Community Health Needs Assessment

Transcription

2012
Community Health
Needs Assessment
NorthCrest Medical
Center
100 Northcrest Drive
Springfield, TN 37172
(615) 384-2411
www.northcrest.com
NorthCrest Medical Center | Springfield, TN
Table of Contents
I.
Introduction
Project Objectives
Brief Overview
Approach
1
1
2
II.
Executive Summary
3
III.
Demographics
Definition of Service Area
Gender, Age, Race/Ethnic Composition
Marital Status
IV.
Social Determinants
Economic Security
 Household Income
 Child Poverty
 Medicaid Population
Education
 Educational Attainment
Housing
 Occupancy
 Households
Employment
Health Insurance
Community Needs Index
V.
7
8
9
10
11
13
14
14
15
15
16
17
Health Indicators
Diabetes
Mental Health Issues
Preventive Care
Cardiovascular Disease
All Cancers
20
23
25
27
29
VI.
Data Gaps Identified
31
VII.
Conclusions
32
VIII. Works Cited
33
IX.
Appendix
Raw Survey Results
The Hanlon Method
I. INTRODUCTION
Project Objectives
NorthCrest Medical Center (“NorthCrest”) partnered with Lattimore Black Morgan & Cain
(“LBMC”) for the following:

Complete a Community Health Needs Assessment (“CHNA”) report that would be
compliant with the Internal Revenue Service (“IRS”) – Treasury;

Provide NorthCrest with information needed to complete the IRS – 990h schedule; and

Produce the information needed for the hospital to issue an assessment of community
health needs and document how it intends to respond to the needs.
Brief Overview of Community Health Needs Assessment
Typically, non-profit hospitals qualify for tax-exempt status as a Charitable Organization, as
described in Section 501(c) 3 of the Internal Revenue Code; however, the term “Charitable
Organization” is undefined. Prior to the passage of Medicare, charity was generally recognized
as care provided to the less fortunate without means to pay. With the introduction of Medicare,
the government met the burden of providing compensation for such care.
In response, IRS Revenue ruling 69-545 eliminated the Charitable Organization standard and
established the Community Benefit Standard as the basis for tax-exemption. Community Benefit
determines if hospitals promote the health of a broad class of individuals in the community,
based on factors including:

Emergency room open to all, regardless of ability to pay;

Surplus funds used to improve patient care, expand facilities, train, etc.;

Controlled by independent civic leaders; and

All available and qualified physicians are privileged.
A CHNA is an important tool in identifying the health needs of a community. The results assist
in prioritizing health needs that lead to the allocation of appropriate resources and the creation of
new partnerships to improve the health of the population. In an era of aging baby boomers,
increased chronic disease, an epidemic prevalence of obesity, a flagging economy, an increasing
number of uninsured citizens and disparate access to care, healthcare organizations are being
challenged to maximize the use of their collective resources to respond to the needs of the
communities they serve.
A Community Health Needs Assessment
Page | 1
Approach
To complete a CHNA, the Hospital must:


Describe the process and methods used to conduct the assessment;

Sources of data, and dates retrieved;

Analytical methods applied;

Information gaps impacting ability to assess the needs; and

Identify with whom the Hospital collaborated.
Describe how the hospital gained input from community representatives;

When and how the organization consulted with these individuals;

Names, titles, and organizations of these individuals; and

Any special knowledge or expertise in public health possessed by these
individuals.

Describe the process and criteria used in prioritizing health needs;

Describe existing resources available to meet the community health needs;

Identify the programs and resources the hospital facility plans to commit to meeting each
identified need and the anticipated impact of those programs and resources on the health
need.
Page | 2
II. EXECUTIVE SUMMARY
NorthCrest, which began operations in 1956 under the name of Jesse Holman Jones Hospital, is
located in Springfield, Tennessee (30 miles north of Nashville), and serves Robertson and
surrounding counties as well as southern Kentucky. December 1995 marked the hospital's move
to a new medical complex located on 43 acres. The 109-bed facility represents multiple
specialties supported by state-of-the-art equipment, including an in-house cardiovascular lab, a
full range of outpatient services and 24-hour emergency services. The NorthCrest campus
includes four medical office buildings.
More than 150 active and consulting physicians are on the NorthCrest Medical Staff. They
provide a variety of services that allow patients the opportunity to receive specialized care
locally. Some of the specialties of the NorthCrest physicians include cardiology, diagnostic and
interventional radiology, emergency medicine, family practice, internal medicine, nephrology,
neurology, obstetrics/gynecology, ophthalmology, orthopedics, otolaryngology (ear, nose and
throat), pediatrics, plastic and reconstructive surgery, pulmonology, general and vascular
surgery, and urology.
Community education programs are ongoing at NorthCrest. Classes, seminars and workshops on
healthy eating, diabetes care, smoking cessation, CPR and AED (automatic external defibrillator)
are a few of the programs offered. NorthCrest also provides workshops, health fairs and health
screenings. Support groups meet regularly, and include diabetics, Parkinson’s disease, and adults
and children who have experienced the loss of a loved one.
The NorthCrest Executive Council in charge of the CHNA process considered the feasibility and
cost involved to utilize an outside consulting firm to perform the CHNA on its behalf. The
Council concluded it would partner with LBMC to conduct the CHNA and the associated
Implementation Strategy. In December 2012, NorthCrest identified key staff members to begin
work on a comprehensive CHNA, under the guidance of LBMC. The NorthCrest Executive
Council identified key personnel to serve on the newly formed CHNA committee. Key
community health and social service stakeholders were engaged to assist in the process to ensure
input from the underserved, chronically ill, low income and minority populations in the
NorthCrest service area was taken into account. Specifically, the following served on the CHNA
Committee:
Page | 3
Name
Robert DeBerry
Kim Pridgen
Adele Watts
Chris Locke
Andrew McDonald
Kyle Hendrickson
Michael Lewis, MD
Dr. Geraldine Farmer
Howard Bradley
Diana Pelham
Dana Holt
Margot Fosness
Company/Department
NorthCrest Community Development
NorthCrest Accounting
NorthCrest Foundation
NorthCrest Physician Services
LBMC Healthcare Consulting
LBMC Healthcare Consulting
Community Physician
Former Educator & School Board Member
County Major & Former Educator
Robertson County YMCA
Robertson County School Nurse
Robertson County Chamber of Commerce
The Committee met twice over the five month time-frame and was requested to assist with and
provide direction for the following responsibilities:

Interpreting and understanding CHNA requirements and deadlines

Identifying primary and secondary data sources

Identifying key community partners

Developing the organization's CHNA instrument and methodology

Developing targeted interview questions including identification of its community's
population health experts

Compiling and interpreting the data accumulated through the 12 question survey

Achieving consensus, with its identified community partners, citizens and public health
experts, in identifying the top health issues facing its community

Developing the Hospital's implementation strategy to address the findings of the CHNA
NorthCrest’s primary data collection vehicle for determining community perception about the
various needs of the community was an online 12-question survey, seeking input regarding
demographics and health status. In order to seek input from the medically underserved,
chronically ill and low-income individuals and to ensure input from the overall population, the
survey was advertised by several different community partners, with paper copies placed on-site
in the NorthCrest Emergency Room as well. The survey was available to the public via a link on
the hospital’s main website for a six-week period, from January 2013 to March 2013.
Page | 4
In order to better gauge the community’s perception of the local health needs, they community
was asked what they perceive to be the most important health issues in their community. A total
of approximately 130 surveys were received in electronic and paper format. Appendix B displays
the raw results for the electronically submitted surveys. Responses for question 9 were weighted
on a point-scale using 6 points for each respondent claiming a “Greater Need”, 5 points for
“Significant Need”, etc. The statistically-weighted responses to the question: “What do you see
as important health issues facing Robertson County and the surrounding communities?” are as
follows:
Affordable Healthcare Insurance
532
Obesity (Lack of Exercise
523
Affordable Prescription Drugs
505
Diabetes
501
Reliable Health Information
500
Mental Health Issues (Anxiety, Depression,…
496
Drug & Substance Abuse
486
Preventive Care (Health Screenings)
479
Heart Disease/Stroke
469
Smoking/Tobacco Use
467
Dental Health
466
Teen Pregnancy
461
Cancer
454
Maternal/Child Healthcare
423
Medical Professional Shortage
416
Transportation for Medical Needs
HIV
Lack of Home Healthcare Equipment
407
338
321
Other primary data sources included a review of the hospital’s top diagnoses codes for inpatient
and outpatient care. Secondary data reviewed included but are not limited to The Centers for
Disease Control and Prevention, The Behavioral Risk Factor Surveillance System (BRFSS), U.S.
Census Bureau, “County Health Rankings,” compiled by the Roberts Woods Johnson
Foundation, and The U.S. Department of Health and Human Services.
In selecting the health issues prioritized for inclusion in the Implementation Strategy, the
Executive Council members considered the following: social determinants of health status in its
community; each participating agency’s mission, vision, and strategic plans; and current health
programming offered by each partner. Opportunities for collaboration to further improve
community health status were a key focus. The Hanlon Method, a mathematical algorithm
developed by Felix, Burdine and Associates was then used to assign numerical values to rate the
size, seriousness, and effectiveness of available interventions for each health issue. The “Pearl”
test was then applied to the list of needs to help screen out health problems based on five
feasibility factors. Information about the Hanlon Method and “Pearl” test can be found on
Appendix A.
Page | 5
After a thorough analysis of primary and secondary data, and applying the Hanlon Method and
“Pearl” test, the members agreed that the following health issues should be prioritized for action:
1. Diabetes
2. Mental Health Issues
3. Preventive Care
4. Cardiovascular Disease
5. All Cancers
Page | 6
III. DEMOGRAPHICS
Definition of Area Served by the Hospital Facility
NorthCrest, in conjunction with LBMC, has defined its primary service area (PSA) as the
following ZIP codes representing approximately 78 percent of discharges in 2010, 2011, and
2012:
37032 - Cedar Hill, TN
37172 - Springfield, TN
37073 - Greenbrier, TN
37146 - Pleasant View, TN
37072 - Goodlettsville, TN
42202 - Adairville, KY
37049 - Cross Plains, TN
37188 - White House, TN
Page | 7
Demographics of the Community
The population of the PSA is 102,2961, with a gender ratio close to state and national ratios of 49
percent male and 51 percent female. The average age within the PSA is younger than the state
and the U.S., which impacts numerous aspects of health including rates of some types of cancer,
violence, and levels of unintended injury. Springfield, the county seat of Robertson County,
makes up approximately 50 percent of the total discharges from NorthCrest. Robertson County
has experienced nearly 22 percent population growth since 2000 (54,433), registering a
population of 66,283 in 2010, and is projected the grow an additional 19 percent to 78,938 in
2020.
Table 1. Age Categories for PSA, Tennessee and the U.S.
PSA
TN
US
0 – 19 years
29%
26%
27%
20 – 44 years
32%
33%
34%
45 – 64 years
27%
27%
27%
65 and older
11%
14%
13%
The ethnic composition of the PSA is mostly a mix between Hispanic/Latino, Black/African
American, and White races. The PSA’s white population is at a higher ratio than the U.S. and
state while the proportion of Black and Hispanic/Latino residents is significantly lower. Ethnic
variation in cultural norms, English comprehension, and beliefs about health impact the mode of
health care delivery and how patients respond to health care services. This variation creates a
need for increased awareness and sensitivity among service providers.
Table 2. Ethnic Composition for PSA, Tennessee, and the U.S. (2010)
91%
78%
65%
17%
16%
5%
White
Black/African American
Tennessee
1
12%
PSA
5%
4%
Hispanic or Latino
US
All population information, unless otherwise cited, sourced from U.S. Census Bureau – American FactFinder
Page | 8
With regard to marital status, The PSA’s population has a notably smaller percentage of people
who have never been married when compared to the state and the nation; Further, the PSA has a
larger comparative percentage of people who are currently married and not separated. The data
regarding separated/divorced residents are similar to state and national averages.
Table 3. Marital Status for PSA, Tennessee, and the U.S. (2010)
59%
53%
52%
35%
31%
22%
13% 13% 14%
Never Married
Currently Married
Tennessee
PSA
Separated/Divorce
US
Page | 9
IV. SOCIAL DETERMINANTS OF HEALTH
Quality of life issues are indicators that include not only wealth and employment, but also the
built environment, physical and mental health, education, recreation and leisure time, and social
belonging. The following section addresses social determinants of health, and how the
NorthCrest PSA rates relative to state and national figures.
Economic Security
Research indicates that people living on limited incomes are more likely to forego visits to the
doctor in order to meet their more pressing financial responsibilities.2 Low-income wage earners
are also less likely to be covered by an employer’s health insurance program, and if they are
covered, they are often less able to pay their share of health expenses. Educational attainment
and family or household income are two indicators commonly used to assess the influence of
socioeconomic circumstances on health. Education is a strong determinant of future employment
and income. In the majority of persons, educational attainment reflects material and other
resources of family of origin and the knowledge and skills attained by young adulthood;
therefore, it captures both the long-term influence of early life circumstances and the influence of
adult circumstances on adult health. Income is the indicator that most directly measures material
resources. Income can also influence health by its direct effect on living standards (e.g., access to
better quality food and housing, leisure-time activities, and health-care services).
The PSA’s median household income of $52,263 is substantially higher than the statewide
median household income of $41,693, and is in-line with the United States of $52,762. Please
refer to Table 4 to gain a better understanding of how the PSA compares to the state and national
indices.
Table 4. Household Income Distribution for PSA, Tennessee and the U.S.
PSA
TN
US
< $15k
11.5%
16.5%
12.1%
$15 – 25k
9.1%
13.7%
10.2%
$25 – 50k
27.4%
27.4%
25.5%
$50 – 75k
21.6%
17.4%
19.5%
$75 – 100k
15.2%
10.6%
12.5%
Over $100k
15.3%
14.4%
20.1%
52,263
61,631
43,989
58,400
52,762
69,821
Median ($)
Mean ($)
2
DeNavas-Walt C, Proctor BD, Mills RJ. Income, Poverty, and Health Insurance Coverage in the United States: 2003. U.S.
Census Bureau, Current Population Reports, P60-226. U.S. Government Printing Office, Washington, DC, 2004 .
Page | 10
Research is clear that poverty is the single greatest threat to children’s well-being.3 While an
adult may fall into poverty temporarily, falling into poverty in childhood can last a lifetime –
rarely does a child get a second chance at an education or a healthy start in life. As such, child
poverty threatens not only the individual child, but is likely to be passed on to future generations,
entrenching and even exacerbating inequality in society. Table 5 reports the percentage of
children aged 0-17 living under 100 percent of the Federal Poverty Level (FPL). This indicator is
relevant because poverty creates barriers to access including health services, healthy food, and
other necessities that contribute to poor health status.
Nearly three thousand children in the Robertson County – 19 percent of all children – live in
families with incomes below the federal poverty level – $23,021 a year for a family of four.4
Research shows that, on average, families need an income of about twice that level to cover basic
expenses. Most of these children have parents who work, but low wages and unstable
employment leave their families struggling to make ends meet. Poverty can impede children’s
ability to learn and contribute to social, emotional, and behavioral problems. Poverty also can
contribute to poor health and mental health. Risks are greatest for children who experience
poverty when they are young and/or experience deep and persistent poverty.
Table 5. Child Poverty for Robertson County, Tennessee and the U.S.
RC
TN
US
16,771
1,466,924
72,906,664
Children in Poverty
3,246
352,438
14,550,805
Children in Poverty (%)
19%
24%
20%
Total Population (For Whom
Poverty Status is Determined)
3
4
National Center for Children in Poverty
U.S. Census Bureau, 2007 – 2011 American Community Survey 5-Year Estimates
Page | 11
As shown below in Figure 1, the percentage of children living in poverty has only risen over the
last decade, from nearly 13 percent in 2002, to over 22 percent in 2011.
Figure 1. Trend of Children Living in Poverty, 2002 - 20115
Not only is there a racial disparity in children living in poverty in Robertson County, but in
Tennessee and the United States as well. Table 6 shows a breakdown of U.S. Census Bureau
information from the American Community Survey, 2006 – 2010. Black children have the
highest poverty rate among the race groups on the county, state, and national level.
Table 6. Percentage of Children Living in Poverty by Race, 2006-2010
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
White
Black
Asian
Native
American /
Alaska Native
Robertson County
5
Native
Hawaiian /
Pacific
Islander
Tennessee
Some Other Multiple R ace
Rac e
Hispanic /
Latino
Non-Hispanic
/ Latino
United States
U.S. Census Bureau – Small Area Income and Poverty Estimates
Page | 12
Figure 2 depicts the most vulnerable areas of children living in poverty by tract for Robertson
County. Springfield appears to be the area of greatest need, in which more time and resources
can be devoted to planning interventions that can help address this disparity.
Figure 2. Percentage of Children Living in Poverty by Tract, 2006-20106
Over 40.0%
30.1 - 40.0%
20.1 - 30.0%
10.1% - 20.0%
Under 10.1%
Table 7 reports the percentage of the population that is enrolled in Medicaid. This indicator is
relevant because it assesses vulnerable populations which are more likely to have multiple health
access, health status, and social support needs; when combined with poverty data, providers can
use this measure to identify gaps in eligibility and enrollment.
Table 7. Medicaid Population for Robertson County, TN and the U.S.7
Poverty Status is Determined)
Medicaid Population
Medicaid Population (%)
RC
TN
US
65,680
6,201,012
301,501,760
10,293
1,134,209
48,541,096
16%
18%
16%
6
U.S. Census Bureau, 2007 – 2011 American Community Survey 5-Year Estimates
7
U.S. Census Bureau, 2008-2010 American Community Survey 3-Year Estimates
Page | 13
Education
A lack of education has been cited as a major indicator of poor health in many studies.8
Educational barriers often turn into impediments to employment, further increasing the
likelihood of poverty and lack of insurance. Lack of adequate health education also impacts a
person’s ability to understand medical information or recognize early symptoms of disease.
The PSA’s income level is adversely correlated with its level of education. While the PSA boasts
a higher high school graduation rate compared to the state and nation; only 18 percent of the
PSA’s residents hold a bachelor’s degree or higher compared to 24 percent statewide and 28
percent nationally, as shown in Table 8. The PSA compares favorably to the state and the nation
in the other education levels shown below.
Table 8. Education Level for PSA, Tennessee and the U.S.
PSA
TN
US
Less than High School
5.7%
6.1%
6.4%
Some High School
11.4%
9.7%
8.9%
High School Degree
37.2%
33.4%
29.0%
Some College/Assoc. Degree
27.6%
27.2%
28.2%
Bachelor’s Degree or Greater
18.1%
23.6%
27.5%
Housing
Healthy homes are essential to a healthy community and population. They contribute to meeting
physical needs (e.g., air, water, food, and shelter) and to the occupants’ psychological and social
health. Housing is typically the greatest single expenditure for a family. Safe housing protects
family members from exposure to environmental hazards, such as chemicals and allergens, and
helps prevent unintentional injuries. Healthy housing can support occupants throughout their life
stages, promote health and safety, and support mental and emotional health. In contrast,
inadequate housing contributes to infectious and chronic diseases and injuries and can affect
child development adversely.
Increased use of rental housing is associated with more transitory lifestyles, a less stable home
and an environment that deters health prevention. For example, rental housing is more likely than
owned housing to be sub-standard, in neighborhoods with higher crime rates, lower quality
schools, limited healthy food choices and fewer recreational opportunities. This measure does
not reflect whether there is a significant population of homeless individuals in an area, a factor
that could influence demands on local health systems in addition to the inherent increase in
overall health risk from lack of stable shelter.
8
Fisher Wilson J. The Crucial Link between Literacy and Health. Annals Internal Medicine. 11/18/2003, Vol. 139 Issue 10,
p875, 4p.
Page | 14
As shown in Table 9, the PSA has a proportionately lower percentage of renter-occupied housing
units compared to the state, as well as the nation. Total households for the PSA is approximately
38,500.
Table 9. Housing Tenure for PSA, Tennessee and the U.S.
PSA
TN
US
Owner-occupied Housing Units
79.1%
69.0%
66.1%
Renter-occupied Housing Units
20.9%
31.0%
33.9%
Total Households
38,535
2,829,025
132,312,404
Employment
Lack of health insurance forces individuals to forgo primary care treatment options, leading to a
markedly increased propensity to be hospitalized for chronic conditions. Employment status also
has a substantial impact on the ability of individuals to obtain insurance. A person without health
insurance who experiences an injury or a new chronic condition has greater difficulty accessing
recommended medical care and takes longer to return to full health, if at all. And if health
remains compromised, it could make it more difficult for an uninsured person to obtain health
insurance in the future.
Table 10. Employment Status for PSA, Tennessee and the U.S.
PSA(2010)
Robertson
Co(2013)
TN(2013)
US(2013)
Labor Force
52,839
35,250
3,129,900
155,524,000
Unemployed
3,665
2,560
243,700
12,032,000
Unemployment Rate
6.9%
7.3%
7.8%
7.7%
With 3,665 people unemployed within the PSA in 2010, the unemployment rate for the PSA was
6.9 percent, which was below the state of Tennessee at 7.8 percent, as well as the national rate of
9.6 percent. As of February 2013, Robertson County reported an unemployment rate of 7.3
percent, comparing favorably to the state unemployment rate of 7.8 percent, and the national
unemployment rate of 7.7 percent.
Page | 15
Health Insurance Coverage
The percentage of the Robertson County population without health insurance continues to be
higher than the state and nation. According to the U.S. Census Bureau - Small Area Health
Insurance Estimates, the percentage of residents in Robertson County without health insurance
coverage was 16.9 percent in 2011, compared to the state at 16.6 percent and the nation at 16.2
percent.
Table 11. Uninsured Status for Robertson County, Tennessee and the U.S.
RC
TN
US
57,963
5,359,465
262,403,381
Uninsured Population
9,792
888,747
46,556,803
Percent Uninsured
16.9%
16.6%
16.2%
Uninsured Status is Determined)
There is a racial and economic disparity among race in health insurance coverage. Among
Hispanics in Robertson County, over 40 percent were without health insurance in 2011. This
compares favorably to the state but is above the national level. Additionally, 27 percent of black
residents were without health insurance in 2011, comparing unfavorably to both the state and
national averages of 18 percent and 21 percent.9
Table 12. Uninsured Status by Race for Robertson County, Tennessee and the U.S.
50.0%
45.0%
40.0%
35.0%
30.0%
White
25.0%
Black
20.0%
Hispanic/Latino
15.0%
10.0%
5.0%
0.0%
Robertson County
9
TN
US
U.S. Census Bureau - Small Area Health Insurance Estimates
Page | 16
Community Needs Index
The Community Needs Index (“CNI”) identifies the severity of health disparities for every ZIP
code in the United States and demonstrates the link between community need, access to care, and
preventable hospitalizations. For each ZIP code in the United States, the CNI aggregates five
socio-economic indicators /barriers to health care access that are known to contribute to health
disparities related to income, education, culture/language, insurance, and housing. LBMC uses
the CNI to identify communities of high need and direct a range of community health and faithbased community outreach efforts to these areas.
To determine the severity of barriers to health care access in the primary service area of
NorthCrest, the CNI gathers data about that community’s socio-economy. For example, what
percentage of the population is elderly and living in poverty; what percentage of the population
is uninsured; what percentage of the population is unemployed, etc. Using this data, the CNI
assigns a score to each barrier condition. A score of 1.0 indicates a zip code with the lowest
socio-economic barriers (low need), while a score of 5.0 represents a zip code with the most
socio-economic barriers (high need). The scores are then aggregated and averaged for a final
CNI score (each barrier receives equal weight in the average). The following map provides the
CNI scores for the 8 zip codes that represent approximately 78 percent of total discharges for
NorthCrest.
Page | 17
A comparison of CNI scores to hospital utilization shows a strong correlation between high need
and high use. Research using admission rates per 1,000 population shows a high correlation
(95.5 percent) between hospitalization rates and CNI scores. In fact, admission rates for the most
highly needy communities (CNI=5.0) are more than 60 percent higher than communities with the
lowest need (CNI=1.0), as illustrated in Figure 3.
Figure 3. Annual Admission Rate per 1000 Population by CNI Score10
Admission rates for ambulatory sensitive conditions (“ASCs”) have also been examined. An
ASC is defined as a condition whereby appropriate ambulatory care services could prevent or
reduce the need for hospital admission (i.e. pneumonia, congestive heart failure and cellulitis).
Hospitalization for some conditions may be reduced if persons had access to effective and timely
care in the community. Prior care could prevent the onset of certain illnesses, help control an
acute episodic illness or condition, or manage a chronic disease or condition. With proper
outpatient care these conditions do not generally require an acute care admission.
When admission rates for ASC conditions were compared to CNI scores, research found that the
highest need communities were experiencing admission rates almost twice as often (97 percent)
as the lowest need communities, as shown in Figure 4. Importantly, there was no relationship
observed between CNI scores and “marker conditions” — such as appendicitis and heart attack,
which require inpatient treatment regardless of socio-economic status. This proves a strong
causal relationship between CNI scores and preventable hospitalization for manageable
conditions (i.e., ASCs).
10
Dignity Health & Thomson Reuters
Page | 18
Figure 4. Annual Admission Rate per 1000 Population by CNI Score
Ambulatory vs. Marker Conditions
Page | 19
V. HEALTH INDICATORS
As part of the assessment process, the Executive Council at NorthCrest was requested to rank the
five most significant health issues facing the PSA. The Council was provided with primary and
secondary data sources to assist them on determining the highest priority health care needs in the
community. The Council compared the raw secondary and primary data and took inventory of
existing services and programming which address identified health needs. Consideration of
community resources, budgetary constraints, available personnel and hospital “mission and
vision” were all considerations in selecting which health needs to prioritize and address through
the CHNA implementation plan strategy. The Hanlon Method, a mathematical algorithm
developed by Felix, Burdine and Associates was used to assign numerical values to rate the size,
seriousness, and effectiveness of available interventions for each health issue.
As a result of reviewing secondary data on the size, seriousness, available community resources,
utilizing the Hanlon Method algorithm, the Council determined the following health needs which
will be targeted for interventions by the CHNA committee in the implementation plan:
1.
Diabetes
2.
Mental Health
3.
Preventive Care
4.
Heart Disease/Stroke
5.
All Cancers
It was determined that addressing the aforementioned needs, coupled with several other factors,
could potentially increase Robertson County’s average life expectancy; which is currently 74.8
years compared to the median for all U.S. counties of 76.5 years.
Diabetes11
Diabetes is a serious, costly, and potentially preventable disease and presents a significant public
health issue in the U.S. Both the prevalence and incidence of diabetes have increased rapidly
since the mid-1990s, with minority racial/ethnic groups and socioeconomically disadvantaged
groups experiencing the steepest increases and most substantial effects from the disease.
Diabetes is a major cause of heart disease and stroke. Death rates for heart disease and the risk of
stroke are about 2–4 times higher among adults with diabetes than among those without
diabetes.12 In addition, 67 percent of U.S. adults who report having diabetes also report having
high blood pressure. For people with diabetes, high blood pressure levels, high cholesterol levels,
and smoking increase the risk of heart disease and stroke. This risk can be reduced by controlling
blood pressure and cholesterol levels and stopping smoking. Diabetes can also lead to other
complications, such as vision loss, kidney failure, and amputations of legs or feet.
11
12
All diabetes information, unless otherwise cited, sourced from Centers for Disease Control and Prevention
Centers for Disease Control and Prevention – Diabetes Report Card 2012
Page | 20
Average medical expenses are more than twice as high for a person with diabetes as they are for
a person without diabetes. In 2013, the estimated cost of diabetes in the United States was $245
billion. That amount included $176 billion in direct medical care costs and $69 billion in indirect
costs (from disability, productivity loss, and premature death).
The fact that diabetes often presents as a co-morbidity with other diseases, it is difficult to
segregate diabetes-specific information. The following table shows the age-adjusted percentage
of adults diagnosed with diabetes by sex.
Table 13. Percentage of Adults Diagnosed with Diabetes by Sex
12.2%
11.8%
11.8%
11.8%
11.6%
10.8%
Tennessee
Robertson County
Men
U.S.
Women
As of 2009, diabetes was the seventh leading cause of death in Robertson County. In 2011,
approximately 12 percent of Robertson County residents were diagnosed with diabetes, which
compared unfavorably to the state and the country, as shown in Table 13. The percentage of
women diagnosed with diabetes in Robertson County is not only higher than the men, but is
substantially higher compared to the state and country levels. As can be seen in Table 14, over
the last decade, the percentage of adults diagnosed with diabetes in Robertson County has
trended upward from 8.7 percent in 2004 to 11.9 percent in 2008.
Table 14. Percentage of Adults Diagnosed with Diabetes in Robertson County
8.7%
2004
9.8%
2005
11.4%
2006
12.4%
2007
11.9%
2008
Page | 21
Figure 5 provides an overall view of how Robertson County compares to many of its peers and
other counties throughout Tennessee. As detailed below, Robertson County ranks among some
of the highest counties in the state possessing incidence rates of diagnosed diabetes among
adults, registering at nearly 12.0 percent.
Figure 5. Trends in Diagnosed Diabetes Among Adults, 2004-2009
Page | 22
Table 15 illustrates the percentage of diabetic Medicare patients who have had a hemoglobin
A1c (hA1c) test, a blood test which measures blood sugar levels, administered by a health care
professional in the past year. This is relevant because engaging in preventive behaviors allows
for early detection and treatment of health problems such as diabetes. This can also highlight a
lack of access to preventive care, a lack of health knowledge, insufficient provider outreach,
and/or social barriers preventing utilization of services. Table 15 provides a breakdown
comparison of Medicare enrollees in Robertson County that are receiving an annual exam
compared to the state and the nation.
Table 15. Percent of Medicare Enrollees w/ Diabetes w/ Annual Exam13
Total Medicare Enrollees
Medicare Enrollees w/ Diabetes
w/ Annual Exam
w/ Annual Exam (%)
RC
TN
US
5,053
569,498
51,875,184
690
78,383
6,218,804
567
67,443
5,212,097
82.3%
86.0%
83.8%
Mental Health
Four of the 10 leading causes of disability in the United States and other developed countries are
mental disorders according to World Health Organization. By 2020 major depressive illness will
be the leading cause of disability in the world for women and children. In the United States, the
annual economic, indirect cost of mental illness is estimated to be $79 billion. Most of that
amount — approximately $63 billion — reflects the loss of productivity as a result of illness.
A combination of pharmacological and psychosocial treatments and support has been known to
reduce symptoms and improve quality of life for between 70 and 90 percent of individuals
diagnosed with mental illness. With appropriate, effective medication and a wide range of
services tailored to their needs, most people who live with serious mental illnesses can
significantly reduce the impact of their illness and find a satisfying degree of achievement and
independence.
Accordingly to the Department of Veteran Affairs, the number of former service members
seeking mental health services has climbed by a third over the last five years. An estimated 22
veterans committed suicide in America each day in 2010. In 2010, of the 1.7 million veterans
who served in Iraq and Afghanistan (300,000), 20 percent suffered from post-traumatic stress
disorder or major depression. Currently, there are approximately 4,500 veterans living in
Robertson County.14
13
14
Dartmouth Atlas of Health Care – Centers for Medicare & Medicaid Services
RAND-Center for Military Health Policy Research, Invisible Wounds of War, 2008
Page | 23
Effective treatments for mental health conditions will help people achieve psychological, social
and emotional wellbeing, which can lead to better overall health. Early identification and access
to appropriate treatment and recovery options can accelerate the recovery process. Additional
resources and coordination of medical, social and financial services are required. Access to a
continuum of services and prevention are especially critical for children and adolescents.
The Behavioral Risk Factor Surveillance System (“BRFSS”), a national system of state-based
surveys, annually assessed how the residents fare with mental health issues. The results, shown
in Table 16, indicate 83.4 percent of Robertson County residents are receiving adequate social or
emotional support. This compares favorably to that of the state and the nation.
Table 16. Percent of Adults Reporting Adequate Social or Emotional Support
RC
TN
US
Surveyed Population (Age 18+)
173
33,041
2,744,636
Adults w/ Adequate Support
144
26,763
2,204,749
83.4%
81.0%
80.3%
Adults w/ Adequate Support (%)
Figure 6. Percentage of Adults with Adequate Social or Emotional Support, 2006-2010
Over 88.0%
84.1 – 88.0%
80.1 – 84.0%
76.1 – 80.0%
Under 76.1%
Page | 24
From 2006 to 2010, the Robertson County suicide rate was 18.7 per 100,000 people.15 That is 30
percent higher than the state, and nearly 62 percent higher than the nation. To put into
perspective, the Healthy People 2020 objective, an organization providing science-based national
objectives for improving the health of Americans, is less than 10.2 per 100,000 for suicide. In
general, more than 90 percent of those who die by suicide have a diagnosable mental disorder. In
2008 an estimated 8.3 million adults in the United States had serious thoughts of suicide in the
past year, with the rate being highest in young adults ages 18 to 25.
Robertson County compares unfavorably to the state and the nation in suicide, and substance
abuse rates as well. Excessive drinking is the third leading lifestyle-related cause of death in the
United States. Over 11 percent of Robertson County residents claimed they excessively drink
alcoholic beverages, compared to 10 percent for the state, and 7 percent for the nation.
While gaps in mental health care are evident, the scope and nature of the problem is not well
understood. Robertson County is involved in a countywide effort composed of government and
private agencies to identify gaps in the current service delivery model. The goal is to move
toward a seamless continuum of care for addressing mental health issues. The prevalence of
substance abuse in the county suggests a need for education and outreach. In particular,
educating children on the consequences of alcohol and drug use, and helping them to develop
coping skills to resist peer pressure may help reduce future substance abuse.
Preventive Care
When patients seek prompt attention from primary care providers for acute illnesses (e.g.,
pneumonia) or worsening of chronic conditions (e.g., diabetes), hospitalization often can be
avoided. Hospitalizations that could have prevented by enhanced access to primary care are
termed “potentially preventable hospitalizations.” Although not all such hospitalizations can be
avoided, rates of potentially preventable hospitalizations vary; communities with poorer access
to coordinated primary care tend to have higher rates of potentially preventable hospitalizations.
Because hospitalizations tend to be more costly than outpatient primary care, potentially
preventable hospitalizations also are used often as markers of the efficiency of the health-care
system. The number and cost of excess potentially preventable hospitalizations can be calculated
by comparing rates for a group with an ideal rate. These estimates can help communities identify
potential cost savings associated with improving primary care and reducing potentially
preventable hospitalizations.
15
Centers for Disease Control and Prevention, National Center for Health Statistics, Underlying Cause of Death, 2006-2010.
Page | 25
Figure 7. Trends in Preventable Hospital Stays, 2003-201016
Access to care requires not only financial coverage, but also, access to providers. While high
utilization rates for specialty physicians have been shown to be associated with higher, and
perhaps unnecessary utilization, sufficient availability of primary care physicians is essential for
preventive and primary care, and when needed, referrals to appropriate specialty care. As shown
in Table 17, Robertson County compares unfavorably to the state and the nation when
calculating the ratio of the county population to primary care physicians, as well as dentists.
Table 17. Ratio of Population to Primary Care Physicians & Dentists17
RC
TN
US
Primary Care Physicians
2,375 : 1
1,409 : 1
1,067 : 1
Dentists
3,733 : 1
2,186 : 1
1,516 : 1
* The number of mid-level providers was not calculated into the aforementioned access ratios
16
17
Dartmouth Atlas of Health Care – Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services – Health Resources and Services Administration
Page | 26
Cardiovascular Disease
Together, heart disease and stroke are among the most widespread and costly health problems
facing the United States today, they are also among the most preventable. Currently, heart
disease is the number one cause of death for both men and women in the United States, claiming
approximately 1 million lives annually, and in 2020 will be the leading cause of death throughout
the world.
In Tennessee, African American/Black residents die from a stroke at a rate that is nearly 51
percent (141.6 deaths per 100,000 population) higher than White residents (93.9 per 100,000
population) and more than triple the rate experienced by Hispanic/Latino residents (36.2 per
100,000 population).18 African Americans/Blacks are also disproportionately affected by heart
disease mortality. The mortality rate for African Americans/Blacks (524.1 per 100,000
population) is five times the rate of Hispanic/Latino residents (101.7 per 100,000 population) and
24 percent higher than the state total (422.4 per 100,000 population).
In Robertson County, heart disease is the second leading cause of death. Total heart disease
mortality in Robertson County from 2007 to 2009 was 20 percent higher as compared to the
state, and 40 percent higher than the U.S. Additionally, stroke mortality in Robertson County
was 38 percent higher than the state, and 74 percent higher than the U.S. The coronary heart
disease rate in Robertson County is similar to the percentages of stroke mortality at 36 percent
higher than the state, and 77 percent higher than the U.S. Disparities do exist in Robertson
County, although they are not as severe as TN and the U.S. The total heart disease mortality rate
for men in Robertson County was nearly twice as high as it was for women, specifically
coronary heart disease; although, women (315.9) were disproportionately affected by stroke
mortality than men (108.9). Please refer to Table 18 for more information.
Table 18. Age-Adjusted Death Rates Per 100,000 U.S. Standard Population, 2007 - 2009
All Heart Disease
Coronary Heart Disease
Stroke
RC
TN
U.S.
RC
TN
U.S.
RC
TN
U.S.
Sex
Female
Male
388.9
601.4
341.6
525.4
287.8
452.0
315.9
513.3
234.3
399.5
177.9
313.7
315.9
108.9
96.8
99.2
76.6
79.7
Race
White
Black
Hispanic
504.3
494.6
113.2
415.4
524.1
101.7
365.9
483.8
254.5
417.9
350.2
77.4
306.9
337.1
78.3
242.6
293.5
181.7
130.2
I/D
I/D
93.9
141.6
36.2
77.1
116.4
61.1
Total
504.0
422.4
359.1
418.5
305.9
236.2
136.7
98.9
78.6
I/D - Insufficient Data
18
All Cardiovascular Disease information, unless otherwise cited, sourced from Centers for Disease Control and Prevention –
Division for Heart Disease and Stoke Prevention
Page | 27
Obesity has been linked to both cardiovascular health and diabetes. Shown in Figure 8, 32
percent of Robertson County residents are obese (BMI >= 30) and over 34 percent of residents
aged 20 and over are physically inactive. According to the Journal of Leisure Research,
decreased physical activity has been related to several disease conditions such as type 2 diabetes,
cancer, stroke, hypertension, cardiovascular disease, and premature mortality, independent of
obesity. In addition, physical inactivity at the county level is related to health care expenditures
for circulatory system diseases.
Figure 8. Overview, Trend & Comparison of Obesity Among Adults, 2004 - 2009
Using hospital utilization data, it was determined that charges associated with cardiology and
cardiovascular surgery represented approximately 13 percent of the total charges for the hospital
in 2012. The average charge for cardiovascular surgery far exceeds any other average charge at
NorthCrest. Although heart disease mortality rates in Robertson County are higher than that of
the state and the nation, the hospital’s 30-day risk adjusted readmission rates are comparable to
the national average, as shown in Table 19.
Page | 28
Table 19. 30-Day Adjusted Readmission Rates19
NorthCrest Medical Center
Measure
# of Patients
Readmission Rate
National Average
Heart Attack
56
19.6%
19.7%
Heart Failure
155
24.6%
24.7%
Pneumonia
316
18.5%
18.5%
All Cancers
Incidence and death rates for all cancers have been declining due to advances in research,
detection and treatment, yet, cancer remains a leading cause of death in the United States. It is
also the leading cause of death for Robertson County residents.20 Robertson County has a higher
mortality rate in three of the four leading malignancies in the United States—lung, female breast,
prostate, and colorectal, as shown in Table 20.
Table 20. Top-4 Cancers Mortality Rate Report, 2005 - 200921
80.0
73.3
70.0
65.7
60.0
50.6
50.0
Robertson Co
40.0
30.0
Tennessee
26.3
23.0
21.6 24.0
25.3 23.6
20.0
21.0 18.2
U.S.
16.7
10.0
0.0
Breast
Lung
Prostate
Colorectal
19
American Hospital Directory
Tennessee Department of Health, Office of Policy, Planning, and Assessment, Division of Health Statistics
21
All Cancer-related information, unless otherwise cited, sourced from National Cancer Institute – State Cancer Profiles
20
Page | 29
While Robertson County breast cancer rates compare favorably to the state and nation, statistics
indicate that Robertson County residents have room for improvement to reduce these rates.
Evidence suggests that mammography screening reduces breast cancer mortality, especially
among older women. A physician’s recommendation or referral—and satisfaction with
physicians—are major factors facilitating breast cancer screening. The percent of women ages
40-69 receiving a mammogram is a widely endorsed quality of care measure. In Robertson
County, 62 percent of female Medicare enrollees aged 67-69 had at least one mammogram over
a two-year period, below the state average of 63 percent and the national average of 73 percent.
Of the top four cancers, the largest unfavorable comparison gap for Robertson County resides
with lung cancer. Cigarette smoking is the number one risk factor for lung cancer. In the United
States, cigarette smoking causes about 90 percent of lung cancers. Tobacco smoke is a toxic mix
of more than 7,000 chemicals. At least 70 of the aforementioned chemicals are known to cause
cancer in people or animals. People who smoke are 15 to 30 times more likely to get lung cancer
or die from lung cancer than people who do not smoke. Even smoking a few cigarettes a day or
smoking occasionally increases the risk of lung cancer. The more years a person smokes and the
more cigarettes smoked each day, the higher the risk goes up. Approximately 23 percent of
Robertson County residents are currently smokers, which is equivalent to the state, but 10
percent higher than the national benchmark.22
The second largest unfavorable comparison gap for Robertson County is colorectal cancer.
Although county level statistics for colorectal cancer could not be ascertained, Tennessee as a
whole, ranks 45th in the nation when compared to colon cancer screenings with 60.5 percent of
Tennesseans reporting they have had a sigmoidoscopy or colonoscopy in 2010, compared to the
national average of 65.6 percent.
22
The Behavioral Risk Factor Surveillance System - Centers for Disease Control and Prevention
Page | 30
VI. DATA GAPS IDENTIFIED
Where available, the most current and up‐to‐date data was used to determine the health needs of
the community. Although the data set available is rich with information, not surprisingly, data
gaps exist.

Data such as health insurance coverage data and cancer screening, incidence and
mortality rates are not available by geographic areas within Robertson County.

Data is not available on all topics to evaluate health needs within each race/ethnicity by
age‐gender specific subgroups.

Diabetes prevalence is not available for children, a group that has had an increasing risk
for type 2 diabetes in recent years due to increasing overweight/obesity rates.

Health risk behaviors that increase the risk for developing chronic diseases, like diabetes,
are difficult to measure accurately in subpopulations, especially the Hispanic/Latino
populations, due to BRFSS methodology issues.

County‐wide data that characterize health risk and lifestyle behaviors like nutrition,
exercise, and sedentary behaviors are not available for children.

Data surrounding the hospitalization rate for ambulatory-care sensitive conditions limits
the population to mostly individuals age 65 and older, and does not account for trends
and disparities among younger age groups.

The ratio of population to primary care physicians does not include mid-level providers,
(i.e. NP & PA) who are a key part across the spectrum of health care to meet the demands
of a growing and aging population.
Page | 31
VII. CONCLUSIONS
This Community Health Needs Assessment was assembled to give readers an overview of the
community’s public health trends and to provide a platform to increase the communication
across non-governmental as well as governmental agencies to improve the lives of residents. The
findings from this process demonstrate that residents include high concentrations of people at an
increased risk for unhealthy living. After examining all the data sources used to create this report
– the survey results, the input from the CHNA Committee, and various secondary data that were
analyzed – it is clear the need for establishing and expanding effective partnerships among city
agencies is critical.
Collaboration holds the promise of allowing progress on issues where multiple parties are
involved. Sustaining collaborations in Robertson County are possible not only because of
established partnerships but also because of efforts such as this needs assessment, which will
further strengthen existing relationships by highlighting where the major needs are.
In order to have improved collaborations throughout the service area, there needs to be better
data exchange among health organizations. Both health and societal data are not consistently
collected, are difficult to compare longitudinally, and frequently may not tell the whole story. To
improve the health of Robertson County residents, NorthCrest and its partners must have access
to accurate local data. There are opportunities to make significant improvements in gathering and
tracking such data on all of these issues, particularly on the issues of chronic diseases and risk
factors that contribute to health disparities. It is imperative that those working in public health
and providers of direct clinical services collaborate to develop a strategic plan for delivery of
health care (including preventive care and mental health services) in a manner best suited to the
community being served.
This report has presented a case that trends in health outcomes are determined not just by
individual-level factors such as genetic make-up or access to medical services, but also by socioeconomic factors. Robertson County stakeholders can no longer afford to ignore evidence
linking social determinants of health with health outcomes. By building on the analysis in this
report and partnerships throughout the city, Robertson County will take significant steps to build
the capacity to understand and address the conditions contributing to the compromised health of
its most vulnerable neighborhoods.
Page | 32
VIII. WORKS CITED
American Hospital Directory. Quality Report. Retrieved from: www.ahd.com
Centers for Disease Control and Prevention. BRFSS Questionnaire. Retrieved from:
http://www.cdc.gov/brfss/questionnaires/english.htm.
Centers for Disease Control and Prevention. Obesity and Overweight for Professionals: Economic
Consequences. Retrieved from: http:/www.cdc.gov/obesity/causes/economics.html.
Centers for Disease Control and Prevention. Division for Heart Disease and Stroke Prevention:
Interactive Atlas. http://apps.nccd.cdc.gov/DHDSPAtlas/
Centers for Disease Control and Prevention. Community Health and Health Equity Program. Retrieved
April19, 2013, from: http://www.cdc.gov/nccdphp/dach/chhep/pdf/SDOHworkbook.pdf.
Centers for Disease Control and Prevention. Chronic Disease Prevention and Health Promotion.
Retrieved April19, 2013, from: http://www.cdc.gov/chronicdisease/overview/index.htm.
Centers for Disease Control and Prevention. Diabetes Public Health Resource: Interactive Atlas
Retrieved April19, 2013, from: http://www.cdc.gov/diabetes/atlas/countydata/atlas.html
Centers for Disease Control and Prevention. Smoking Attributable Mortality, Years of Potential Life
Lost, and Productivity Losses — United States, 2000-2004.Morbidity and Mortality Weekly Report, 57.
County Health Rankings 2011. Retrieved from: http://www.countyhealthrankings.org
Dignity Health. Community Need Index. Retrieved from: http://cni.chw-interactive.org/
National Diabetes Information Clearinghouse. National Diabetes Statistics. Retrieved from:
http://diabetes.niddk.nih.gov/DM/PUBS/statistics/#deaths.
National Cancer Institute. State Cancer Profiles. Retrieved from: http://statecancerprofiles.cancer.gov/
Tennessee Department of Health. Office of Policy, Planning and Assessment, Division of Health
Statistics. Retrieved from: http://health.state.tn.us/statistics/data.htm
U.S.Census Bureau. State and County Quick Facts. Retrieved from:
http://quickfacts.census.gov/qfd/states/47000.html
U.S.Census Bureau. American Community Survey.
U.S. Department of Health and Human Services. National Women’s Health Indicators Database
(NWHID) Retrieved from: http://www.healthstatus2020.com/owhexplore/select_fips.aspx
Page | 33
U.S. Department of Health & Human Services. Health Resources and Services Administration Retrieved
from: http://arf.hrsa.gov/index.htm
U.S. Department of Health & Human Services. General Health Status. Retrieved from:
http://www.healthypeople.gov/2020/default.aspx
U.S. Department of Health & Human Services. Healthy People 2020. Washington D.C: U.S. Government
Printing Office.
U.S. Department of Health & Human Services. Community Health Status Indicators.
Retrieved March 8, 2013 from:
http://wwwn.cdc.gov/CommunityHealth/Demographics.aspx?GeogCD=47147&PeerStrat=45&state=Ten
nessee&county=Robertson
Page | 34

Community Health Needs Assessment

Transcription

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