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A. Improving Community Health - A Comprehensive Effort
Community Health Needs Assessment 2013. As part of the federal requirements included in the Affordable Care Act (ACA), nonprofit hospital systems under 501(c)(3) status are required to conduct a broad based community health needs assessment (CHNA) at least once every three years, beginning with tax year 2013. While generally consistent with California (SB697) requirements, the ACA also requires that that the CHNA development process incorporate expertise and feedback from specific individuals and groups (community leaders, residents and public health experts), that the CHNA be made available to the public online, and that the CHNA be filed with the IRS.T
The 2013 CHNA process has been conducted against a backdrop of significant local and national change. New models for healthcare delivery are developing across the country, informing and stimulating efforts to make local health care delivery systems more effective and efficient. The Affordable Care Act, with its promise of expanded access and its emphasis on the prevention of chronic disease and the elimination of health disparities, represents a new and powerful platform from which to address the basic issues of access, affordability and quality. An emerging understanding of the impact of social determinants on health status is changing long-held beliefs about prevention and health promotion. These and a variety of other local initiatives and developments, highlighted below, are nurturing an environment of collaboration, innovation and change, which has the potential to improve health and wellbeing for all Sonoma County residents.
Aligning with Triple Aim. Triple Aim is a framework developed by the Institute for Healthcare Improvement (IHI) that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions that:
- Enhance the patient experience of care (quality, access, and reliability)
- Improve the health of populations
- Reduce or control the cost of health care
The IHI Triple Aim entails ambitious improvement at all levels of the system. To be effective, it is important to harness a range of community determinants of health, empower individuals and families, substantially broaden the role and impact of primary care and other community based services, and assure a seamless system of care. The Affordable Care Act (ACA) reflects Triple Aim thinking, including: accountable care organizations (ACOs), bundled payments, and other innovative financing approaches; new models of primary care, such as patient-centered medical homes; sanctions for avoidable events, such as hospital readmissions or infections; and the integration of information technology.
The Affordable Care Act (ACA). Together, the Patient Protection and Affordable Care Act and the Reconciliation Bill make unprecedented investments in health delivery systems that will fundamentally change the country’s health insurance and health care delivery systems. The dramatic expansion of insurance coverage will mean more people can access primary and preventive care. The law’s direct investment in health centers and in the primary care workforce will provide a necessary backbone of support for service delivery. The Affordable Care Act expands access to health care for many people who had not been able to obtain coverage before, including people with pre-existing conditions, people in their 20s whose coverage under their parents’ insurance used to be terminated, and people with incomes above previous Medi-Cal limits.
Patient Centered Medical Home (PCMH). While the medical home concept has its origins in pediatric care, the concept has expanded as the general healthcare system shifts from a focus on episodic acute care to a focus on managing the health of defined populations, especially those living with chronic health conditions. Sonoma County’s community health centers, working with Redwood Community Health Coalition (RCHC), are developing the patient centered medical home. The PCMH approaches the organization and delivery of health care around the patient’s needs. New healthcare models like the PCMH provide greater access to health care providers, the coordination of care and individual empowerment over health decisions.
Focus on Collective Impact. Sonoma County health and social services organizations have a history working collaboratively across sectors on issues of mutual concern. “Collective impact” is an approach to solving societal problems based on the idea that coordination of efforts among organizations working toward similar goals can result in greater impact in the community. A collective impact approach requires the commitment of all sectors – including nonprofits, government, business, and philanthropy – to coordinate their efforts around a clearly defined goal. All collective impact initiatives share five key components: a common agenda, shared measurement, mutually reinforcing activities, continuous communication, and infrastructure support.
Fostering Understanding about Social Determinants. Complex relationships exist between the health status of populations and socioeconomic factors such as income, education level, stress and generational racism. The research is clear that shortfalls in medical care are responsible for a fraction of illness and death. Also important are the conditions in which people live, work and age. A third group of factors, social and economic conditions, are also now recognized as key determinants of health status. Social and economic Inequities can contribute to inequalities in health status. While it is difficult at the local level to change underlying conditions such as generational racism, stress and income inequity, it is possible to address the neighborhood conditions (both natural and built) that can perpetuate these health inequities. Place-based projects in Sonoma County like Health Eating Active Living (HEAL) and Health Action, that focus on changing policies and practices in schools, places of employment and other community settings are seen as promising strategies to reduce disparities and promote community health.
Reducing Health Disparities. Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups. In Sonoma County, communities of color and low-income families and individuals suffer disproportionately from lack of access to health care and the impact of social determinants and the built environment on their health and well-being. Recognition of the role of health disparities is driving new prevention strategies focused on improving health by enhancing access to economic, educational, employment, and housing opportunities.
The Community Health Needs Assessment is a critical planning document for the hospitals, and a call to action for the community on health needs. Every individual and organization can find a place on The Spectrum of Prevention (Appendix I.) and join the work to improve overall health and well being in Sonoma County.
B. Community Health Needs Assessment Report Overview
The 2013 Community Health Needs Assessment provides a guide for the hospitals’ community benefit planning, as well as important information to inform other local planning efforts to strengthen the health of the community.
The 2013 Sonoma County Community Health Needs Assessment includes the following sections:
CHNA Data Development Process (Section IV.)
This section describes the various methods used by the CHNA partners to collect and analyze both primary and secondary data from local, state and national sources. This section highlights findings from the key informant and focus group processes and telephone surveys and describes secondary data sources utilized in the development of the CHNA.
Population Overview (Section V. A.)
This section provides a demographic summary of Sonoma County’s current population and includes population growth projections when available. Information is provided on a variety of demographic indicators including age, ethnicity, income, healthcare coverage, education and employment.
Leading Health Indicators (Section V. B.)
This section contains summary data from a variety of secondary sources identifying health conditions that compromise the health and healthy development of children and contribute most prominently to illness and injury, disability and death for Sonoma County adults and children. This information is presented using the following age categories:
- Prenatal to first birthday
- Ages 1 to 12
- Age 13 – 17
- Adults 18 to 60
- Seniors 60 and over
Where known, information on contributing factors (e.g. lack of access to care) and risk behaviors (e.g. smoking rates) is presented along with each health indicator. Where significant, health disparities among specific sub-populations are also highlighted.
Prioritized Community Health Needs (Section VI)
This section highlights a set of health issues that have been identified by a panel of community health and social service experts convened through the CHNA process to develop consensus recommendations on health issues of greatest urgency for Sonoma County. Recommendations were developed using information from the data profile, findings from the key informant, focus group and telephone surveys and other local data sources. A description of the process and criteria for priority setting is included along with a brief rationale for selection of each priority health issue. An asset inventory of local resources that could be leveraged to address each priority is also included.
Conclusion and Next Steps (Section VII)
This section includes information on how the CHNA will be used to develop implementation plans for each of the participating hospitals and on how the CHNA itself will be made available as a resource to the broader community.
The health priorities identified are:
- Healthy eating and physical fitness. Poor nutrition and lack of physical activity are driving a national and local obesity epidemic and are contributing to increasing rates chronic disease, disability and premature mortality in Sonoma County. Low-income children and families are especially at risk when they reside in neighborhoods that offer few options to obtain healthy, nutritious food or engage safely in physical activity. Expansion of current efforts in schools and communities to improve nutrition and fitness among youth and adults can help to reduce the growing burden of disease.
- Gaps in access to primary care. Strong primary care systems are associated with improved health outcomes and reduced health care costs. While most Sonoma County residents have a regular source of care and can access health care when they need it, too many do not. Those who are uninsured, low-income, or are members of racial and ethnic minorities are less likely to have an ongoing source of care and more likely to defer needed care, medicines and diagnostics, often at the cost of unnecessary suffering and poor health outcomes. Increasing access to affordable, prevention-focused primary care can help to eliminate health disparities and promote health and well-being.
- Access to services for substance use disorders. Treatment works. Early screening, intervention and appropriate treatment for harmful substance use and addiction behaviors is critical to intervening with teens, pregnant women and others who can benefit from treatment. Unfortunately, despite increasing levels of addiction, access to substance abuse treatment in Sonoma County is severely limited for low-income individuals without healthcare coverage. Insuring timely access to culturally competent substance abuse treatment, tailored to the specific needs of those seeking help can break the cycle of addiction and benefit individuals, families and the community.
- Barriers to healthy aging. People over 60 now make up a larger proportion of the population of Sonoma County than ever before. As growth in this population continues, it will challenge families and communities to provide the support seniors need to stay healthy, safe, engaged and independent. Current senior service “systems” are fragmented, under-funded and often difficult for seniors and their families to understand and utilize. Low-income seniors are especially at risk for neglect, abuse and isolation. Lack of adequate, local supportive services often result in early institutionalization, poor health outcomes and reduced quality of life for many vulnerable seniors. Further development of community-based systems of services and supports for seniors can improve health outcomes and quality of life and significantly reduce costs for long-term institutional care.
- Access to mental health services. Many mental health problems can be effectively treated and managed with access to assessment, early detection, and links with ongoing treatment and supports. In Sonoma County, however, many low income individuals with mental health concerns do not have access to the treatment they need. Insufficient private insurance coverage for mental health services and insufficient availability of publicly-funded treatment services are significant barriers for many. Limited integration of mental health services within the health care system also leads to missed opportunities for early problem identification and prevention.
- Disparities in educational attainment. Educational attainment is the single greatest predictor of both income and employment status in later life and both factors are powerful determinants of health and wellbeing. In Sonoma County, Hispanics currently lag behind their White counterparts in educational attainment at all levels. Just over 6% of Whites do not have a high school diploma as compared with 45.9% of the Hispanic population. Among current students, 93.6% of White 9th - graders graduate from high school 4 years later as compared with only 64.4% of Latino students.
- Cardiovascular disease. Cardiovascular disease is the third leading cause of death for people ages 18-59 in Sonoma County. For residents, age 60 and older, coronary heart disease and stroke are the second and third most common cause of death, behind cancer. Major behavioral contributors to cardiovascular disease include tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol. Education and prevention efforts targeting these “lifestyle” choices and behaviors should be expanded along with continued emphasis on early detection and management of chronic disease.
- Adverse childhood exposure to stress (ACES). “Adverse childhood experiences (ACES),” which include a variety of ongoing conditions or events that can be categorized as recurrent childhood trauma, have been documented to lead to health and social problems, risk-taking behaviors and a shortened lifespan for the adults who survive them. ACES have been linked to a range of adverse health outcomes in adulthood, including substance abuse, depression, cardiovascular disease, diabetes, cancer, and premature mortality. The prevalence of ACES underscores the need for additional efforts to reduce and prevent child maltreatment and associated family dysfunction and the need for further development and dissemination of trauma-focused services to treat stress-related health outcomes associated with ACES.
- Access to health care coverage. Insuring access to affordable, quality health care services is important to protecting both individual and population health, eliminating health disparities and promoting overall quality of life in the community. For uninsured people, the cost of both routine and emergency care can be financially devastating. Individuals without health care insurance coverage may defer needed care, diagnostics and medicines for themselves and their families and may, as a result, experience higher rates of preventable illness, suffering, disability and mortality than those who have insurance. While a significant portion of Sonoma County’s uninsured population will be eligible for more affordable health care coverage under The Affordable Care Act, financial barriers may still exist for low-wage earners who are unable to meet premium requirements. And, undocumented individuals will continue to be ineligible for publicly- funded coverage, leaving many individuals and families vulnerable.
- Tobacco use. Approximately one-third of all tobacco-using Americans will die prematurely from lung cancer, emphysema, cardiovascular disease and other causes related to their dependence on tobacco. Chewing tobacco is a principal contributor to oral cancers. Most smokers become addicted before the age of 19. Those who start smoking young are more likely to have difficulty quitting and more likely to develop smoking-related illness and disability. Sonoma County’s adult smoking rate does not meet the Healthy People 2020 target and is higher than the California average. Smoking rates for teens also exceeds both national and state-level benchmarks. Education programs to prevent smoking initiation among youth should be strengthened along with efforts to expand access to cessation programs for both youth and adults.
- Coordination and integration of local health care system. Integration of health care services may take a variety of forms, but essentially consists of the coordination of care to reduce fragmentation and unnecessary use of services, prevent avoidable conditions, and promote independence and self-care. The ability of care providers to effectively develop and use Electronic Medical Records will be critical to the coordination and integration of care. The Affordable Care Act expands health care coverage options for more Sonoma County residents. To maximize resources and provide high quality health care for newly insured patients and those already established in care, local health care services must be better coordinated and integrated with an emphasis on those most vulnerable – the aged, those living in poverty or geographic isolation and those with multiple disabilities.
- Disparities in oral health. Poor oral health status can threaten the health and healthy development of young children and compromise the health and well-being of adults. Low-income children suffer disproportionately from dental caries in Sonoma County.
Low-income residents have few options for affordable oral health care and even those with insurance find access to preventive services severely limited. Fluoridated drinking water has proven to be an effective public health measure for prevention of tooth decay, yet only 3% of the public water supply in Sonoma County is fluoridated. Among the cities, only Healdsburg fluoridates its water. Stronger prevention initiatives and expanded access to prevention-focused oral health care are critical to protecting the health and wellbeing of low-income children and adults.
- Lung, breast, and colorectal cancer. With the exception of stomach cancer, Sonoma County’s all-cancer incidence is higher than the California rate. Research shows that routine screening for certain cancers, including breast, cervical and colorectal cancers, can increase detection at an early and often treatable stage, thereby reducing morbidity and mortality. Lung, breast, and colorectal cancer were identified as priorities because they are significant contributors to morbidity and mortality in Sonoma County and present significant opportunities for early detection through expanded education and screening.
Health Priority Profiles and Community Assets
A profile was prepared for each of the thirteen health priorities including the rationale for selecting each issue as a priority. A list of community assets per priority are identified as consideration for collaboration opportunities and to leverage efforts to address each selected issue.
The purpose of the Community Health Needs Assessment (CHNA) 2013-2016 is to document key information on the health and well being of Sonoma County residents. The CHNA will be used by the hospital partners to develop Community Benefit implementation strategies as required by the Affordable Care Act. The CHNA will also be made available as a resource to the broader community. It is hoped that, in this way, the CHNA be a useful resource for further communitywide health improvement efforts.