2016 COMMUNITY HEALTH NEEDS ASSESSMENT

Transcription

1 Navajo health Foundation Sage Memorial Hospital 2016 COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION PLAN ADOPTED BY BOARD OF DIRECTORS RESOLUTION SEPTEMBER 27, MISSION STATEMENT - Navajo Health Foundation Sage Memorial Hospital, Inc. provides quality healthcare services in a fiscally responsible manner, focusing on the patient s physical, social, and spiritual well-being.

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3 2016 COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION PLAN Dear Community Members, Navajo Health Foundation/Sage Memorial Hospital is pleased to present this Community Health Needs Assessment and Implementation Plan to the residents of the communities served by the hospital and its clinics. With the help of your direct input, along with demographic research and data analysis, Sage has identified unique public health needs. As part of this effort, Sage has developed and implemented a continuous improvement plan for quality health care. This document supports the longterm strategic plan developed by the Board of Directors following the 2013 Community Health Needs Assessment currently implemented by its Management. The Sage Hospital Board of Directors would like to thank you for your candid and valuable input that has allowed us to create this document. We look forward to further collaboration with you as we strive to continually improve and better meet your health care needs. Our hope is that this document will help give you a better understanding of the unique health care needs faced by the community, and will enable us to move forward together as both a hospital and a community to improve our way of life. Thank you, STENSON WAUNEKA Chairperson LINDA SALABIYEYAZZIE Vice Chairperson RAY ANN TERRY Secretary APRIL DEDMAN Treasurer MAYBELLE KELEWOOD Board Member JOYCE MOORE Board Member Board of Directors Board of Directors Navajo Health Foundation/Sage Memorial Hospital, Inc. 2 Navajo Health Foundation Sage Memorial Hos pital ANDREW SIMPSON Board Member

4 TABLE OF CONTENTS EXECUTIVE SUMMARY... 5 Approach... 5 Summary of Findings... 6 Demographics... 6 Health Care Needs... 6 Addressing the Health Care Needs of the Community... 6 BACKGROUND INFORMATION... 8 History of Navajo Health Foundation/Sage Memorial Hospital... 8 Services Provided by Sage Memorial Hospital... 9 Definition of the Community served by Sage Memorial Hospital Other Regional Healthcare Facilities CHNA APPROACH Overview Methodology The Process for Consulting with Persons Representing the Community s Interests Data Collection Community Survey Focus Group with Community Representatives Health Care Provider Survey Health Information Systems Data Secondary Data Data Analysis The Process for Identifying and Prioritizing Community Health Needs and Services KEY FINDINGS Community Demographics Population As illustrated by the above figure, the population of Sage s service area declined between the years of 2000 and 2010, however since the latest decennial census, the population of the service area is estimated to be rising Race/Ethnicity Population by Age and Sex Population by Educational Attainment Language Poverty Rate Household Income Unemployment Rate Community Needs Index Service Area CNI Primary and chronic disease care access, quality of care, and other health needs of uninsured persons, low-income persons, and minority groups Uninsured persons Navajo Health Foundation Sage Memorial Hospital 3

5 Low-income and ethnic minority groups care access and quality disparities Disparity improvement/worsening by unique ethnic/minority group Causes of Death among American Indians/Alaska Natives compared to all other races The Health Needs of the Community How Sage is Addressing Behavioral Health Needs Pediatric Care How Sage is Addressing Pediatric Care Diabetes Care How Sage is Addressing Diabetes Care Accessible Health Care Services How Sage is Addressing Accessible Health Services Emergency Trauma Care How Sage is Addressing Emergency Trauma Care ADDRESSING THE HEALTH NEEDS OF THE COMMUNITY Implementation Strategy Challenges in Meeting the Long-Term Needs of the Community Medical and Clinical Staff Recruitment Employee Housing Outpatient Medical Center New Hospital Financial Challenges of Meeting Long-Term Needs of the Community APPENDICES Appendix A - Individuals Participating as Local Advisors Appendix B Secondary data Sources Relied Upon Appendix C Board Member Interview Primary Qualitative Data Appendix D Comments from Selected Community Survey Questions Appendix E Copy of Community and Provider Survey Questions Navajo Health Foundation Sage Memorial Hospital

6 EXECUTIVE SUMMARY Established in 1978, Navajo Health Foundation - Sage Memorial Hospital, Inc. ( Sage ) is an Arizona private 501(c)(3) not-for-profit healthcare corporation. The organization includes a 25-bed Critical Access Hospital and outpatient clinic located in Ganado, Arizona and an outpatient clinic located in Greasewood Springs, Arizona. Sage is a private, Native-managed comprehensive healthcare system, and is the only Nativegoverned hospital to hold a license from the Arizona Department of Health and Accreditation from the Joint Commission. Today, Sage serves approximately 23,000 people as the sole provider of health care services across the Navajo Nation chapters and communities of Cornfields, Ganado, Kinlichee, Klagetoh, Greasewood Springs, Steamboat, Wide Ruins, and a portion of Nazlini encompassing the communities south of Route 26. Many patients from outside of our community service area choose to travel to Sage to receive health care services. Sage facilitated a comprehensive Community Health Needs Assessment ( CHNA ) for both the main campus and satellite clinic. The purpose was to understand the public health needs facing those communities for which it provides health care services. This CHNA was conducted between February and May 2016 as an update to the CHNA performed by Sage in This report fulfills federal regulations requiring that non-profit hospitals conduct community health needs assessments every three years. 1 Performing this assessment at regular intervals enables the hospital to monitor and respond to the community s changing public health needs. This report summarizes findings from community input and secondary research to identify high-priority health needs in Sage s service area, and presents future actions planned by the hospital s Board of Directors to address these needs. APPROACH Sage performed the CHNA with the collaboration hospital administration, executive leadership, public health professionals, and clinical staff ( Assessment Team or Team ). The Assessment Team conducted surveys with community members and focus groups, and 1 Internal Revenue Service. (2015, 06 09). New Requirements for 501(c)(3) Hospitals Under the Affordable Care Act. Retrieved 03 16, 2016, from IRS.gov: 501%28c%29%283%29-Hospitals-Under-the-Affordable-Care-Act Navajo Health Foundation Sage Memorial Hospital 5

7 researched secondary data sources for relevant community health information. The Assessment Team analyzed the collected data and cross-referenced it with relevant public databases. The Team then developed this report that summarizes key findings and outlines the implementation plan developed by the Board of Directors and its Management to meet the most immediate and vital community health needs. SUMMARY OF FINDINGS Demographics Approximately 95% of the residents served by Sage are of American Indian or Alaska Native ( AI/AN ) descent. The age distribution of the population is weighted toward younger age groups, with approximately 32% of the population under the age of 20. Compared to national averages, the community has a lower level of education, a higher poverty rate, a higher unemployment rate, and lower average household income. The Navajo language (or another language other than English) is spoken in 75% of the households served by Sage, and 18% of the population speaks English less than very well. Health Care Needs The Assessment Team identified the following high-priority health care needs within the service area served by the hospital: o Behavioral Health Treatment o Diabetes Care o Pediatric Care o Geographic Accessibility of Health Care Services o Emergency Trauma Care Several of these needs were identified as high-priority during the 2013 CHNA and are expected to be major health care concerns in the future due largely to the remote frontier location. ADDRESSING THE HEALTH CARE NEEDS OF THE COMMUNITY Based on the findings of the 2013 CHNA, Sage s leadership adopted and began executing an implementation strategy to meet the high-priority health care needs of the community. Sage continues to expand upon the 2013 strategy through the following actions that address the community s health care needs : 3 3 Full implementation and timing of this strategy may be impacted by state and federal budget allocations, physician recruitment, and unforeseen impacts of the PPACA. 6 Navajo Health Foundation Sage Memorial Hospital

8 Behavioral Health Expansion of Behavioral Health services; Expand capacity for increased psychotherapy and counseling utilizing professionals with a working understanding of Navajo culture; Implement an outreach program that identifies individuals at risk for Behavioral Health issues; Collaborate with local schools to identify at-risk children; Explore viable expansion of the substance abuse rehabilitation programs. Pediatric Care Expand public health immunization programs for children ages 6-months and older; Increase nutritional education outreach programs; Continue to recruit and retain an additional Board certified Pediatrician; Expand the capacity for pediatric services at the Sage Ganado Clinic and Greasewood Springs clinic. Diabetes Care Continue the community outreach program to educate community members about diabetes, and refer them to the program; Increase the number of community activities that encourage exercise and healthy lifestyle habits; Recruit and retain a clinical nurse case manager to manage the care of the diabetes program patients; Develop and support the Native Diabetes Wellness Program initiative to coincide with emerging Medicare trends shifting towards preventative care versus tertiary care; Continue to expand the community garden to increase community involvement in wellness activities and supplement nutritional resources with healthy food alternatives; Expand health screenings at the community chapter level to identify at-risk individuals. Navajo Health Foundation Sage Memorial Hospital 7

9 Accessibility to Health Care Services Emergency Trauma Care Expansion of services within the Chapter communities; Review the viability of tele-medicine programs that would allow patients to access providers through a virtual environment; Coordinate patient home visits by Community Health Nurses and collaborate with the Community Health Representatives to increase patient compliance with physicians plan of care for patients who do not have reliable transportation. Expand the Emergency Department to increase treatment capacity; Recruit and retain additional Emergency Department physicians to better handle high volumes of emergency trauma cases; Review and evaluate Level IV Trauma Center designation. Background Information HISTORY OF NAVAJO HEALTH FOUNDATION/SAGE MEMORIAL HOSPITAL Navajo Health Foundation/Sage Memorial Hospital, Inc. ( Sage ) is a private Arizona 501(c)(3) not-for-profit healthcare organization governed by a Navajo Board of Directors. The organization is located in Ganado, Arizona, on private landed surrounded by the Navajo Nation and owned by the Presbyterian Church. The main Sage campus consists of 82 buildings on approximately 110 acres, which include facilities such as the main hospital, an outpatient clinic, administrative offices, an employee day care center, employee wellness center, and subsidized employee housing. Sage is licensed by the Arizona Department of Health as a Rural General Hospital, and maintains the Gold Seal of Approval and Accreditation from the Joint Commission. The Sage healthcare system includes the following facilities: o 25-bed Critical Access Hospital, Ganado, AZ o Outpatient Clinic, Ganado, AZ o Outpatient Clinic, Greasewood Springs, AZ In response the needs observed in the 2013 CHNA, Sage is working to collaborate with the Wide Ruins Chapter in order to construct an additional satellite outpatient clinic in Wide 8 Navajo Health Foundation Sage Memorial Hospital

10 Ruins to provide outpatient primary care, with the option of expanding to provide dental services in the future. Since 2010, Sage was recognized for providing high quality healthcare with the Managerial Excellence Award from the United States Department of Health and Human Services Indian Health Service; Best in Class in the area of Diversity in Leadership and Governance Award from the American Hospital Association; 4 and, Performance Leadership in Patient Outcomes Award from the National Organization of State Offices of Rural Health (NOSORH) and ivantage Health. 5 SERVICES PROVIDED BY SAGE MEMORIAL HOSPITAL Sage provides the following health care services to the community: Emergency Medical Services Emergency Medical Transportation (Ground and Air) Hospital inpatient services, including: o Medical Floor o Telemetry o Swing Bed o Pharmacy o Radiology o Medical Imaging o Respiratory Therapy o Physical Therapy Outpatient Services o Primary Care o Pediatrics o Dental o Optometry o Rehabilitative Services o Speech Therapy o Community Health Nursing o Pharmacy 4 Watteau, M. (2012, 06 06). Diversity and Disparities Survey Provides a Snapshot of Current Practices, Hospitals honored for performance in key categories. Retrieved from Institute for Diversity in Health Management, an affiliate of the American Hospital Association: 5 Strycker, M. (2015, 11 10). ivantage Celebrates National Rural Health Day. Retrieved from National Organization of State Offices of Rural Health: Navajo Health Foundation Sage Memorial Hospital 9

11 o Radiology o Medical Imaging o CLIA Laboratory o Behavioral Health and Social Services o Respiratory Therapy Community based health promotion and disease prevention activities o Diabetes program o Mass vaccinations o Diabetes wellness center referrals All other health care services in the region are referred to health care facilities in the surrounding areas. DEFINITION OF THE COMMUNITY SERVED BY SAGE MEMORIAL HOSPITAL Sage primarily serves the Navajo Nation communities and Chapters of Cornfields, Ganado, Kinlichee, Klagetoh, Greasewood Springs, Steamboat, Wide Ruins, and the portion of Nazlini that includes the communities south of Route 26. The region is predominantly part of the Apache County of Arizona, with some overlap into Navajo County. Figure 1: Map of the Navajo Nation indicating Sage s location and service area Chapters 6 6 Argueso, L. Navajo Health Foundation - Sage Memorial Hospital, Inc. Expert Report of Luis A. Argueso on Management Services, Board of Directors Compensation, and Economic Impact. Litigation Report, HealthCare Appraisers, Inc. 10 Navajo Health Foundation Sage Memorial Hospital

12 Figure 2: Map of Arizona highlighting Sage service area and Chapters Phoenix OTHER REGIONAL HEALTHCARE FACILITIES Sage is the sole provider of health care services within its service area. There are two (2) hospitals located approximately 50 miles outside of Sage s primary service area: Chinle Comprehensive Health Care Facility, which is a hospital operated by the Indian Health Services, and Tsehootsooi Medical Center. Many patients from outside of our community service area choose to travel to Sage to receive health care services. Figure 3: Navajo Nation map with health care facilities Navajo Health Foundation Sage Memorial Hospital 11

13 CHNA Approach OVERVIEW Sage s Assessment Team, comprised of hospital administration and executive leadership, public health professionals, and clinical staff, implemented a comprehensive approach in assessing the health care needs of Sage s service area. First, the team engaged with the community through surveys and interviews to capture firsthand input about health needs and factors affecting the access and delivery of health care services to the region. The Team then researched secondary data sources to better understand the demographics of the community, and its associated health issues. Finally, the Team analyzed the community input and secondary data. Sage s executive leadership, together with medical and clinical staff and public health experts with institutional knowledge of the overall health needs of the region, reviewed and presented the data to the Board of Directors and its Management, who then prepared an implementation plan addressing the needs identified in the CHNA. METHODOLOGY The Process for Consulting with Persons Representing the Community s Interests The Assessment team identified two (2) groups to represent the community s health interests: Individual members of the community; Members of Sage s Board of Directors, who are also community members of the Navajo Nation. These groups participated in surveys and focus groups coordinated by those Assessment Team members with public health expertise. The results supported identification and prioritization of the community s health needs. Data Collection The team obtained information using the following sources: A focus group with Sage Board Members; A survey of community within Sage s service area; A survey of medical and clinical staff from the hospital; A survey of all other Sage hospital staff; Sage health information systems data; and, Relevant secondary data from publicly available resources such as the United States Census Bureau and its American Community Survey. 12 Navajo Health Foundation Sage Memorial Hospital

14 Community Survey The Assessment Team developed a community health needs assessment survey and worked to gather data from a representative group of community members. Paper surveys consisting of 49 questions were distributed to members of the community and non-clinical Sage staff during a two-day community survey event. Of the surveys distributed, a total of 382 were completed and returned. Additional copies of the surveys were distributed to community members via and 65 were completed utilizing online survey software. A combined total of 447 paper and online surveys were used to identify the health needs of the community. The survey contained questions tailored specifically to the communities represented. 8 Participants were asked what social and health issues they believe are affecting their community, and what factors contribute negatively to the health of the people in the community. The survey included questions about family and lifestyle backgrounds, demographics, health behaviors, community needs and concerns, environmental concerns, and access to and availability of healthcare resources. The survey also included questions about the quality and level of health care received specifically from Sage. Focus Group with Community Representatives The Assessment Team conducted a focus group with members of the hospital s Board of Directors, who also have extensive expertise in areas such as Education, Healthcare, and Navajo Nation Government, to obtain in-depth input about the needs of the community. The focus group had four (4) objectives: 1. Identify the top health care concerns affecting their individual communities; 2. Determine underlying factors that impact the health care of community members; 3. Identify perceived strengths and weaknesses of Sage; and, 4. Identify barriers that inhibit community members from obtaining and maintaining overall good health. Health Care Provider Survey Members of the Sage Medical Staff and Clinical Staff completed a survey gathering their observations based on their observations providing medical care to members of the community. The employee survey consisted of twenty-three (23) questions and asked participants what they considered to be top community and health issues affecting the hospital and its communities. Eight (8) providers completed and returned the survey. 8 See Appendix E for a copy of questions in the survey that was distributed to community members and providers. Navajo Health Foundation Sage Memorial Hospital 13

15 Health Information Systems Data Sage s Health Information System contains historical hospital patient encounters data with ICD-9 and ICD-10 CM medical diagnosis codes. The Health Information Systems Department provided the Assessment Team with standard reports consistent with the Health Insurance Portability and Accountability Act ( HIPAA ) rules and standards, which were used to quantify patient volumes and compare with qualitative data from the surveys and focus group. Secondary Data The Assessment Team gathered and reviewed data from various authoritative sources such as the United States Census Bureau and the U.S. Department of Health and Human Services to complete the initial assessment and help determine the priorities of the CHNA; these secondary data sources appear as footnoted citations throughout this document. 9 The information in these secondary sources is summarized on varying levels of geographic granularity. Where statistics and information were not available for the defined service area, a combination of zip code and/or Arizona Apache County data was used. Data Analysis The Assessment Team reviewed and analyzed the qualitative primary data gathered from the community and focus group surveys with the objective of mining useful information that suggest the top health care trends and concerns in the community. The trends were then cross-referenced with national healthcare databases to either validate or negate the outcomes. The validated outcomes were then correlated with the health care provider surveys to further confirm the community s top public health needs. The Process for Identifying and Prioritizing Community Health Needs and Services The Assessment Team presented the conclusions of the primary and secondary Data Analyses process to Sage s executive leadership team for additional input, cost-benefit analysis, and an implementation feasibility analysis. Based on this information, the Assessment Team then prioritized and recommended the top-five (5) health care needs of the community, as listed above. 9 For a comprehensive list of all secondary data sources relied upon, refer to Appendix B. 14 Navajo Health Foundation Sage Memorial Hospital

16 Key Findings COMMUNITY DEMOGRAPHICS Population The eight-chapter service area total population was estimated at 10, individuals at the end of The figure below illustrates the total population compared with the local county, state, and national historical census data and current 5-year estimates. Figure 4: Total population of service area compared to county, state, national census Total Population Service Area Apache County Arizona United States 2000 Census 11,753 69,423 5,130, ,421, Census 10,835 71,518 6,392, ,745, Estimates % change present 10,972 72,142 6,731, ,857, As illustrated by the above figure, the population of Sage s service area declined between the years of 2000 and 2010, however since the latest decennial census completed in 2010, the population of the service area is estimated to be rising. Race/Ethnicity Utilizing the data provided by the American Community Survey 5-year estimates ( ACS ), the population of Sage s service area is predominantly American Indian/Alaska Native (95.25%), along with a small Caucasian (2.57%) population. 1.18% of the population is two or more races, while exactly one percent (1.00%) combined is Black, Asian, Native Hawaiian, or some other race. 11 These ACS estimates follow closely with latest decennial census values, according to the Navajo Nation Division of Economic Development. 12 Data 10 Although this is the estimated total population of Sage s service area, many patients travel from outside the eight designated service area Chapters to receive care at the hospital, so it is not possible to know the total population served. 11 US Census Bureau. (2014). American Community Survey 5-year estimates Race. Navajo Nation Reservation and Off-Reservation Trust Land, AZ--NM--UT. Retrieved 03 21, 2016, from American Fact Finder. 12 Navajo Nation Division of Economic Development. (2010). Navajo Nation Data & Statistics. Retrieved 03 17, 2016, from 2010 Census Summary Files: Navajo Health Foundation Sage Memorial Hospital 15

17 collected through the CHNA survey confirms these race/ethnicity trends, with nearly 93.0% of the survey respondents indicating AI/AN decent, less than 3% indicating Caucasian/White, with the remainder divided closely between Black/African American, Asian/Pacific Islander, Hispanic/Latino, multi-racial, or some other race. Figure 5: Race/Ethnicity of Total Service Area Population (2014) American Indian/Alaska Native Caucasian Two or more races Black, Asian, Native Hawaiian or some other race Population by Age and Sex The population of Sage s service area, according to the latest ACS estimates, is skewed toward younger individuals, with roughly 32% of the total population under the age of 20, and nearly 14% over the age of 65. According to a report by HealthCare Appraisers, the healthcare needs of residents in the Navajo Nation differ from the needs of the general American population; for example, there is less of a need to focus on specialized care for the elderly than there is to ensure the primary care needs of children. 16 Navajo Health Foundation Sage Memorial Hospital

18 Figure 6: Total Population by Age and Sex (2014) % 90% 80% 70% 60% 50% 40% 30% 20% 10% 14.16% 17.37% 13.03% 9.25% 11.72% 13.64% 8.35% 16.50% 16.28% 14.41% 10.32% 14.35% 12.61% 8.24% 8.06% 4.41% 5.14% 2.15% Female Male 0% 0 to 9 10 to to to to to to to and over Age Group Males generally outnumber females from the ages of zero to 49, however, ages 50 and over show equal or higher numbers of women in the population as compared to males; this is a normal trend in most populations due to the commonly known fact that women generally live longer than men. Overall, the gender split of Sage s service area is very close to equal at 51% male and 49% female. Population by Educational Attainment According to ACS 5-year estimates for 2014, and as can been seen illustrated in Figure 7 below, the educational attainment of the population of Sage s service area is well below national averages by age group. Nearly 19% of the population aged 25 and older has attained less than a 9 th grade education (5.8% is the national average), while another 13% completed more than 9 th grade but never received a high school diploma or GED (7.8% is the national average), and only 5% of the population achieved at least a Bachelor s degree from a college or university (18.3% is the national average) US Census Bureau. (2014). American Community Survey 5-year estimates Age and Sex. Navajo Nation Reservation and Off-Reservation Trust Land, AZ--NM--UT. Retrieved 03 21, 2016, from American Fact Finder. 14 US Census Bureau. (2014). American Community Survey 5-year estimates Educational Attainment. United States. Retrieved 03 22, 2016, from American Fact Finder. Navajo Health Foundation Sage Memorial Hospital 17

19 Figure 7: Educational Attainment of the Population Ages 25 and Older 15 Associate's degree 6% Some college, no degree 22% Bachelor's degree 5% High school graduate (includes equivalency) 33% Graduate or professional degree 2% Less than 9th grade 19% 9th - 12th grade, no diploma 13% Language Navajo, a form of Athabaskan, is the second language spoken in Sage s service area; nearly seventy-five percent (75%) of the population within the service area over the age of five (5) years speaks a language other than English in their household, which is generally Navajo. Close to eighteen percent (18%) of those within the service area speak English less than very well, according to the latest ACS estimates. 16 The prevalence of individuals speaking a language other than English as their primary form of communication can cause language barriers and is therefore an important factor in the public health needs of the community, especially among those patients more advanced in age. Patients with limited English proficiency are less likely to seek preventative care; they also tend to be less satisfied with the care they do receive, and are more likely to report overall problems with care and may be at an increased risk of experiencing medical errors US Census Bureau. (2014). American Community Survey 5-year estimates Educational Attainment. Navajo Nation Reservation and Off-Reservation Trust Land, AZ--NM--UT. Retrieved 03 22, 2016, from American Fact Finder. 16 US Census Bureau. (2014). American Community Survey 5-year estimates Selected Social Characteristics. Navajo Nation Reservation and Off-Reservation Trust Land, AZ--NM--UT. Retrieved 03 22, 2016, from American Fact Finder. 17 Jacobs, E.A. (2004) Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services. American Journal of Public Health, 94(5), Navajo Health Foundation Sage Memorial Hospital

20 Poverty Rate The 42.73% rate of poverty 18 for all people found in Sage s service area is significantly higher than the U.S. national average of 15.6%, 19 according to the latest ACS 5-year estimates. The figure below further compares poverty rate statistics by age group for the service area against national averages. As is illustrated, across all age groups the poverty rate in Sage s service area remains more than double that of the national rate. Figure 8: Percent of people below the poverty rate by age group compared with US national rates 60.0% 50.0% 40.0% 42.7% 49.7% 40.0% 40.4% 30.0% 21.9% 20.0% 15.6% 14.6% 10.0% 9.4% 0.0% All People Under 18 years 18 to 64 years 65 years and over Service Area Avg. US National Avg. Household Income The majority of households in the service area have incomes of less than $10,000 annually, while the percentage of households with a six-figure income is negligible. 20 The next largest household income group is in the $15,000 to $24,999 range. It is important to note the lack 18 US Census Bureau. (2014). American Community Survey 5-year estimates Selected Economic Characteristics. Navajo Nation Reservation and Off-Reservation Trust Land, AZ--NM--UT. Retrieved 03 23, 2016, from American Fact Finder. 19 US Census Bureau. (2014). American Community Survey 5-year estimates Selected Economic Characteristics. United States. Retrieved 03 23, 2016, from American Fact Finder. 20 US Census Bureau. (2014). American Community Survey 5-year estimates Selected Economic Characteristics. Navajo Nation Reservation and Off-Reservation Trust Land, AZ--NM--UT. Retrieved 03 23, 2016, from American Fact Finder. Navajo Health Foundation Sage Memorial Hospital 19

21 of income disparity within the community; in many areas of the country there are numerous households on both ends of the income spectrum within a given community. However, in this region, it is apparent the community is predominantly of low socio-economic status. Below is a figure comparing the household income for Sage s service area with national averages, according to the latest 5-year ACS estimates. 21 Over 36% of the community survey respondents indicated a household income of less than $10,000, with another 23% indicating a household income between $10,000 and $24,999 annually. Figure 9: Household income compared to US national averages 25.6% Percent of Households 4.7% 12.4% 3.2% 16.9% 8.0% 11.0% 8.9% 12.9% 11.9% 12.1% 18.9% 6.0% 14.2% 3.4% 16.2% 6.5% 6.6% 0.3% 0.3% Less than $10,000 $10,000 to $14,999 $15,000 to $24,999 $25,000 to $34,999 $35,000 to $49,999 $50,000 to $74,999 $75,000 to $99, ,000 to $149,999 $150,000 to $200,000 or $199,999 more Service Area Avg. US National Avg. Unemployment Rate Although employment statistics are constantly fluctuating over time, the unemployment rate in the service area and overall region consistently remains much higher than the national rate. According to the latest ACS 5-year estimates, the U.S. national unemployment rate is 21 US Census Bureau. (2014). American Community Survey 5-year estimates Selected Economic Characteristics. United States. Retrieved 03 23, 2016, from American Fact Finder. 20 Navajo Health Foundation Sage Memorial Hospital

22 9.2%, whereas the unemployment rate in Sage s service area is much higher at 31.0%. 22 Qualitative primary data collected through community surveys indicates the unemployment rate currently remains high in the service area. COMMUNITY NEEDS INDEX The Community Needs Index ( CNI ) 23 is a tool that was developed by Catholic Healthcare West, Thompson Reuters, and the information products company, Solucient, to help health care organizations address barriers to health care access in their communities. According to the CNI, the top five (5) socioeconomic indications that contribute to health disparity are: 1. Income the percentage of elderly, children, and adults living in poverty 2. Culture/language the percentage of elderly, children, and adults over the age of 25 with limited English proficiency 3. Education the percentage of individuals over 25 without a high school diploma 4. Housing status the percentage of individuals who are renting houses 5. Insurance coverage the percentage of individuals without health insurance and unemployed By aggregating these factors and applying them to the Chapters within the service area, we are able to score each area between 1.0 (low need) and 5.0 (high need). 24 According to the CNI methodology, residents of communities with the highest CNI scores [are] twice as likely to experience preventable hospitalization for manageable conditions such as ear infections, pneumonia or congestive heart failure as communities with the lowest CNI scores. Service Area CNI Using the accepted methodology to calculate the CNI for Sage s service area Chapters, the following nine (9) questions were used to determine the score for the socioeconomic indicators mentioned above: Income Barriers What percentage of the population is elderly and in poverty? What percentage of the population is composed of children in poverty? 22 These estimates include the entire population ages 16 an older and may differ from the U.S. Bureau of Labor Statistics figures, which only include unemployment rates for those individuals actively seeking employment. 23 Barsi, E., & Roth, R. (2005, July). The "Community Needs Index". Health Progress: 24 The CNI generally defines each area by zip code, however, some of the Chapters within Sage s service area share zip codes, so for the sake of this analysis and report, we have chosen to distinguish area by Chapter rather than zip code. Navajo Health Foundation Sage Memorial Hospital 21

23 What percentage of the population is composed of single-parent households in poverty? Cultural/Language Barriers What percentage of the population is of minority status? What percentage of the population is monolingual (not including English) or has limited English-speaking proficiency? Educational Barriers What percentage of the population lacks a high school diploma? Insurance Barriers What percentage of the population lacks health insurance? What percentage of the population is unemployed? Housing Barriers What percentage of the population rents its shelter (house or apartment)? The figure below illustrates the CNI score for each of the eight Chapters within Sage s service area utilizing the ACA estimates data. These figures were calculated by assigning a score of 1 to 5 for each of the question categories stated above, then averaging the combined score for each category to assign a unique CNI value. Figure 10: Socio-Economic Factors Affecting Health Care Chapter Tot Pop Rent 25 No HS dip Unemp Uninsur Minor Lim Eng M w/ch Pov Sin w/ Ch Pov 65+ pov Inc Rank Insur Rank Educ Rank Cult Rank Hous Rank CNI Score Ganado % 18.6% 29.9% 12.3% 94.9% 12.9% 29.9% 32.0% 39.0% Cornfields % 37.0% 35.5% 20.6% 100% 20.6% 40.0% 55.8% 32.5% Greasewood % 31.9% 23.9% 24.2% 98.7% 25.0% 35.2% 59.1% 40.2% Nazlini % 33.9% 26.4% 18.2% 99.5% 18.2% 28.1% 56.8% 36.4% Klagetoh % 28.9% 32.7% 18.4% 98.6% 18.4% 59.4% 45.8% 44.7% Kinlichee % 29.5% 22.8% 15.2% 100% 15.2% 36.0% 41.8% 45.7% Steamboat % 41.1% 21.6% 18.9% 99.7% 19.1% 36.9% 58.9% 37.0% Wide Ruins % 38.6% 26.2% 12.8% 89.4% 18.7% 37.0% 80.8% 49.6% According to the CNI methodology, a score over 3.0 generally indicates the area has a higher level of socio-economic factors that impact the community s access to health care. As can be seen from the figure above, all of the Chapters in Sage s service area have a score above 3.0, and all but one Chapter have a score above 4.0, indicating all of these communities have a high need for community health services. A closer examination of these scores reveals the following observations: 25 Decennial U.S. Census rates for 2010 were used for these calculations, as ACA current estimates of the population percent renting a house were unavailable. 22 Navajo Health Foundation Sage Memorial Hospital

24 The Wide Ruins community has the highest percentage of households with a single parent and children living in poverty (80.8%); The Greasewood Springs and Ganado communities have the highest housing barriers, with 30.1% and 33.6% of the population currently renting, respectively; The Steamboat community has the highest rate of unemployment (41.1%); The Cornfield and Kinlichee communities both have 100% minority populations; The Klagetoh community has the highest rate of married couples with children living in poverty (59.4%); The Greasewood Springs Chapter has the highest rate of individuals who speak English less than well (25.0%), and also has the highest rate of individuals over the age of 25 with no high school diploma or equivalent (24.2%). PRIMARY AND CHRONIC DISEASE CARE ACCESS, QUALITY OF CARE, AND OTHER HEALTH NEEDS OF UNINSURED PERSONS, LOW-INCOME PERSONS, AND MINORITY GROUPS According to the Assessment Team s secondary research, studies identifying specific group needs distinct from the general population at the Navajo Nation Chapter unit level of analysis are not available from secondary sources. In 1999, Congress passed the Healthcare Research and Quality Act (P.L ), mandating that the Agency for Healthcare Research and Quality ( AHRQ ) produce an annual report on national trends in the quality of health care provided to the American people, titled the National Healthcare Disparities Report ( NHDR ). As of 2014, the NDHR has been combined with the National Healthcare Quality Report ( NHQR ) to replace both reports and form a new report entitled the National Healthcare Quality & Disparities Report ( QDR ). This annual report provides a comprehensive overview of the quality of health care received by the general U.S. population and disparities in care experienced by different racial, ethnic, and socioeconomic groups. This report examines the quality and disparities in health care received by designated care differences in each priority population, however, it does not provide a complete assessment of health care differences in each priority population. The measures tracked were selected as applicable across many population groups with the purpose of tracking quality and disparities data at the national level. 26 According to the latest QDR report, national trends observed were: National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; May AHRQ Pub. No Navajo Health Foundation Sage Memorial Hospital 23

25 Uninsured persons The QDR indicated that the lack of health insurance coverage was one of the most significant contributing factors to poor quality of care, but that since the PPACA was passed in 2010 and coverage began in 2014, a marked decrease in the rate of uninsurance has been observed. The QDR identified the following statistics as most significant in relation to uninsured persons: After years without improvement, the percentage of uninsured adults (ages 18-64) increased substantially during the first half of 2014; From 2000 to 2010, the percentage of adults ages who reported they were without health insurance coverage at the time of interview increased from 18.7% to 22.3%; From 2010 to 2013, the percentage without health insurance decreased from 22.3% to 20.4%; During the first half of 2014, the percentage without health insurance decreased to 15.6%; During the first half of 2014, the percentage of adults ages without health insurance decreased more quickly among Blacks and Hispanics 27 than Whites, but differences in uninsurance rates between groups remained. Low-income and ethnic minority groups care access and quality disparities The QDR states that care access and quality disparities are observed in the largest number in poor households, followed by Hispanics 28 and Blacks. Poor indicates a family income less than the federal poverty level which would include the majority of the households in Sage s service area, as illustrated in Figures 8 and 9 above. 29 The following care access and quality disparities were identified in the 2014 QDR regarding the issues low-income groups face on a national level: Care Access In 2012, people in poor households had worse access to care than people in highincome households on all access measures; Asians and American Indians and Alaska Natives had worse access to care than Whites for about one-third of access measures; Through 2012, most disparities in access to care related to race, ethnicity, or income showed no significant change, neither getting smaller nor larger; Blacks had worse access to care than Whites for about half of access measures; 27 Hispanics includes all races other than Blacks and Whites. 28 Hispanics includes all races other than Blacks and Whites National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; May AHRQ Pub. No Navajo Health Foundation Sage Memorial Hospital

26 Hispanics had worse access to care than Whites for two-thirds of access measures; Blacks received worse care than Whites for about one-third of quality measures. Quality of Care Hispanics, American Indians and Alaska Natives, and Asians received worse care than Whites for some quality measures and better care for some measures; People in poor households received worse care than people in high-income households on more than half of quality measures; Through 2012, at least one disparity related to hospice care grew larger for Blacks, American Indians and Alaska Natives, and Hispanics; also, people in poor households experienced worsening disparities related to chronic diseases; When changes in disparities occurred, measures of disparities were more likely to show improvement than decline. However, for people in poor households, more measures showed worsening disparities than improvement. Disparity improvement/worsening by unique ethnic/minority group Specific ethnic and/or minority groups saw some improvements or worsening of specific disparities as compared to Whites that were unique to those specific ethnic or minority groups, according to the QDR report as follows: American Indian/Alaska Native ( AI/AN ) Measures for which the gap between AI/ANs and Whites grew smaller, indicating improvement: o Children ages months who received 3 or more doses of the hepatitis vaccine. Measures for which the gap between AI/ANs and Whites grew larger, indicating worsening disparities: o Hospice patient caregivers who perceived a patient was referred to hospice at the right time. Black or African American Measures for which the gap between Blacks and Whites grew smaller, indicating improvement: o Mechanical adverse events in patients receiving central venous catheter placement, age 18+; o Hospital patients with an anticoagulant-related adverse drug event to lowmolecular-weight heparin and factor Xa, age 18+; o Children ages months who received 1+ doses of measles-mumps-rubella vaccine; o Deaths per 1,000 hospital admissions with abdominal aortic aneurysm repair, Navajo Health Foundation Sage Memorial Hospital 25

27 age 18+; o Postoperative respiratory failure per 1,000 elective-surgery admissions, age 18+; o Admissions with iatrogenic pneumothorax per 1,000 discharges, age 18+. Measures for which the gap between Blacks and Whites grew larger, indicating worsening disparities: o Adult current smokers who obtained a checkup in the past year, and were advised in the last 12 months to quit smoking; o Breast cancer diagnosed at advanced stage per 100,000 women age 40+; o People age 12+ who needed treatment for illicit drug use and who received treatment at a specialty facility in the last 12 months; o Family caregivers who did not want more information about what to expect while the patient was dying. Asian Measures for which the gap between Asians and Whites grew smaller, indicating improvement: o Adults age 40+ with diagnosed diabetes who had their feet checked in the calendar year; o Adults age 40+ with diagnosed diabetes who received a dilated eye examination in the calendar year; o Adults age 65+ who received an influenza vaccination in the last 12 months; o Adult hospital patients who sometimes or never had good communication with doctors; o Patients under age 70 diagnosed with chronic kidney failure who received a transplant within 3 years of the date of their renal failure; o Adults who had a visit in the last 12 months whose health providers sometimes or never listened carefully to them. Measures for which the gap between Asians and Whites grew larger, indicating worsening disparities: o Admissions with iatrogenic pneumothorax per 1,000 discharges, age 18+. Hispanic or Latino Measures for which the gap between Hispanics and Whites grew smaller, indicating improvement: o Adults with obesity who ever received advice from a health professional about eating fewer high-fat foods. 26 Navajo Health Foundation Sage Memorial Hospital

28 Measures for which the gap between Hispanics and Whites grew larger, indicating worsening disparities: o Hospice patients who received care consistent with their stated end-of-life wishes; o Hospice patients who received the right amount of medicine for pain management. Native Hawaiian and other Pacific Islanders ( NHOPIs ) No data available. Causes of Death among American Indians/Alaska Natives compared to all other races 30 Studies identifying specific group needs distinct from the general population at the Navajo Nation Chapter unit level of analysis are not available from secondary sources according to secondary data research conducted by the Assessment Team, however, there is data available that specifically studies the health trends of the minority group of American Indians/Alaska Natives ( AI/AN ) residing in the Indian Health Service s ( IHS ) service area. Since over 95% of Sage s service area falls into the AI/AN category and also resides in the Indian Health Service service area, this data is valuable to consider apart from the QDR data on health needs of minority groups nationally. In 2014, the Department of Health & Human Services Indian Health Service, in conjunction with the Office of Public Health Support and the Division of Program Statistics, published a report titled Trends in Indian Health ( TIHR ), which presented statistics related to the health trends of the AI/AN population of the IHS service area. One of the most alarming statistics presented was the cause of death among AI/AN populations as compared to all races in the United States. According to the TIHR, AI/AN ( data) have higher death rates than all U.S. races (2008 data) from the following causes: Alcohol related 520% greater; Tuberculosis 450% greater; Chronic liver disease and cirrhosis 368% greater; Motor vehicle crashes 207% greater; Diabetes mellitus 177% greater; Unintentional injuries 141% greater; Poisoning 118% greater; Homicide 86% greater; 30 U.S. Department of Health and Human Services - Indian Health Service. (2014). Trends in Indian Health: 2014 Edition. Retrieved from Indian Health Service: Navajo Health Foundation Sage Memorial Hospital 27

29 Suicide 60% greater; Pneumonia and influenza 37% greater; and, Firearm injury 16% greater. Many of these causes of death are chronic illnesses or behavioral health issues that are often preventable with the right care. The fact that AI/AN populations see much higher percentages of deaths attributed to these causes indicates a higher need for care and prevention services related to these health issues. Considering the high prevalence of AI/AN individuals within Sage s service area as a subset of the large AI/AN population residing within the IHS service area, one can conclude the need for care related to these health issues also translates as a public health need specifically among Sage s service area. THE HEALTH NEEDS OF THE COMMUNITY Using the process outlined above, the Assessment Team identified the following high priority health needs of the community: o Behavioral Health Treatment o Diabetes Care o Pediatric Care o Geographic Accessibility of Health Care Services o Emergency Trauma Care BEHAVIORAL HEALTH TREATMENT Behavioral health issues are more prevalent among the AI/AN population than the overall population of the United States. AI/AN individuals are 1.7 times more likely to experience serious psychological distress than are non-hispanic whites. In 2009, suicide was the second leading cause of death for AI/AN populations between the ages of 10 and 34. Among people aged 15 to 24 years of age, AI/AN women are 3.6 times more likely to die from suicide than non-hispanic white women of the same age group. Similarly, AI/AN men of this age group are 1.9 times more likely to commit suicide than white men. 31 Alcohol and drug addiction remains a tremendous problem in AI/AN populations nationwide and its impact is felt throughout Sage s service community. Alcohol and drug abuse has a detrimental effect on the physical and mental wellbeing of the addicted individuals, in addition to negatively affecting the people involved in the addict s life, such as friends and family members. Substance abuse was identified in both the community surveys and the focus groups as a major health concern in the region. 31 CDC, Health United States, Table Navajo Health Foundation Sage Memorial Hospital