47% 24% 28% 44% 3% 1% 9% Bay Ridge and 38% 28% 60% 22% 15% 1% 2% 14% Dyker Heights Bensonhurst 55% 47% 48% 36% 13% 1% 2% 15% Coney Island 55% 46% 57% 13% 17% 13% 0% 21% Flatbush and 45% 28% 37% 10% 16% 36% 1% 12% Midwood Sheepshead Bay 46% 31% 71% 16% 8% 3% 2% 16% *Categories other than Hispanic represent non-hispanic members of the indicated racial group eg White Non-Hispanic (Source: DOHMH Community Health Profiles, 2015) Maimonides Engagement with its Community Community engagement as a means of fostering healthy communities has been a key priority at Maimonides for decades. Maimonides Community Relations department has built strong partnerships with community- and faithbased leaders, elected officials, and community boards, along with key community organizations that collectively represent a broad base of the residents of South Brooklyn. In addition to co-hosting health fairs and educational symposia in community-based settings, Maimonides recruits patient representatives from diverse communities in its catchment area often those that are bilingual to serve as liaisons and patient navigators during a patient s inpatient, outpatient or Emergency Department visit. Maimonides also hosts one of the country s largest hospital volunteer programs, training and deploying 1,800 volunteers across the hospital annually. Every year Maimonides hosts one to two meetings of the Council of Community Organizations (COCO), a group of faith- and community-based groups and leaders from in and around the communities it serves. Present at these meetings are rabbis, imams, pastors, community-based leaders, health care providers, area residents, and elected officials. Agenda items cover new initiatives at the hospital and in the community aimed at improving health and wellbeing, including prevention-oriented programming, and open dialogue about health-related issues. To formally evaluate the met and unmet healthcare needs of the communities it serves, Maimonides conducted a comprehensive community health needs assessment in , and has done so again over this past year, in an effort to better understand the communities within its service areas. This CHNA is composed of both a quantitative component (a review and analysis of key health indicators) and a qualitative component (Public Deliberations and key informant interviews), that focus on resident health needs, priorities and behaviors, as well as social and economic determinants of health. Community Care of Brooklyn (CCB): Overview and Alignment with MMC s Community Health Program While the majority of patients Maimonides serves reside in Southern Brooklyn, Maimonides efforts to foster healthy communities and improve the healthcare delivery system reach beyond its primary and secondary service areas. Leveraging its experience developing and implementing collaborative care models and broad health 8

10 coalitions, Maimonides is playing a leadership role in the transformation of Brooklyn s healthcare delivery system, in particular for Medicaid enrollees. Maimonides is the fiduciary for Community Care of Brooklyn (CCB), which is the largest Performing Provider System (PPS) in Brooklyn. PPS entities were established as part of New York State s Delivery System Reform Incentive Payment (DSRIP) program. As described in the DSRIP Brooklyn Community Needs Assessment (CNA): In April, 2014, New York State finalized a waiver amendment from the Centers for Medicaid and Medicare Services that allows for reinvestment of approximately $8 billion in projected savings resulting from the State s Medicaid Redesign Team reforms. These funds will be used to support transformation of the health care system in NYS to promote clinical and population health. The majority of the funds will be distributed through a Delivery System Reform Incentive Payment (DSRIP) program. A central part of DSRIP is the formation of Performing Provider Systems (PPS) - collaborative partnerships between hospitals, community-based organizations, and other health care providers across the full spectrum of care. The goal of DSRIP is to advance innovative projects designed to transform the safety net health care delivery system, improve population health, and reduce avoidable hospitalizations. (DSRIP CNA, 8) Through DSRIP, CCB is responsible for managing care for 600,000 Medicaid beneficiaries nearly half of the Medicaid beneficiaries in Brooklyn and 10% of the total Medicaid population of New York State. The CCB network is comprised of over 4,600 medical practitioners, six hospitals (including Maimonides), ten federally qualified health centers (FQHCs), and 350 social service organizations. Together, this consortium is implementing a coordinated approach to managing the care of chronically ill populations. The PPS is responsible for implementing evidence-based initiatives and integrating primary, specialty and behavioral healthcare in community settings, with hospitals used primarily for emergency and tertiary level services. Through community-level collaborations, the PPS will work to achieve the triple aim of better health, better care, and reduced costs, reduce avoidable inpatient admissions by 25% and decrease emergency room visits over five years. Maimonides is participating in a number of DSRIP projects, and also serves as a tertiary anchor for Brooklyn, providing advanced specialty care services to PPS partners. Maimonides also plays a key role in the Southwest Brooklyn Health Home, an organization it established in 2012, and which was subsequently reorganized as an independent LLC for which Maimonides holds the management contract. In this entity, Maimonides partners with a network of 25+ providers and community-based organizations to coordinate services for Medicaid beneficiaries who have high-cost and complex chronic conditions. This is done primarily through care managers who help members access needed services to stay healthy in the community, aided by an innovative and dynamic health information technology platform. These services include housing, social services, medical and behavioral health, substance use, home care, and family support and education, which are coordinated and integrated to improve health outcomes for this population and control health care costs.. 9

11 2. Identification of Health Needs Quantitative Analysis: Health Indicators & Disparities Methods The October 2015 DOHMH Community Health Profiles include health data on each neighborhood in the City as well as how those neighborhoods compare to the rest of the borough and to New York City. The profiles address both health outcomes as well as social determinants of health such as educational attainment and income levels. Maimonides analyzed data from these profiles, in addition to health indicators from the New York State Prevention Agenda and the U.S. Census. The data below focus on the seven community districts in which the majority of Maimonides patients collectively live. Findings Data from the 2015 DOHMH Community Health Profiles are composed of aggregated data from annual Community Health Surveys from They revealed trends across neighborhoods in Maimonides catchment area, and also showed key differences and unique challenges facing certain neighborhoods, all of which help define the health needs of the community. This report does not focus solely on a single neighborhood; rather, it aims holistically to address both specific and broad health needs across Southern Brooklyn. The primary health challenges facing the communities served by Maimonides involve chronic disease prevention and treatment, which are shown to be influenced by inadequate access to healthcare and healthy foods, and additional social, economic, and cultural factors that influence childhood vaccination, physical activity, nutrition, access to prenatal care, and more. MMC Service Area: Overall Health Status Neighborhood Self-Reported Health Excellent, Very Good, or Good 1 Premature Mortality Per 100,000 2 New York City 78% Brooklyn 75% Borough Park 74% Sunset Park 68% Bay Ridge and Dyker Heights 81% Bensonhurst 70% Coney Island 65%* Flatbush and Midwood 77% Sheepshead Bay 64% Source: DOHMH Community Health Profiles, Age-adjusted percent of adults responding in this way, on a five-level scale that also includes Poor and Fair 2. Age-adjusted rate of premature deaths, defined as death < 65 years, per 100,000 population * Interpret Coney Island statistic with caution due to limited sample size or other statistical factor Social Determinants of Health Chronic disease risk and burden are significantly impacted by social, economic, and environmental factors, such as low incomes, working long hours or multiple jobs, and lack of comprehensive health education. This remains true among the communities that Maimonides serves, as many immigrant and low-income communities report working very long hours, sometimes in multiple jobs, which can make it difficult to maintain healthy habits. 10

12 High poverty rates pose a persistent challenge to healthy living, particularly in Borough Park and Sunset Park, where 32% and 29% of residents, respectively, live in poverty, compared to 24% of residents in Brooklyn and 21% in New York City overall. Low educational attainment in Brooklyn Park and Sunset Park also contribute to poorer health outcomes. Limited access to supermarkets, often linked with diminished access to fresh, affordable and healthy foods was also found to be a barrier, particularly in Bay Ridge/Dyker Heights, Bensonhurst, and Coney Island, according to the DOHMH Health Profiles. MMC Service Area: Social Determinants of Health Neighborhood Housing Defect Rate 1 Air Pollution Indicator 2 Supermarket Indicator 3 Educational Attainment Poverty Rate New York City 59% % col. grad 20% less than HS 21% Brooklyn 62% % col. grad 21% less than HS 24% Borough Park 52% % col. grad 23% less than HS 32% Sunset Park 58% % col. grad 42% less than HS 29% Bay Ridge and 43% col. grad 43% Dyker Heights 21% less than HS 16% Bensonhurst 41% % col. grad 28% less than HS 18% Coney Island 56% % co. grad 18% less thank HS 27% Flatbush and 41% col. grad 72% Midwood 18% less than HS 21% Sheepshead 44% col. grad 46% Bay 14% less than HS 17% Source: DOHMH Community Health Profiles, Percent of renter-occupied homes with at least one maintenance defect. Lower is better. 2. Annual average of micrograms of fine particulate matter (PM 2.5) per cubic meter. Lower is better. 3. Supermarket square footage per 100 population. Higher is better. High rates of poverty and lower levels of educational attainment in Borough Park and Sunset Park in particular as well as insufficient access to supermarkets and fresh foods particularly impacting Bay Ridge/Dyker Heights, Bensonhurst, Coney Island, Flatbush, and Sheepshead Bay play a substantial role in the health of communities and impact access to healthy environments and lifestyles. Healthcare Access Lack of access to quality healthcare can lead to negative health outcomes and often means that patients are treated for disease and illness at more advanced stages. Lack of health insurance remains a barrier to care in Maimonides services area, where 27% of residents in Sunset Park and Coney Island report having no health insurance, compared to only 20% in Brooklyn and 20% in New York City overall. 11

13 MMC Service Area: Access to Healthcare Neighborhood No Health Insurance 1 Went Without Medical Care 2 New York City 20% 11% Brooklyn 20% 12% Borough Park 20% 10% Sunset Park 27% 9% Bay Ridge and Dyker Heights 16% 6% Bensonhurst 19% 10% Coney Island 27% 11% Flatbush and Midwood 24% 15% Sheepshead Bay 18% 9% Source: DOHMH Community Health Profiles, Age-adjusted percent of adults that reported not having health insurance 2. Age-adjusted percent of adults that reported needing medical care in the past 12 months but did not receive it Immigrant communities, particularly undocumented residents, face magnified barriers to accessing healthcare services, including linguistic and cultural barriers, ineligibility for insurance, and lack of knowledge about where and how to access care in their communities. Due to fear of deportation or arrest, some residents may be less likely to provide personal information that is often required to obtain care. The Medicaid population also has profound challenges obtaining access to preventive care, as detailed in the DSRIP CNA: There are approximately 1.3 million Medicaid beneficiaries living in Brooklyn, which is 1 out of 5 (21.1%) of all Medicaid beneficiaries in New York State and more than one-third (34.3%) of all Medicaid beneficiaries in New York City. The percentage of the Brooklyn population who are Medicaid Beneficiaries varies across zip codes from 11.8% to 84.9% (See Appendix A, Map 1). The highest proportion of the population who are Medicaid Beneficiaries are in two large clusters, one in the northeast part of the borough from Williamsburg through Bushwick, Bedford-Stuyvesant, Brownsville, and East New York; and the other in southwest and south central Brooklyn, from Sunset Park to Borough Park, Flatbush, East Flatbush, and Bensonhurst. (DSRIP CNA, 28) In 2013, there were approximately 79.5 FTE primary care physicians per 100,000 population in Brooklyn, lower than NYC (90.2 per 100,000) and NYS (84.5 per 100,000) rates for the same time period. 1 (DSRIP CNA, 10) A key component of DSRIP is to reduce avoidable services by bolstering primary care providers and community based organizations (CBOs) to enhance coordination of care, prevention and disease management, particularly for those with chronic conditions. We find the distribution of primary care providers uneven in Brooklyn, with sparse numbers in certain neighborhoods... 2 The data also suggest there is a lack of culturally and linguistically competent specialists and multi-specialty centers that could provide a one-stop shopping experience that many patients seek. 3 (DSRIP CNA, 4) Health Behaviors Health behaviors vary widely across different neighborhoods of Southern Brooklyn. Key data reveal behavior trends that may influence residents risk of developing chronic disease. In particular, relatively high adult smoking rates and lack of regular physical activity impact health in Maimonides communities, and are linked with high blood pressure, diabetes, and some cancers. 1 The Health Care Workforce in New York: Trends in the Supply and Demand for Health Workers Center for Health Workforce Studies, 2013 data, published June NYAM Primary Data Collection, preliminary findings, August, Brooklyn Healthcare Improvement Project (B-HIP) Final Report: Making the Connection to Care in Northern and Central Brooklyn, August, Ibid. 12

14 MMC Service Area: Healthy Behaviors Neighborhood Current Smokers > 1 Sugary Drink/Day At Least 1 Fruit or Veg./Day Physical Activity in Last 30 Days New York City 15% 27% 88% 77% Brooklyn 16% 27% 87% 75% Borough Park 14% 22% 89% 72% Sunset Park 15% 29% 87% 67% Bay Ridge and Dyker Heights 14% 21% 89% 77% Bensonhurst 18% 22% 93% 69% Coney Island 18% 26% 92% 71% Flatbush and 14% 28% 84% 79% Midwood Sheepshead Bay 19% 25% 89% 73% Source: DOHMH Community Health Profiles, 2015 Chronic Diseases The predominant primary health challenges among the communities Maimonides serves center around chronic disease prevention and treatment. The leading causes of death across southern Brooklyn are heart disease and cancer. High rates of obesity, which can lead to heart disease, diabetes, and other chronic illnesses, as well as high blood pressure and high cholesterol, are seen across Maimonides service areas, with the highest rates in Coney Island and Sheepshead Bay. Diabetes rates in the Maimonides service area are fairly consistent with rates across Brooklyn and New York City, and have a profound impact on the health and well-being of residents. MMC Service Area: Obesity and Diabetes Neighborhood Obesity Rates Diabetes Rates New York City 24% 10% Brooklyn 27% 11% Borough Park 23% 9% Sunset Park 19% 9% Bay Ridge and Dyker Heights 19% 6% Bensonhurst 23% 9% Coney Island 31% 11% Flatbush and Midwood 28% 11% Sheepshead Bay 30% 11% Source: DOHMH Community Health Profiles, 2015 The health impacts of obesity and diabetes in Maimonides service area are consistent with the broader trend in the borough: Diabetes is considered by many residents and key informants to be the most significant health issue in Brooklyn. The number of beneficiaries in Brooklyn who had a diabetes-related service utilization totaled 139,755 in 2012, representing 11.3% of the beneficiary population. The proportion of the population with a diabetes-related service ranged from 6.2% to 28.7% across Brooklyn zip codes. (DSRIP CNA, 49) 13

15 Cancer is the second leading cause of death across neighborhoods in Maimonides catchment area. According to the New York State Department of Health, New York City Cancer Registry, the highest rates of incidence are seen for the following cancer types in both male and female: colorectal, lung and bronchus, female breast, and prostate. Note that female breast is the highest cancer incidence in females across all neighborhoods studied. Prostate cancer is the highest cancer incidence for males, across all neighborhoods studied. MMC Service Area: Cancer Rates by Neighborhood Borough Park Southwest Brooklyn 11209, 11228, Flatlands, Canarsie, Mill Basin 11234, 11236,11239 Sunset Park 11220, Central Brooklyn 11213, 11216, 11218, Flatbush 11203, 11210, 11225, Top 5 Highest Cancer Incidence in MALES Prostate Lung & Bronchus 92.2 Colorectal 71.2 Urinary Bladder 54.2 Colon (excluding rectum) 47.8 Female Breast Colorectal 75.0 Thyroid 70.4 Lung & Bronchus 69.0 Colon (excluding rectum) 55.8 Prostate Lung & Bronchus 79.8 Colorectal 55.4 Urinary Bladder 43.3 Colon (excluding rectum) 38.4 Prostate Lung & Bronchus 53.8 Colorectal 48.8 Colon (excluding rectum) 34.4 Urinary Bladder 23.8 Prostate 40.4 Lung & Bronchus 31.4 Colorectal 29.8 Colon (excluding rectum) 19.2 Liver /intrapatic bile duct 16.6 Top 5 Highest Cancer Incidence in FEMALES Female Breast Lung & Bronchus 71.4 Colorectal 57.8 Thyroid 46.4 Colon (excluding rectum) 45.0 Female Breast Colorectal 49.6 Corpus uterus & NOS 48.0 Lung & Bronchus 45.2 Colon (excluding rectum) 38.2 Female Breast 58.8 Thyroid 27.4 Colorectal 24.4 Lung & Bronchus 22.2 Colon (excluding rectum) 16.6 Prostate Lung & Bronchus 78.4 Colorectal 64.4 Colon (excluding rectum) 43.6 Non-Hodgkin lymphomas 27.4 Female Breast Colorectal 72.2 Lung & Bronchus 67.0 Corpus uterus & NOS 60.4 Colon (excluding rectum) 56.6 * New York State Cancer Registry Data, Rate per 100,000. Listed from most to fewest annual cases. Prostate Colorectal 60.6 Lung & Bronchus 51.0 Colon (excluding rectum) 46.0 Myeloma 17.2 Female Breast Corpus uterus & NOS 66.4 Colorectal 65.6 Lung & Bronchus 52.2 Colon (excluding rectum)

16 In addition to their impact on individuals and communities, chronic diseases tend to tax the resources of local healthcare systems. As noted in the Brooklyn CNA: In Brooklyn, the greatest proportion of potentially preventable admissions (PQI) is for chronic conditions including respiratory conditions such as asthma, cardiovascular conditions such as hypertension, and diabetes; these conditions and diseases represent the areas of opportunity for reducing preventable inpatient stays. 4 (DSRIP CNA, 4) The highest Observed / Expected PQI ratios are consistently found in north-central Brooklyn... and in Coney Island. (DSRIP CNA, 35) In 2012, the number of potentially preventable hospitalizations among Medicaid beneficiaries for circulatory conditions (PQI S02 Circulatory Composite) in Brooklyn was 3,694, accounting for more than one in five (23.3%) of all such admissions in the State. However, the ratio of observed/expected (O/E) admissions in Brooklyn (1.04) was lower than the ratio for NYC (1.06) for the same time period. At the zip code level within the borough, the highest Observed / Expected PQI ratios for Circulatory Composite are in north-central Brooklyn and in Flatbush, East Flatbush, and Coney Island - Sheepshead Bay. (See Appendix A. Map 39, and table below.) (DSRIP CNA, 51) Prevention and Screening Neighborhoods around Maimonides service area have some of the lowest rates of vaccination for HPV and flu in the city, as well as for cancer screening. Refusal to immunize children can be partially attributed to concerns and misinformation about vaccines. Additionally, limited focus on prevention, and the tendency to not seek medical or preventive care when people feel healthy, impact low vaccination levels in the community. MMC Service Area: Vaccination Neighborhood HPV Vaccination Flu Vaccination New York City 43% 40% Brooklyn 36% 36% Borough Park 20% 33% Sunset Park 53% 39% Bay Ridge and Dyker Heights 30% 35% Bensonhurst 34% 34% Coney Island 29% 31% Flatbush and Midwood 31% 36% Sheepshead Bay 22% 37% Source: DOHMH Community Health Profiles, 2015 Cancer Screening The charts below that depict rates of screenings for colon and breast cancer in 2012 by neighborhood reveal low rates of screening across several neighborhoods in Maimonides catchment area, particularly Borough Park, Bensonhurst/Bay Ridge, and East Flatbush/Flatbush. Low screening rates is an additional risk factor for high cancer incidence. 4 The rate of potentially preventable inpatient admissions for chronic conditions (PQI 92) is 1,283 per 100,000 Medicaid beneficiaries in Brooklyn versus 480 per 100,000 beneficiaries for acute conditions (PQI 91). However, this measure does not assess length of stay or cost for these admission types. 15

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18 Maternal & Infant Health Indicators of maternal and infant health vary greatly across Maimonides service area. In Maimonides primary service areas of Borough Park and Sunset Park, rates of late/no prenatal care and of infant mortality are among the lowest in the City. In areas more distant from the hospital such as Coney Island, Flatbush, and Midwood, these indicators are at or above (worse) than the citywide averages. MMC Service Area: Maternal & Infant Health Neighborhood Late/No Prenatal Care Rate 1 Preterm Birth Rate 2 Teen Births Per 1,000 3 Infant Mortality Per 1,000 4 New York City 7.4% 9.0% Brooklyn 6.4% 8.8% Borough Park 2.7% 6.4% Sunset Park 3.3% 7.2% Bay Ridge and Dyker 6.1% 7.0% Heights Bensonhurst 5.3% 7.3% Coney Island 11.0% 11.3% Flatbush and Midwood 7.7% 8.5% Sheepshead Bay 5.9% 7.3% Source: DOHMH Community Health Profiles, Percent of live births receiving late prenatal care (i.e., after the first and second trimesters) or no prenatal care 2. Percent of preterm births (<37 weeks gestation) among all live births 3. Rate of births in which the mother is under 20 years old per 1,000 women ages years 4. Rate of deaths of infants under one year old per 1,000 live births Mental Health & Substance Use Mental health is less emphasized than physical health in the DOHMH Community Health Profiles, but the DSRIP Brooklyn CNA contains a number of important findings about the extent of mental health needs in the borough and in specific communities that Maimonides serves: Among the Brooklyn population as a whole, the age-adjusted percentage of adults with poor mental health for 14 or more days of 7.4%, as well as the age-adjusted suicide rate of 4.6%, were lower than the state and city rates. 6.1% of all people in Brooklyn report experiencing serious psychological distress, compared to 5.5% in NYC overall. In NYC, people who are currently experiencing psychological distress are more likely to report binge drinking in the last 30 days than people who did not report psychological stress and are more than twice as likely to report being a current smoker. Coney Island, in particular, appears to be disproportionately impacted by psychological distress with 12% of residents reporting it, nearly double the rate for the Borough (6.0%). Those in Bay Ridge/Bensonhurst and Williamsburg/Bushwick also report high rates of psychological distress, with approximately one in ten residents surveyed reporting it. (See table, Appendix B.) (DSRIP CNA, 42) Access to mental health services is reported to be limited, although it might be the case that community organizations and residents are not aware of available services or how to access them. In addition, behavioral health issues generally carry greater stigma than other health concerns, which tends to limit use of services. Key informants and focus group participants both reported that many affected families try to address problems internally. 5 (DSRIP CNA, 42) 5 Ibid. 17

19 Many patients with behavioral health conditions also have chronic physical health conditions. According to data from the NYS Office of Mental Health (OMH), approximately 55% (13,141/23,994) of Brooklyn clients served had at least one chronic medical condition. (See table and chart, Appendix B.) The 2011 PCS found that 51.5% of Brooklyn Adults surveyed had cardiac or metabolic illnesses; and 10.4% of Brooklyn children surveyed had a pulmonary condition. Chronic physical illness co-morbidities are clearly a significant factor in the health of behavioral health patients in Brooklyn. Looking at Brooklyn inpatient hospital admissions by zip code for beneficiaries who have utilized some mental health services in the 2012 calendar year, including behavioral health prescription medicines we see a geographic pattern of hospital admissions very similar to the Chronic Disease Composite PQI (PQI 92) map. This is consistent with the literature noting that the majority of inpatient admissions for beneficiaries with a behavioral health condition are for physical health conditions. (DSRIP CNA, 42) In recent years Brooklyn has been increasingly impacted by the growth in opioid use and addiction that has been experienced across the U.S. This trend is evident in the use of hospital emergency departments, among other indicators, and reflects increases in addiction to both heroin and prescribed opioid analgesics. Opioid-Related Emergency Department Admissions by County of Residence, Rate Per 100,000 Population % Chg Area New York State % Brooklyn % Source: New York State Opioid Poisoning, Overdose and Prevention: 2015 Report to the Governor and NYS Legislature, NYS DOH While this trend represents a growing health need, the communities in Maimonides service area experience relatively low rates of drug-related hospitalizations as compared to borough-wide and citywide average rates. MMC Service Area: Drug-Related Hospitalizations Drug-Related Hospitalizations Neighborhood Per 100,000 1 New York City 907 Brooklyn 921 Borough Park 272 Sunset Park 529 Bay Ridge and Dyker Heights 370 Bensonhurst 267 Coney Island 860 Flatbush and Midwood 649 Sheepshead Bay 314 Source: DOHMH Community Health Profiles, Age-adjusted rate of drug-related hospitalizations per 100,000 adults 18

20 Qualitative Component: Public Deliberations Overview To more deeply understand the health challenges and needs facing our communities, Maimonides sought input from members of the community who represent the broad interests of the community through multiple mechanisms including: Partnering with the New York Academy of Medicine to convene and facilitate deliberative public deliberation sessions, described below; Interviews with leadership at community-based organizations and local community boards; and Convening a meeting of the Council of Community Organizations (COCO) to gain feedback from community and faith-based leaders, elected officials, healthcare providers and public health specialists Additionally, Maimonides has engaged in numerous conversations with staff in NYC Department of Health and Mental Hygiene s Center for Health Equity, including with Dr. Torian Easterling, the Commissioner for the Brooklyn District Public Health Office, as well as with the Director of Nutrition and Physical Activity at the Brooklyn District Public Health Office. These discussions addressed community health needs, programs and initiatives the DOHMH were establishing, opportunities to partner on Brooklyn public and community health initiatives, and feedback on Maimonides strategy. Public Deliberation Methods Beginning in the fall of 2015, with funding from the Agency for Healthcare Research and Quality (AHRQ), The New York Academy of Medicine (The Academy) and Maimonides Medical Center hosted Prioritize Health! a public deliberation model to elicit recommendations for Maimonides focused on preferred approaches to prevent chronic disease. The New York Academy of Medicine convened and facilitated three 2-day deliberative sessions to elicit recommendations for Maimonides Medical Center focused on approaches to prevent chronic disease within the communities they serve. Public deliberation is a method of engaging a group of community members in informed discussion in order to provide advice to institutions and/or policy makers that are considering a complex, value-laden decision that lacks a technical solution. 7,11 As part of the deliberative process, participating community members receive relevant background information and hear presentations that allow them to explore the different considerations that are relevant to a decision making context. Participants interact with the facilitators, the presenters, and most importantly with one another as they consider case studies and/or exercises developed to facilitate discussion that will elucidate preferences, priorities and recommendations for the sponsoring institution or policy maker. Deliberative sessions typically pose specific questions to participating community members, which articulate the decision the sponsoring institution or policy maker is considering. 19

21 Each deliberative session involved participants who were selected from a group of nearly 300 Brooklyn residents that completed screening forms for the project. Extensive outreach was conducted to identify participants, including phone calls to community members that have previously participated in Maimonides community programming; signs in libraries and other public places; engagement of local elected officials to assist with dissemination of information; announcements on social media sites including Facebook, Twitter and craigslist; and outreach at health fairs, libraries and to community organizations serving diverse populations. Eligibility criteria included Brooklyn resident, age 18 or older, self-reported comfort with English, and a correct response to one numeracy item. Participants were purposefully selected for diversity according to age, race and ethnicity, educational attainment, and neighborhood, as reported on the screening form. (see Tables 1 and 2 for participant characteristics). The deliberative sessions were framed around two main questions that participating community members considered. The questions were intentionally framed broadly such that the hospital would have general guidance to approaches favored by the community, but not be constrained by highly specific recommendations. The questions were: 1. Should Maimonides efforts to improve health focus primarily on: a. Improving prevention services delivered by medical staff in the hospital s clinics b. Community interventions that decrease risk factors for disease; c. Working to change policies (e.g., of the government, of employers, of schools) that make it easier for people to stay healthy 2. Should Maimonides concentrate its efforts to prevent disability and disease primarily on: a. Children b. Working age adults c. Older individuals d. People who have the highest risk for early disability or death due to their living circumstances. Table 1: Prioritize Health! Demographic Characteristics (N=66) Characteristics n (%) Age (16.7%) (19.7%) (19.7%) (31.8%) 75 and older 8 (12.1%) Education Less than HS Graduate 2 (3.0%) HS Graduate or GED 9 (13.6%) Some College but no Degree 17 (25.8%) College Degree or Higher 38 (57.6%) Gender Male 22 (33.3%) Female 44 (66.7%) Race/Ethnicity* White 34 (51.5%) Black or African American 13 (19.7%) American Indian/Native American 1 (1.5%) Hispanic/Latino 6 (9.1%) Asian/Asian American 7 (10.6%) Arab/Arab American 1 (1.5%) Missing 4 (6.1%) Religion* Christian/Catholic 32 (48.5%) Jewish 10 (15.2%) Muslim 3 (4.6%) Other 6 (9.1%) No religion 7 (10.6%) Missing 8 (12.1%) Employment Status* Full Time 15 (22.7%) Part Time 15 (22.7%) Retired 23 (34.9%) Not working 7 (10.6%) Homemaker/ Caregiver 2 (3.0%) Other 3 (4.6%) * Percents do not add to 100 due to missing values 20

22 In advance of each deliberative session, participants were furnished with background materials that provided context for the deliberation (see Appendix A). Deliberative sessions were facilitated by Academy staff and an expert consultant. Each included presentations to participants on health characteristics (e.g. obesity, cardiovascular disease), behavioral risk factors (e.g. physical activity and fruit and vegetable consumption), and social and environmental risk factors (e.g. education, community resources) (see Appendix B). In addition, each included educational presentations (in person or by teleconference) by recognized experts in the field (see Appendix C), which focused on the different approaches to prevention: clinical, community and policy. Small and large group discussions throughout the two days allowed participants to explore and discuss with the facilitators, and with one another a variety of approaches to chronic disease prevention, targeting different populations and/or operating at different levels (i.e., clinical, community or policy) (see Appendix D). All approaches presented were built from evidence-based reviews conducted by the U.S. Preventive Services Task Force, the Community Guide to Prevention and/or Cochrane reviews. Table 2 Neighborhoods Represented n (%) United Hospital Fund Neighborhood Coney Island-Sheepshead Bay 20 (30.3%) Bensonhurst-Bay Ridge 9 (13.6%) Borough Park 8 (12.1%) Downtown-Heights-Park Slope 7 (10.6%) Canarsie 6 (9.1%) Sunset Park 4 (6.1%) Flatbush 4 (6.1%) Williamsburg-Bushwick 4 (6.0%) Bedford Stuyvesant-Crown Heights 3 (4.6%) Greenpoint 1 (1.5%) Findings The public deliberation sessions and key informant interviews strongly aligned with the findings from the Community Health Profiles, and input from the sessions is summarized below. Participants cited the limited access to healthy and affordable foods, noting that for many community members it is too expensive to eat well, fast food options are too prevalent and available, and parents often do not have enough time to cook nutritious meals. As a result, one participant said, families end up having to serve packaged and fast food meals. Among children, participants said, it is particularly important to enhance access to healthy foods, as school meals are unhealthy, and even when there are healthy options, kids still choose junk food. Children seem to be a very vulnerable group today. They are getting sicker. They are obese. I think that there are a lot of organizations in the community where you can Maimonides can impact with and maybe get the children to learn how to eat better, how to have better health habits despite their living conditions and also Maimonides might be able to send some speakers to a school I think children are a real important target group and I think sometimes the parents can t do it. They re too busy, they re not knowledgeable enough, they rely on quick fixes, they take their kids to fast food places, etc. 21