Department of Health Services

County Of Sonoma › Health and Human Services › Health Services › About Us › Prioritized Community Health Needs

Prioritized Community Health Needs

DHS banner wide

A. Methodology for Criteria for Prioritization

In September 2012, the Community Health Improvement Committee (CHIC) sponsored a priority-setting session of 20 Sonoma County health and community leaders. The purpose was to facilitate a meeting of local Sonoma County experts to review preliminary data and work together to select priority health issues for inclusion in CHNA document. Recommendations were developed using information from the CHNA data profile, findings from the key informant interviews, focus groups, telephone surveys and other local data sources. The list of participants in the priority-setting session can be found in Appendix IV.

The following criteria were used for selection of the top health priorities.

Significant impact: this health issue is important in both scope (affects a large number of people within the population) and scale (has serious consequences for those affected).
Benchmark issue: Sonoma County lags behind other California counties on this health issue and/or is not on track to achieve Healthy People 2020 goals.
Disparities in health status: this health issue disproportionately impacts the health status of one or more subpopulations.
Links to chronic disease: this indicator is linked to chronic disease and related health outcomes.
Potential for change: Local efforts by hospitals and other partners are likely to result in meaningful improvement in the scope and/or severity of this health issue.
Prevention opportunity: this indicator represents a significant opportunity to improve health outcomes using prevention-focused approaches.

B. Prioritized Health Needs and Health Need Profiles

Participants in the priority-setting session analyzed the data collected from various sources, contributed their expertise, and utilized the agreed-upon criteria to identify top health priorities for inclusion in the CHNA. The first four health concerns were identified as most critical with an additional nine issues highlighted as very important.

The health priorities identified were:

Healthy eating and physical fitness
Gaps in access to primary care
Access to substance use disorder services
Barriers to healthy aging
Access to mental health services
Disparities in educational attainment
Cardiovascular disease (Stroke, Diabetes)
Adverse childhood experiences (ACES)
Access to health care coverage
Tobacco use
Coordination and integration of the local health care system
Disparities in oral health
Lung, breast, and colorectal cancer

Health Priority Summaries and Community Assets

Health priority summaries were prepared for each of the 13 selected priorities. The summaries provide the rationale for the selection, highlight data that informed the choice as a priority and include a preliminary inventory of community assets that offer opportunities for collaboration and leveraging.

1. Healthy Eating and Physical Fitness

Healthy eating and physical activity are essential to healthy child development and to maintaining good physical and mental health at all ages. A healthy diet and physical activity levels can help to prevent the onset or worsening of chronic diseases such as Type 2 diabetes, heart disease and cancer. Poor nutrition contributes to childhood anemia and poor pregnancy outcomes. Breastfeeding helps babies develop immunities to diseases and improves child health in other important ways. Unhealthy food choices, especially in low-income communities, are often the result of environmental conditions. Lack of community infrastructure(transportation, neighborhood based full-service grocery stores) may limit access to affordable healthy food choices. Similarly, concerns about neighborhood safety can inhibit use of parks and playgrounds, resulting in reduced physical activity by residents.

Why this issue/condition is important in Sonoma County?

Poor nutrition and lack of physical activity are driving an epidemic of obesity in both children and adults.

Morbidity and Mortality Benchmark

Healthy eating and physical fitness were highlighted in the Data Profile as leading causes of morbidity and mortality

One quarter of Santa Rosa elementary school students are obese. Among older children, 25% of Sonoma County students ages 12-19 are obese. Both groups exceed the California rate and do not meet Healthy People 2020 targets.
In every age category, Sonoma County residents do not meet Healthy People 2020 goals for weight.

Health Disparity

The obesity epidemic disproportionately affects low-income populations, with higher rates of obesity among low-income Latino children at all age levels.
In school fitness testing, only 15.4% of Hispanic fifth-graders met 6 out of 6 criteria, as compared with 34.2% of White, non-Hispanic children. Students identified as “socioeconomically disadvantaged” (based on school criteria for family income and parental education level) were less likely to meet fitness criteria than more advantaged students – 22% versus 36% for 7th graders and 25.4% versus 40.2% for 9th graders.
In school fitness testing, only 15.4% of Hispanic fifth-graders met 6 out of 6 criteria, as compared with 34.2% of White, non-Hispanic children.
Childhood anemia, an indicator of poor nutritional status, also exceeds the state rate among low-income children.

How this issue is identified as a priority:

CHNA Priority Setting Process
Healthy eating and physical fitness were identified as the highest priority during the CHNA Priority Setting Process.

Selection Criteria
Healthy eating and physical fitness meet priority selection criteria for scope and scale, benchmark issue (obesity, anemia, fitness levels), disparities in health status, links to chronic disease, potential for health improvement based on local intervention, and opportunities for prevention approaches.

Key Informants
Among key informants, 8 of 18 identified chronic disease as a critical community health concern and 6 of those informants identified obesity as a key factor.

Focus Groups
Within the focus groups, 17 of 19 respondents identified obesity as a major health issue affecting their community while 10 identified the lack of access to healthy food. In describing the attributes of a “healthy community,” 10 participants identified healthy eating as a critical asset

Community resources and assets:

The community asset mapping process generated the following list of resources, services and programs in Sonoma County. The list is not comprehensive. In some instances specific programs are “spotlighted’ as representative of similar programs or services available in the county.

Policy and Initiatives

Collaborations and Networks

Physical Activity

Nutrition

2. Access to Primary Care

Strong systems of primary care services are associated with improved health outcomes and reduced health care costs. Access to quality primary care is important to eliminate health disparities and promote the health, quality of life and longevity of all Sonoma County residents. While many Sonoma County residents enjoy good access to primary care and have a trusted

source of care, too many do not. Those who are uninsured, low-income, less well-educated or are members of racial and ethnic minorities are less likely to receive needed ongoing, primary care, because they lack access due to economic, geographic, cultural or language barriers.

These disparities are growing.

Although having insurance increases access to the health care system, it is not sufficient alone to ensure access to high quality primary care or appropriate use of services. The delivery system itself must offer the range and mix of services necessary to support patients in their efforts to protect and promote health. Primary care is the cornerstone of this system – bringing health promotion and prevention, cure and care together in a patient-centered, culturally competent medical home. In the medical home model, the primary care team coordinates the patient’s ongoing care, links the patient to other parts of the health care delivery system, manages health care resources to achieve jointly defined health goals and offers patients a continuum of prevention and treatment options based on their unique needs. Effective use of this model can empower patients to manage their own health, promote the cost-effective use of health care resources, and improve health outcomes for individuals and communities.

Why this issue/condition is important in Sonoma County:

Lack of insurance is the primary barrier to health care access in Sonoma County. With implementation of the Affordable Care Act in January 2014, 14% of Sonoma County’s

population, currently uninsured, will have new options for coverage and access to health care. However, some low-income populations, because of their immigration status are ineligible for coverage under the new plans and others may find the required premiums beyond their reach. For these groups, access barriers will continue.

Even with insurance, for some populations – those with Medicare, individuals with geographic or language barriers – access is not guaranteed. Continued growth in the county population coupled with a dwindling physician supply, as older physicians retire and are not replaced, has created significant pressure on the county’s current primary care and specialist cadres. A recent primary care capacity study, conducted by the Department of Health Services, highlighted concerns about projected increasing shortfalls in the physician workforce for both primary care and specialist disciplines.

How this issue is identified as a priority:

CHNA Priority Setting Process
Gaps in access to primary care services were identified as a priority during the CHNA Priority Setting Process.

Selection Criteria
Access to primary care meets the priority selection criteria for scope and scale, links to chronic disease, disparities in health status, potential for health improvement based on local intervention, and opportunities for prevention approaches.

Key Informants
Among key informants, 7 of 18 identified capacity issues related to access to primary care services. Many key informants noted that the local health care system is experiencing rapid change. Most saw this as positive and expressed support for increased integration across the health care delivery system, renewed emphasis on primary care and continued development of patient centered medical homes.

Focus Groups
Participants in the focus groups identified a number of barriers to health care access in their communities, including social determinants of health such as low wages, lack of transportation, lack of insurance and minimal preventive care for the uninsured.

Community resources and assets:

The community asset mapping process generated the following list of resources, services and programs in Sonoma County. The list is not comprehensive.

Health Care Reform

Patient Care – Treatment and Prevention Services

Provider Training - Workforce Development

3. Access to Substance Use Disorder Services

Substance (alcohol and other drug) abuse and abuse-related problems are among society's most pervasive health and social concerns. The abuse of prescription drugs, especially painkillers, is becoming more prevalent among both youth and adults. Substance use and abuse are significant contributors to poor health outcomes and are a major cause of unintentional injury and premature mortality. Addicted persons may engage in self-destructive or criminal

behavior, which can result in injury or death. Recreational substance use (use while driving, during sex, etc.) is a risk factor for injury, sexually transmitted disease, violence and unintentional overdose.

Alcohol and drug use can have serious health and safety consequences for youth and is associated with a variety of social and developmental problems during adolescence and in later life. Substance use during pregnancy can contribute to fetal loss, birth complications and long- term health and learning problems for children. Even moderate use of alcohol and other drugs (AOD) during pregnancy is proven to impair brain development and affect children’s health.

Continued use of alcohol and other drugs after birth can impair parents’ responsiveness to their newborn’s needs.

Treatment works. Timely access to culturally competent substance abuse treatment, tailored to the specific needs of those seeking treatment can break the cycle of addiction and benefit individuals, families and the community. Early screening for harmful substance use and addiction behaviors is critical to intervening with teens, pregnant women and others who can benefit from treatment. A broad continuum of treatment options, including detoxification, in- patient (residential) and outpatient treatment, post-treatment housing, community-based support and follow-up services are essential to meet the often life-long needs of addicts seeking to remain clean and sober.

Why this issue/condition is important in Sonoma County:

Prevalence

Nearly 20% of adults ages 18-59 reported needing help for emotional/mental health problems or alcohol/drug issues, while 43% reported binge drinking in the previous year.

Benchmark

Sonoma County residents, including teens and pregnant women, exhibit higher rates of alcohol and other drug (AOD) use than do Californians as a whole.
A significantly higher percentage of Sonoma County mothers report using alcohol during the first or third trimesters of pregnancy than do Californian mothers as a whole (18.3% vs. 12.1%).
Among Sonoma County 11th graders, 44% acknowledged having a drink in the past 30 days as compared to 36% of California students. Similarly, 26% of Sonoma County 11th graders compared to 22% of California 11th graders reported binge drinking in the past 30 days, both significantly higher than the Healthy People 2020 target of 8.5%.
More Sonoma County 11th graders also reported ever taking prescription painkillers than their counterparts in the state (24% vs. 17%).

Health Disparities

Treatment resources for low-income teens and adults are severely limited in Sonoma County, especially for non-criminal justice residential services. Medi-Cal does not cover residential services. For this reason, low-income adults uninvolved with law enforcement have very limited access to AOD residential services. Sonoma County contracts with non-profit community-based substance abuse treatment providers for approximately 135 “beds” i.e., treatment slots for low-income resident. However, only 37 of these are designated as “community beds” – treatment slots available to low-income individuals who have not been referred through the criminal justice system. The remaining beds are designated for law enforcement-referred clients. Of the community beds, approximately half are restricted to 30-day treatment episodes, making long-term treatment extremely difficult to access for low-income clients needing a longer treatment course. Low-income pregnant and post partum women have greater access to treatment services, however, waiting lists are common.

The following table offers an overview of treatment capacity and admission average waiting times for low-income clients in County-funded treatment facilities.

Provider	WRS	DAAC Residential	DAAC Outpatient	DAAC Perinatal Outpatient	CHD Residential	CHD Outpatient
Avg. Wait - Days	14	25	0	45	15	0
Contracted Beds - Non Criminal Justice	13	19	N/A	N/A	5	N/A
Contracted Beds – Criminal Justice	1	70	N/A	N/A	26	N/A
Beds - Non Contracted w/ Sonoma County Behavioral Health	6	9	N/A	N/A	10	N/A

Source: Sonoma County Behavioral Health Division Mental Health & Substance Use Disorder Services, Jan 2013)

How this issue is identified as a priority:

CHNA Priority Setting Process
Limited access to substance use disorder services particularly for low-income residents was identified as a priority during the CHNA Priority Setting Process.

Selection Criteria
Access to treatment services meets priority selection criteria for scope and scale, benchmark issue, links to chronic disease, contribution to health disparities, potential for health improvement based on local intervention, and opportunities for prevention approaches.

Key Informants
Key informants identified drug and alcohol abuse treatment services as a critical service gap in Sonoma County.

Focus Groups
A majority of focus group respondents (17 of 21 respondents) identified drugs as a major challenge to the health of their community and 16 of 20 respondents recommended that the community focus efforts on drug and gang prevention.

Eight of 19 respondents identified markets selling alcohol as the most important issue affecting the health of people in the community.

Community resources and assets:

Sonoma County Department of Health Services

Prevention Programs

Alcohol and Drug Treatment and Treatment Access

Community-based Prevention Collaborations and Coalitions

4. Barriers to Healthy Aging

People over 60 make up a larger proportion of the population of the county, state, and country than ever before. In Sonoma County, 13.9% of the population is 65 years or older. Sonoma County’s senior population is projected to grow to 143,636 by 2030 when it will represent nearly a quarter (24%) of the county’s total population. This growth will have major implications for both individual and community life. It will challenge families and community organizations to provide the supports 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.

Why this issue/condition is important in Sonoma County:

Population Growth

Sonoma County’s senior population is projected to grow from 102,639 in 2012 to 128,589 in 2020, with the fastest growth in the 70–74 age group—the baby boom “age wave.” This age wave, combined with increased longevity, will continue to drive escalating growth in senior populations, especially in the 75 and over age group. Sonoma County’s current health care and social service infrastructure is inadequate, especially in outlying communities, to meet the needs of this growing population of aging seniors.

Mortality

For those 60 years and older, the death rate for falls is higher than the California rate and almost three times the Healthy People 2020 goal.

Health Indicators

For many health indicators, Sonoma County older residents’ health status fares poorly in comparison to their peers in California or the Healthy People 2020 targets.
22% of seniors aged 65 and older have incomes less than 200% of FPL; for seniors over age 75, the percentage rises to 27%.
Among seniors aged 65 and older, 30% live alone, representing 38.4% of the women and 18.9% of the men in this age group.

Benchmark

Among those age 60 and older, 44,000 (47%) individuals report having been diagnosed with hypertension as compared with the Healthy People 2020 goal of 26.9%.

Health Disparity

88.5% of seniors with incomes above 200% FPL report good or better health as compared with 63.1% of those with annual income below this level
Geographic and social isolation create significant barriers in accessing basic services such as transportation, safe housing, health care, nutritious food and opportunities for socialization. These barriers are compounded for seniors living in poverty.

How this issue is identified as a priority:

Key Informants
Among key informants, 5 of 18 identified seniors, emphasizing low income and isolated seniors as the population with the greatest challenges in maintaining their health.

CHNA Priority Setting Process
Barriers to healthy aging were identified as a priority during the CHNA Priority Setting Process.

Selection Criteria
Barriers to healthy aging meet the priority selection criteria for links to chronic disease, disparities in health status, potential for health improvement based on local intervention, and opportunities for prevention approaches.

Community assets and resources and assets:

Support Services

Collaborations

The Older Adult Collaborative (OAC)

Care Coordination

Mental Health Services

Family Service Agency Senior Peer Counseling Services

Transportation

5. Gaps in Access to Mental Health Services

Good mental health plays a crucial role in the health and well being of individuals and their communities. Mental health disorders can interfere with healthy social functioning and create significant burdens on individuals, families, and communities. Mental health disorders vary in severity and in their impact on people’s lives. Many behavioral health problems can be effectively treated. Early detection, assessment, and links with treatment and supports can help prevent mental health problems from worsening. However, many individuals with mental health concerns do not have access to the treatment they need based on income and on lack of available services. Insufficient private insurance coverage for behavioral health services and insufficient availability of publicly funded treatment services are significant barriers for many who seek mental health services and supports in Sonoma County. Lack of an integrated approach to mental health within the health care system can lead to missed opportunities for early problem identification and prevention.

Why this issue is important in Sonoma County:

Scope and Scale

According to estimates compiled by the Sonoma County Department of Health Services, approximately 70,000 – 80,000 individuals (14% of total population) are currently uninsured for health care. Many others who have individual or employer based health insurance lack affordable access to mental health services because such services are excluded from coverage.

Benchmark

Nearly one-fifth (19.6%) of Sonoma County adults 18-59 reported needing help for emotional/mental health problems or use of alcohol or drugs as compared to 16.1% in California.
More Sonoma County residents age 60 and older stated that they need help for mental health issues than Californian seniors as a whole (10.5% vs. 7.4%).
The overall Sonoma County death rate from suicide for all age groups (14/100,000) exceeds both the California rate (9.7%) and the Healthy People 2020 rate (10.2%). The death rate from suicide for adults ages 18-59 in Sonoma County (18.6%) is higher than the California rate (12.0%) and the Healthy People 2020 target (10.2%). The death rate from suicide for seniors in Sonoma County (20.8%) is higher that the California rate (15.9%) and nearly twice the Healthy People 2020 target (10.2%).

Health Indicators

Depression during pregnancy and the first year after the birth of a child affects more than one in eight women. Lack of treatment can have a profound impact on women and their families, interfering with maternal-infant bonding and contributing to developmental and behavioral problems in young children.

Health Disparity

Low-income individuals experience severe limitations in access to affordable mental health services and report more mental health problems than those with higher incomes. Information gathered through the 2012 St. Joseph Health System Behavioral Risk Factor Survey highlights disparities in self-reported>mental health status. Among respondents living under 200% of Federal Poverty Level (FPL), 40.2% reported “excellent” or “very good” mental health as compared with 71.2% of those with higher incomes. Among those living below FPL, over 30% report “fair” or “poor” mental health.
Treatment and support resources for low-income children, teens, adults, and seniors are severely limited in Sonoma County, with specific needs for culturally competent outpatient services, and for more basic mental health services in outlying communities. Recent and continuing reductions in the publicly funded safety net of mental health services and supports for low-income and others at- risk further threaten the well being of these vulnerable populations.

How this issue is identified as a priority:

CHNA Priority Setting Process
Gaps in access to mental health services were identified as a priority during the CHNA Priority Setting Process.

Selection Criteria
Gaps in mental health services were selected as a focus area because this meets priority selection criteria for scope and scale, disparities in health status, potential for health improvement based on local intervention, and opportunities for prevention approaches.

Key Informants
Eight of 18 key informants identified improved integration of primary care and behavioral health as a top health issue in Sonoma County.

Community resources and assets:

Health Care Reform

Affordable Care Act

Sonoma County Department of Health Services

Mental Health Services Act - Supported Programs

Community Health Centers

Redwood Community Health Coalition (RCHC)

Community Based Organizations

Coalitions and Collaborations

Consumer Input and Engagement

Sonoma County Mental Health Board

6. Disparities in Educational Attainment

Educational attainment is the single greatest predictor of both income and employment status in later life. As the economy continues to shift toward jobs that require workers to have greater analytical and interactive skills and specialized training, those who do not finish high school are far less likely than better educated workers to succeed in finding employment. Low levels of education are linked to poor health outcomes and disparities in access to care.

Why this issue/condition is important in Sonoma County:

In Sonoma County, levels of educational attainment vary modestly by gender but significantly by ethnicity, with Hispanics currently lagging behind their White counterparts in 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 In Sonoma County, 93.6% of White 9th graders graduate from high school 4 years later as compared with only 64.4% of Latino students.

How this issue is identified as a priority:

CHNA Priority Setting Process
Disparity in educational attainment was identified as a priority during the CHNA Priority Setting Process and highlighted in the Data Profile as a leading contributor to unemployment and poverty and as a social determinant of poor health outcomes.

Selection Criteria
Disparities in educational attainment meet priority selection criteria for scope and scale, disparities in health status, potential for improvement based on local intervention, and opportunities for prevention approaches.

Key Informants
Fifteen of eighteen key informants identified educational attainment as one of the most critical issues facing Sonoma County. Education was also mentioned, along with income, as a major driver for chronic diseases and obesity.

Community resources and assets:

Sonoma County Department of Health Services

Early Childhood Education and Child Care

Mentoring Programs

College and Career Readiness

Intervention and Support Programs

Workforce Development

7. Cardiovascular Disease (Stroke, Diabetes)

Cardiovascular disease (CVD) is a group of disorders of the heart and blood vessels, including coronary heart disease, cerebrovascular disease (stroke), elevated blood pressure (hypertension), peripheral artery disease, rheumatic heart disease, congenital heart disease, heart failure, some types of kidney disease, and diabetes. Major behavioral contributors to cardiovascular disease include tobacco use, harmful use of alcohol, obesity, physical inactivity, unhealthy diet and stress.

Why this issue/condition is important in Sonoma County:

Morbidity and Mortality

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.

Benchmark

The death rate due to coronary heart disease (630.2/100,000) is more than six times the Healthy People 2020 target of 100.8/100,000.
The percentage of people 60 and older with hypertension (47%) is significantly higher than the Healthy People 2020 target of 26.9%.

How this issue is identified as a priority:

CHNA Priority Setting Process
Cardiovascular disease, specifically stroke and diabetes, was identified as a priority during the CHNA Priority Setting Process.

Selection Criteria
Stoke and diabetes were selected as focus areas because they meet priority selection criteria of scope and scale, benchmark issue, links to chronic disease, potential for health improvement based on local intervention, contribution to health disparities, and opportunities for prevention.

Key Informants
Key informants identified contributors to cardiovascular disease i.e., poor nutrition and sedentary lifestyle, and other unhealthy behaviors as key health concerns.

Focus Groups
Among focus group participants, diabetes and high blood pressure were highlighted as important issues affecting the health of their community.

Community assets and resources and assets:

The community asset mapping process generated the following list of resources, services and programs in Sonoma County. The list is not comprehensive. In some instances specific programs

Patient Care - Treatment Services

Intervention and Support Services

Resources

8. Adverse Childhood Experiences (ACES)

“Adverse childhood experiences (ACES),” 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 include verbal, physical, or sexual abuse; an incarcerated, mentally ill, or substance-abusing family member; domestic violence; absence of a parent because of divorce or separation; or other types of serious family dysfunction. ACES have been linked to a range of adverse health outcomes in adulthood, including substance abuse, depression, cardiovascular disease, diabetes, cancer, and premature mortality.

Why this issue/condition is important in Sonoma County:

Incidence and Prevalence

While local data are not available on the incidence and prevalence of ACES, data from the 2009 ACE module of the Behavioral Risk Factor Surveillance System (BRFSS), demonstrate that, overall, 59.4% of respondents reported having at least one ACE, and 8.7% reported five or more ACEs.
While one or two ACES may represent minimal risk for many children, those who experience multiple ACES during childhood are at heightened risk for health and social problems in their teen and adult years.
The prevalence of ACES underscores the need for additional efforts at the state and local levels 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.

How this issue is identified as a priority:

CHNA Priority Setting Process
Adverse childhood experiences were identified as a medium priority during the CHNA Priority Setting Process.

Selection Criteria
ACES meet the priority selection criteria for links to chronic disease, potential for health improvement based on local intervention, and opportunities for prevention approaches.

Key Informants
One key informant identified ACES as a significant health concern.

Community Resources and Assets

Sonoma County Department of Health and Human Services

Intervention Services

Safety Net Services

9. 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. While many individuals face significant barriers to care – geographic, cultural and language barriers, for example – foremost among them are financial barriers. The cost of both routine and emergency care for uninsured patients 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 affordable health care coverage. With implementation of the Affordable Care Act, it is anticipated that a significant portion of Sonoma County’s uninsured population will be eligible for more affordable health care coverage under expanded Medicaid programs or newly developed Health Exchange insurance plans.

Why this issue/condition is important:

Prevalence

The Sonoma County Department of Health Services estimates that 70,000 – 80,000 individuals (14% of total population) are currently uninsured.
Many others who have health care coverage are considered “underinsured,” which means they lack access to essential health care services such as dental, mental health or specialty care because their insurance does not cover these services or does not pay at a level that local health care providers accept.

Health Disparity

More respondents with incomes below Federal Poverty Level (FPL) reported difficulty finding medical care “when they needed it” than did those living at 200% FPL and above (5.3%/23%). Among adults with incomes between 100- 200% of FPL, over 15% reported similar difficulty. Over 25% of those with with incomes below 200% FPL reported that they did not get “a prescription medicine that they needed” during the past year because they could not afford it while 5.8% of those reporting higher incomes did.
Low-income individuals, many of whom lack health care coverage, experience significant disadvantages in accessing health care services. Financial barriers may still be problematic for low-wage earners with incomes too high to qualify for Medi-Cal but too low to meet premium requirements. And, under the ACA, undocumented individuals will continue to be ineligible for publicly-funded coverage, leaving many individuals and families vulnerable.

How this issue is identified as a priority:

CHNA Priority Setting Process

Access to health care coverage was identified as a priority health issue during the community priority setting process.

Selection Criteria

Access to health care coverage was selected as a focus area because it meets priority selection criteria for scope and scale, links to chronic disease, potential for health improvement based on local intervention, and contribution to health disparities.

Key Informants

Among key informants 12 of 18 raised access to primary care services as the most critical issue facing the community. 4 of 18 key informants noted that increasing access to care is important to people with chronic diseases.

Focus Groups

Participants in the focus groups identified a number of barriers to health care access in their community including low wages, lack of transportation, limited health insurance and minimal preventive care for the uninsured.

Community assets and resources:

The community asset mapping process generated the following list of resources, services and programs in Sonoma County. The list is not comprehensive.

Community Health Centers

Redwood Community Health Coalition (RCHC)

Health Care Coverage

County Wide Initiatives

10. Tobacco Use

Nationally, tobacco use causes almost half a million premature deaths each year. 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. Exposure to secondhand smoke can cause or exacerbate a wide range of health conditions including cancer, respiratory infections, and asthma. 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. Tobacco use during pregnancy can lead to miscarriage, premature birth, low birth weight, and infant death.

Why this issue/condition is important in Sonoma County:

Benchmark

The Healthy People 2020 target for the percentage of adults aged 18 years and older that smoke cigarettes is 12.0%. Sonoma County’s adult smoking rate does not meet this target and is higher than the California average.
Smoking rates for teens also exceed both national and state-level benchmarks. Approximately 16% of 11th graders and 11% of 9th graders identify as current smokers.

Health Disparity

Tobacco use disproportionately affects low-income populations - 20.1% of lower income adults report smoking cigarettes in the past 30 days as compared with 8.9% of higher income adults.

How this issue is identified as a priority:

CHNA Priority Setting Process
Tobacco use was identified as a priority during the CHNA Priority Setting Process and was highlighted in the Data Profile as a leading cause of morbidity and mortality.

Selection Criteria
Tobacco use meets priority selection criteria for scope and scale, benchmark issue (smoking), link to chronic disease, contribution to health disparities, potential for health improvement based on local intervention, and opportunities for prevention approaches.

Key Informants
Several key informants identified tobacco use as a risk factor for chronic diseases, low-birth weight and pediatric asthma.

Community assets and resources:

Resources

American Lung Association (ALA)

Prevention Coalitions

Programs and Services

11. Coordination and Integration of Local Health Services

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. Single, categorical services provided to persons with multiple related risks may miss opportunities to diagnose, treat, and prevent disease.

In a report to the Commonwealth Fund, care management was identified as one of few policy options to contain costs while improving health outcomes for high-risk populations. Care management is at the core of the Patient Centered Medical Home approach which shifts focus from episodic acute care to managing the health of defined populations, especially those living with chronic health conditions. In the Patient-Centered Medical Home model, the primary care clinical team acts as the case manager and facilitator to assure that patients receive the full spectrum of diagnosis-specific health care services and supports, both from within and without the medical home. Critical transitions from hospital to skilled nursing to home are case managed to assure positive health outcomes. The clinical care team is supported by information technologies, such as health information exchange, to assure that patients get appropriate care when and where they need and want it in a culturally and linguistically appropriate manner.

Why this issue/condition is important in Sonoma County:

As the Affordable Care Act expands health care coverage options for more Sonoma County residents, making available to them a more comprehensive range of services, increased emphasis must be placed on coordination and integration of these services. 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.

Broad adoption of the patient centered medical home model, case management and patient navigator services, greater use of technology and other approaches to enhanced care coordination will offer opportunities to implement effective prevention and better identify, manage and improve outcomes for those with chronic disease.

The county’s network of community health centers, social services providers and community hospitals have a long history of collaboration to improve health outcomes that can be leveraged to accomplish this goal. Successful efforts to expand adoption of the medical home model; integrate behavioral health services within community health centers; improve hospital-to- home transitions for patients, link chronic patients with health promotion resources in local communities; outstation and co-locate health and social services for geographically isolated populations and address communitywide needs for healthcare-related transportation, language assistance, and community education have created a strong foundation upon which to build.

How this issue is identified as a priority:

CHNA Priority Setting Process
Coordination and integration of the local health care system was identified as a priority health issue during the CHNA Priority Setting Process.

Selection Criteria
Coordination and integration of the local health care system meets priority selection criteria for scope and scale, links to chronic disease, contribution to health disparities, potential for health improvement based on local intervention, and opportunities for prevention approaches.

Key Informants
12 of 18 key informants identifying collaboration as a countywide strength that needs to be maintained, especially in anticipation of Health Care Reform. Ten key informants discussed health care system improvement, effectively implementing the patient centered medical home and the appropriate allocation of resources such as use of multi-level professional care teams, and integration of primary care and mental health services. Additional mention was made of the work to develop palliative care options, and the policy work on the use of prescription drugs. Key informants emphasized the need to continue the work of the Community Health Improvement Committee (CHIC), Health Action, the Care Transitions Project, the Healthy Eating Active Living Initiative (HEAL), and other upstream approaches now underway.

Focus Groups
Ten of nineteen focus group participants identified more collaboration among public and private entities as the most important issue facing their community.

Community resources and assets:

The community asset mapping process generated the following list of resources, services and programs in Sonoma County. The list is not comprehensive.

The county’s network of community health centers, social services providers and community hospitals have a history of collaboration to improve health outcomes that can be leveraged to accomplish this goal.

Patient Care – Treatment Services

Health Care Reform

Accountable Care Organizations (ACOs)

Countywide Initiatives

Health Action - iCare – Excellence in Health Care

Care Transitions

Care Transitions Group

Workforce Development

12. Disparities in Oral Health

Good oral health – healthy mouth, teeth and gums - is essential to overall health. Poor oral health can threaten the health and healthy development of young children and compromise the health and wellbeing of adults. Conditions of the mouth, teeth, gums and throat, from dental caries to cancer, cause pain and disability for millions of Americans each year. Oral disease is largely preventable with timely assessment and preventive care. 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. While many children and adults in Sonoma County enjoy good oral health and access to high-quality dental care, too many children in our community are unable to eat, sleep or learn because of painful, untreated decay. Many adults are seeking emergency room care for urgent dental conditions that could have been prevented with access to basic dental care.

Why this issue/condition is important in Sonoma County:

Prevalence
In 2010, over 838 low-income Sonoma County children received hospital dentistry services at the PDI Surgery Center, to treat caries that were either so numerous or so severe that they could not be treated without general anesthesia.

Health Disparity
Low-income adults and children suffer disproportionately from poor oral health largely because of limited access to affordable prevention-focused oral health care.

How this issue is identified as a priority:

CHNA Priority Setting Process
Disparities in oral health were identified as a priority health issue during the CHNA Priority Setting Process.

Selection Criteria
Oral health disparities meet the priority selection for scope and scale, contribution to health disparities, potential for health improvement based on local intervention, and opportunities for prevention approaches.

Key Informants
Four of eighteen key informants identified disparities in oral health as a critical issue, while several noted that integrating oral health assessment and referral into routine primary care would improve oral health.

Behavioral Health Risk Survey
Information gathered through the 2012 St. Joseph Health System Behavioral Risk Factor Survey documents disparities with regard to dental care access. Seventy-seven percent (77%) of survey respondents with incomes at 200% of FPL or higher reported having had their teeth cleaned by a dentist or dental hygienist within the past year, as compared with 47% of those with incomes below that level. Among respondents living below FPL, only 35% report cleaning within the past year; 16% report not having had their teeth cleaned in the past 5 years; and 11% report never having had them cleaned.

Community resources and assets:

The community asset mapping process generated a list of community resources and programs in Sonoma County. The list is not comprehensive. In some instances specific programs are “spotlighted’ as representative of similar programs or services available in the county.

Dental Services

Resources

Collaborations

Sonoma County Oral Health Access Coalition (SCOHAC)

Prevention Programs

Professional Training Workforce Development

Santa Rosa Junior College (SRJC)

13. Cancer (Lung, Breast, and Colorectal)

Cancer is a general name for a group of more than 100 diseases in which abnormal cells divide without control and are able to invade and damage healthy tissues. Cancer cells can spread to other parts of the body through the blood and lymph systems. Cancer is the second leading cause of death in the United States, exceeded only by heart disease.

The number of new cancer cases can be reduced, and many cancer deaths can be prevented. Research shows that screening for breast, cervical and colorectal cancers, as recommended, can increase detection of these cancers at an early and often treatable stage, thereby reducing morbidity and mortality.

Why this issue/condition is important in Sonoma County:

Morbidity and Mortality
Cancer is a leading cause of death in Sonoma County: the county exceeds the Healthy People 2020 target for all-cancer death rate. With the exception of stomach cancer, Sonoma County’s all-cancer incidence - the number of new cases reported annually per 100,000 in population - is higher than the California rate.

Lung cancer, with 234 annual deaths, is the leading cause of cancer death in Sonoma County, exceeding the state average. Other leading causes of cancer death are colorectal cancer, female breast cancer, and prostate cancer, all of which are higher than the California rate and do not meet Healthy People 2020 targets.

How this issue is identified as a priority:

CHNA Priority Setting Process
Cancer was identified as a priority during the CHNA Priority Setting Process and highlighted in the Data Profile as a leading cause of morbidity and mortality.

>Selection Criteria
Lung, breast, and colorectal cancer were identified as a focus area because they meet priority selection criteria for scope and scale, benchmark issue (female breast cancer, lung and colorectal cancer), and opportunities for prevention approaches.

Community assets and resources:

Support Services

Treatment Services

Oncology Providers:

Sonoma County Oncology Nurse Navigators: