2016-2019 community health needs assessment and … · 2016. 6. 23. · 3 summary of the 2016...

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2016-2019

Community Health Needs Assessment and Implementation Plan

Adopted by Community Health Board: June 23, 2016

Community Health Needs Assessment | PeaceHealth United General Medical Center 1

Table of Contents I. EXECUTIVE SUMMARY .......................................................................................................................... 2

II. OVERVIEW ............................................................................................................................................ 6

State, Regional and Community Partners ...................................................................................... 6

Community Health Framework ...................................................................................................... 8

III. 2015 CHNA REVIEW .............................................................................................................................. 9

IV. PEACEHEALTH UNITED GENERAL SERVICE AREA DEMOGRAPHIC AND SOCIOECONOMIC PROFILE .. 11

V. KEY HEALTH INDICATORS .................................................................................................................... 14

Method ......................................................................................................................................... 14

Healthy, Active Living ................................................................................................................... 15

Child & Family Wellbeing ............................................................................................................. 19

Health Delivery Systems ............................................................................................................... 24

Equity ............................................................................................................................................ 28

VI. COMMUNITY CONVENING .................................................................................................................. 30

Method ......................................................................................................................................... 30

Community Convening ........................................................................................................................ 30

VII. IMPLEMENTATION PLAN .................................................................................................................... 32

Introduction ................................................................................................................................. 32

Needs Not Addressed ................................................................................................................... 34


I. EXECUTIVE SUMMARY

Overview

PeaceHealth United General Medical Center

PeaceHealth United General Medical Center (PeaceHealth United General) is one of ten hospitals within PeaceHealth, an integrated, not-for-profit health system in the Pacific Northwest. PeaceHealth United General is a Critical Access Hospital (CAH) located in Sedro-Woolley, Washington, providing a range of services to the local community.

Community Health Needs Assessment

PeaceHealth United General conducted a Community Health Needs Assessment (CHNA), a systematic process involving the community to understand community health needs in order to prioritize, plan and outline solutions.

The 2016 CHNA was carried out with community input, including public health and nonprofit community groups representing minority and low-income residents. Both primary and secondary data were collected and incorporated. We also held a community forum in which needs from the 2015 CHNA were re-affirmed and any significant gaps and/or strategies to address these were identified.

Data and local perspectives are presented and analyzed using a four-pillar structure of community health: 1) Healthy, Active Living; 2) Child & Family Wellbeing; 3) Integrated Health Delivery Systems (including medical dental and behavioral health services); and 4) Equity.

PeaceHealth United General conducted this CHNA in conjunction with state, regional, and local community health planning in Washington, the North Sound Region and Skagit County.

2015 CHNA

PeaceHealth United General became part of PeaceHealth in April 2014. Consistent with IRS requirements, PeaceHealth United General, in close coordination with the community, conducted and adopted a CHNA in December 2015. As noted in the 2015 CHNA, PeaceHealth intended to “refresh” the PeaceHealth United General CHNA come 2016 so that the PeaceHealth United General CHNA cycle aligns with the system-wide cycle. This ‘refreshed’ CHNA builds on the recently completed (2015) CHNA, and includes community perspectives, a formal process of updating data (where available) and concludes with a new implementation plan.


Summary of the 2016 Community Health Needs Assessment

Demographic and Secondary Data

Skagit County has about 118,000 residents. 25% are children 0-19 years old, 60% are adults age 18-64, and the remaining 17% are seniors age 65+. Approximately 36% of Skagit County residents are either “Asset Limited, Income Constrained, Employed” or live below the poverty line. 17% of the County’s population is Hispanic.

PeaceHealth United General is located in Skagit County, it’s primary service area is defined the communities of Sedro-Woolley, Burlington, Concrete, Bow, Lyman, Marblemount, Rockport, Clear Lake, and Hamilton, which largely parallels the boundaries of Public Hospital District #304. The remainder of Skagit County is considered a secondary service area.

The primary service area has about 48,000 residents. 26% are children 0-19 years old, 60% are adults age 20-64, and the remaining 15% are seniors age 65+. Sedro-Woolley is the largest city in the service area representing nearly 51% of the service area’s population. 15% of the service area’s population is Hispanic. However, most health-related data are not available at a smaller level than county. When data for the smaller areas were available, they were used.

Key health indicators were organized into the four community health pillars using primary data from Robert Wood Johnson’s 2016 County Health Rankings and other state sources. Health outcomes gaps in each area are summarized below.

HEALTHY, ACTIVE LIVING: Major issues identified include abuse of opiates and negative effects of that abuse. The rate of treatment for opiate addiction is by far the highest in the state, suggesting that Skagit County is responding to the opiate abuse epidemic.

CHILD & FAMILY WELLBEING: Inequities in readiness to learn among kindergarteners entering school make it harder for children of low-income families and children with limited English skills to do well in school. The lower rates of vaccine completion in Skagit County relative to the state negatively impact the health of the community.

HEALTH DELIVERY: While overall access to care in Skagit County appears similar to Washington State as a whole, data show that there are significant differences in rates of being insured by race/ethnicity. Addressing these inequities is vital to the health of the community.

EQUITY: Affordable housing is a key component of financial wellbeing and stability, and forms the basis of good health. Skagit County does poorly in measures of affordability—over a third of Skagit residents cannot afford a basic household budget. Levels of income inequality are similar to overall Washington state income inequality levels.


Community Engagement and Local Perspectives

PeaceHealth United General conducted a “community conversation” on May 27th with a number of key organizations in the region representing public health and medically underserved and vulnerable groups. This “community conversation” provided an update of the 2015 CHNA priorities and a review of 2016 secondary data.

As part of this conversation, attendees were asked to consider and discuss whether there are any significant gaps or opportunities beyond the 2015 priorities that need to be considered. Table 1 summarizes the results of this community stakeholder meeting, including newly identified needs and potential intervention strategies.

Table 1. Results of the Community Stakeholder Meeting

Major Health Problems/Gaps Strategic Opportunities

Healthy, Active Living

Obesity, diabetes, hypertension

Low fruit and vegetable consumption

Youth marijuana use

Opioid use

Chlamydia rate

Lack of places to exercise

Comprehensive continuum of behavioral health services

Food security initiative

Community Health Worker

Child & Family Wellbeing

Childhood immunization

Prenatal care

Adverse Childhood experiences

Domestic violence

Youth violence

Youth depression and suicide

Enhance primary care and behavioral health integration and coordination


Tax levy to support early childhood services

Health Delivery Systems

Unaffordable health care

Lack of mental and behavioral health care providers

Lack of preventive medical care and primary care

Too little case management/care coordination

Integration of medical care with dental and mental health

More primary care and dental providers that accept Medicaid and Medicare

Incentives for providers to accept Medicaid patients


Implementation Plan

The Implementation Plan strategies summarized below were extrapolated from the data and from community input. Our plan is comprehensive in the sense that there are strategies that impact the focus areas within each of the community health pillars (and a number of strategies cross pillars); however, the display of strategies is not intended to be a complete listing of all of the activities that PeaceHealth will undertake with its community partners to affect the health status of the community. Rather, it is a statement of our community health priorities.

PeaceHealth United General CHNA 2016 Priorities

Ensure effective information exchange and care coordination for select populations (e.g. PeaceHealth Medical Group patients with complex health and psychosocial conditions who are served by multiple organizations) through the PeaceHealth Transforming Clinical Practice Initiative (TCPI) and other community collaborations.

Increase participation in the PeaceHealth employee wellness program, particularly for caregivers at the lower end of the compensation scale.

As part of our ongoing efforts to create an inclusive organization that exercises cultural humility, recruit for and support a workforce that reflects the changing ethnic, racial and cultural diversity of the communities that we serve.

Advocate for and actively support the development of a comprehensive continuum of behavioral health services that includes access to crisis stabilization, transitional and long-term housing, substance abuse treatment services, and psychiatry that is available to children and seniors.

Institute a “food security initiative” for people who have chronic diseases such as asthma, diabetes and hypertension.

Support and actively participate with the Population Health Trust collaborative to stem the opioid epidemic in Skagit County.


“ ”

II. OVERVIEW Founded by the Sisters of St. Joseph of Peace in 1890, PeaceHealth is a Catholic Healthcare Ministry serving in the communities of Alaska, Washington and Oregon. Today, PeaceHealth is a 10 hospital integrated not-for-profit health system that offers a full continuum of health and wellness services.

PeaceHealth’s mission is to carry on the healing mission of Jesus Christ by promoting personal and community health, relieving pain and suffering, and treating each person in a loving and caring way. The fulfillment of our Mission is our shared purpose. It drives all that we are and all that we do. We have embraced the CHNA process as a means of engaging and partnering with the community in identifying disparities and prioritizing health needs, and importantly, in aligning our work to address prioritized needs.

Caring for those in our community is not new to PeaceHealth; it’s been in practice since the Sisters of St. Joseph of Peace arrived in Fairhaven, Washington to serve the needs of the loggers, mill workers, fishermen and their families more than 125 years ago. Even then, they knew that strong, healthy communities benefit individuals and society, and that social and economic factors can make some community members especially vulnerable. The Sisters believed they had a responsibility to care for them, and that ultimately, healthier communities enable all of us to rise to a better life. This philosophy inspires us today and guides us toward the future.

State, Regional and Community Partners

PeaceHealth’s 2016 CHNA process was undertaken in the context of other recent or concurrent planning activities in the State, region and County related to community health:

The Washington State Health Improvement Plan (2014-2017 Creating a Culture of Health in Washington) provides a statewide framework for health improvement efforts.

Wellness is something we nurture, something we build into our policies, something we come together to create as public health professionals, doctors, nurses, lawyers, transportation planners, neighborhood advocates and PTAs, and others.

John Wiesman, DrPH, MPH Washington State Secretary of Health

http://www.doh.wa.gov/Portals/1/Documents/Pubs/822-034_SHIPreport.pdf

http://www.doh.wa.gov/Portals/1/Documents/Pubs/822-034_SHIPreport.pdf


The North Sound Accountable Community of Health (NS-ACH) includes representatives from the five-county area that includes San Juan, Island, Skagit, Snohomish and Whatcom counties.

An Accountable Community of Health (ACH) is a regional coalition consisting of leaders from a variety of different sectors working together to improve health in their region. As part of the Healthier Washington Initiative, nine ACHs began formally organizing across Washington in 2015. They are intended to strengthen collaboration, develop regional health improvement plans and projects, and provide feedback to state agencies about their regions’ health needs and priorities. The Health Care Authority (HCA) is supporting ACH development through guidance, technical assistance (TA), and funding.

Population Health Trust Advisory Committee was convened in February 2015 and conducted a Community Health Assessment in conjunction with community partners. This community health assessment identified the following health issues as important priorities for action: childhood immunization, prenatal care and routine preventive medical care, adult obesity, fruit and vegetable consumption, marijuana use (among youth) and opioid use, chlamydia, youth violence (among youth peer and by adults), youth depression and suicide, affordable housing and living wage jobs. An action plan will be completed in 2016. PeaceHealth serves on the Trust board.

Map 1. Accountable Community of Health Regions

Source: Washington Health Care Authority

http://www.skagitcounty.net/PHTAC/Documents/Community

http://www.skagitcounty.net/PHTAC/Documents/Community

http://www.hca.wa.gov/hw/Pages/communities_of_health.aspx


Community Health Framework

Drawing from the CHNAs conducted by PeaceHealth hospitals, and after reviewing existing community health improvement plans and collecting public data on health status and the social determinants of health, a PeaceHealth Community Health Framework was developed. This four-pillar framework, depicted below, was used to organize data and collect input from community stakeholders. The subcategories, or “focus areas” were used as guideposts for considering community health improvement strategies.

Figure 1. 2016 PeaceHealth Community Health Framework Pillars

Healthy, Active Living

Child & Family Wellbeing

Integrated Health Delivery Systems

Equity

Physical activity

Healthy Eating

Tobacco, alcohol and other drug prevention

Social engagement

Maternal-child health

Adverse Childhood Experiences (ACEs) and family resiliency

Access to quality

and affordable medical, behavioral health and dental services

Assistance for people who are homeless

Cultural humility

There are two terms that are used in the above table that perhaps need to be defined, and they are:

Adverse Childhood Experiences (or ACEs) are traumatic events that occur in childhood and cause stress that changes a child’s brain development. Exposure to ACEs has been shown to have a dose-response relationship with adverse health and social outcomes in adulthood, including but not limited to depression, heart disease, COPD, risk for intimate partner violence, and alcohol and drug abuse.

Cultural humility is a term used to describe a way of infusing multiculturalism into a workplace. Replacing the idea of cultural competency, cultural humility is based on the idea of focusing on self-reflection and lifelong learning.


III. 2015 CHNA REVIEW PeaceHealth United General became part of PeaceHealth in 2014. Consistent with IRS requirements, PeaceHealth United General, in close coordination with the community, conducted and adopted a CHNA in 2015. As such, the next CHNA is due in 2018. However, as noted in the 2015 CHNA, PeaceHealth intended to “refresh” the PeaceHealth United General CHNA come 2016 so that the PeaceHealth United General CHNA cycle aligns with system-wide cycle. This “refreshed” CHNA builds on the recently completed (2015) CHNA and includes community perspectives, a formal process of updating data (where available) and concludes with a new implementation plan. Table 2 summarizes our 2015-2018 CHNA and includes available baseline metrics. Given the relative lack of time between the baseline and current periods, there are no new data available.

Table 2. 2015 CHNA Summary and Current Status

Objectives Strategies Outcomes

Baseline Current

Objective 1: Establish the Infrastructure to assure success in Health Improvement

Institute a CHNA oversight committee as part of the PeaceHealth United General Community Health Board.

Establish a set of basic community health metrics (see baseline measures to the right)

Work teams will be convened to address specific projects as needed.

Uninsured adults (Skagit County): 9%

Vaccination Rates:

19-35 month old vaccination: 40%

13-17 year olds up vaccination: 23%

Prenatal care in 1st trimester: 72.6%

Not available (NA)

Objective 2: Increase mental health and substance abuse access and treatment capacity within the Service Area

Evaluate potential service lines related to behavioral health under consideration include: Post-treatment Monitoring Supportive Housing and Outpatient

Care Residential Treatment Recovery Center (including detox

and outreach facilities)

Partner with local foundations and community to align collaborative efforts.

Poor Mental Health Days: 3.5

Adult Excessive Drinking: 19%

Publicly funded treatment admissions involving any opiate: 585.3/100,000

NA


Objectives Strategies Outcomes

Baseline Current

Objective 3: Continue and increase efforts to provide access to and awareness of healthy foods, including those with chronic conditions (i.e. asthma, diabetes, and hypertension).

Partner with District #304 Community Health Outreach Programs in development, expansion and sustaining a food prescription program.

The food prescription program would be initiated with PeaceHealth Medical Group (PHMG) physicians. Once established, the food prescription program would be offered to community physicians not with PHMG

Establish check-in system with food prescription recipients to assess success of program and continued support for a healthy lifestyle.

Childhood food insecurity: 23.4%

Adult Obesity: 28%

Food environment index: 7.6

NA

NA

NA

Objective 4: Increase access to medical specialty services for rural Skagit County

Expand specialty services specifically for Tele-psych and Tele-intensivists

Engage PHMG specialty physicians in support of this work.

Continue outreach efforts to reach, inform, and enroll community in Medicaid expansion and the Exchange.

Measures TBD

Uninsured adults (Skagit County): 9%

NA

*data methods changed/can’t compare to prior years Sources: Robert Wood Johnson County Health Rankings, Enroll America, Washington State Department of Health: Center for Health Statistics, Washington State Behavioral Risk Factors Surveillance System

The 2015 CHNA was approved in December of 2015 and the work of convening a CHNA oversight group and implementing identified objectives was not begun until the first quarter of 2016. While we have not had a lot of time to “move the dials”, there has been a lot of time put into building the relationships necessary to engage effectively with our community partners.

Under the leadership of the Skagit County Public Health Department, the Public Health Trust has been steadily building the relationships and administrative capacity to be an agent of change for community health. PeaceHealth has contributed funding and the PeaceHealth United CAO (Chief Administrative Officer) sits on the Trust board. Over the last year we have to see that the Trust is well positioned to help bring the right people to a table to get action on a number of issues, including some of our CHNA Implementation plan strategies. We are learning how to maintain multiple partnerships (with the Trust and with the District and others) even as we build our own Community Health Board CHNA oversight committee.


IV. PEACEHEALTH UNITED GENERAL SERVICE AREA DEMOGRAPHIC AND SOCIOECONOMIC PROFILE

PeaceHealth United General serves the communities of Sedro-Woolley, Burlington, Concrete, Bow, Lyman, Marblemount, Rockport, Clear Lake, and Hamilton, which largely parallels the boundaries of Public Hospital District #304. The remainder of Skagit County is its secondary service area.1

Map 2. PeaceHealth United General Service Area

Current Profile

Skagit County has about 118,364 residents

7,487 (6.3%) are preschoolers under age 5 22,723 (19.2%) are 5-19 years old 70,476 (59.5%) are adults age 18-64 20,645 (17.4%) are seniors age 65+ 20,544 (17.4%) are Hispanic, a 11% increase since 2010

The PeaceHealth United General service area has about 48,007 residents

2,823 (5.9%) are preschoolers age 5 or younger 9,216 (19.2%) are 5-19 years old 28,576 (59.5%) are adults age 20-64 7,453 (15.5%) are seniors age 65+ 7,009 (14.6%) are Hispanic, an 9.1% increase since 2010

1 All data in this section is from the American Community Survey (US Census Bureau) unless otherwise noted.

Of Note:

The 2015 United Ways of the Pacific Northwest ALICE report summarizes the status of ALICE families—an acronym that stands for Asset Limited, Income Constrained, Employed. These are families that work hard and earn above the Federal Poverty Level (FPL), but do not earn enough to afford a basic household budget of housing, child care, food, transportation, and health care. Most do not qualify for Medicaid coverage.

In Skagit County, 36% of all households are either in poverty or are ALICE households. This is similar to Washington State overall, wherein 32% of all households are either ALICE or in poverty.


More than 41% of Skagit County residents live in the PeaceHealth United General service area. Table 3 identifies some key socioeconomic determinates of the individual areas in the PeaceHealth United General service area as compared to Skagit County and the State.

88% of Skagit County adults have a high school diploma. The service area high school diploma rate ranges from a low of 68% to a high of 100%.

15% of Skagit County individuals live below the Federal Poverty Level. This percentage varies greatly within the service area, with Burlington, Hamilton and Concrete having the highest poverty rates.

Additionally, data for Skagit County demonstrates:

36% of all households in are either in poverty or cannot afford basic household expenses 351 people are homeless in Skagit County, both sheltered and unsheltered (Homelessness in

Washington State: 2015 Annual Report on the Homeless Grant Programs, Department of Commerce).

In the Sedro-Woolley School District, 175 children in grades K-12 are reported from homeless families (35) or doubled up (living with other families) (140) (2014-2015 Homeless Student Data Report, Office of Superintendent of Public Instruction).

Table 3. PeaceHealth United General Service Area, WA Sociodemographic Profile

City High school diploma (%)

Individuals living below the

FPL (%)

Median Household

Income

People over age 5 who are

linguistically isolated

Bow (zip: 98232) 97.0% 1.7% $74,750 0.30%

Burlington (zip: 98233) 85.7% 15.7% $54,867 7.70%

Clear Lake (CDP) 87.2% 9.5% $68,750 0.70%

Concrete (town) 83.8% 27.5% $36,667 1.20%

Hamilton (town) 68.4% 34.1% $53,482 0.00%

Marblemount (CDP) 100.0% 0.0% $24,783 0%

Rockport (CDP) 89.2% 10.8% $31,964 0%

Sedro-Woolley (town) 89.8% 20.1% $44,014 2.20%

Skagit County 88.2% 14.9% $54,917 5.90%

Washington State 90.2% 13.5% $60,294 7.80%


The Community Need Index (CNI), a tool created by Dignity Health, measures a community’s social and economic health on five measures: income, cultural diversity, education level, unemployment and health insurance, and housing. The CNI demonstrates that within Skagit County, there are pockets of higher and lower need:

Map 3. Skagit County Community Need Index Map, 2015

Source: Dignity Health

Key Take-Aways

A third of all Skagit County residents are either below the Federal Poverty Level (FPL), or, if above, do not earn enough to afford a basic household budget of housing, child care, food, transportation, and health care.

Within Skagit County, there are pockets of high poverty and low educational attainment, with highest need areas concentrated in and around Sedro-Woolley.


V. KEY HEALTH INDICATORS

Method

Data for each of the four PeaceHealth pillars is detailed on the following pages. For each pillar, we provide a description, how the community compares to other Washington counties, provide a profile of the community, identify important indicators and provide key takeaways.

PeaceHealth selected the most currently available data from publically available sources. Data elements were selected that align with the focus of the CHNA. The goal was to identify metrics that could be consistently measured, monitored and benchmarked for all PeaceHealth communities throughout the Pacific Northwest.

Data from the Robert Wood Johnson Foundation (RWJF) was used as a primary source. RWJF’s county health rankings data compare counties within each state on more than 30 factors. Counties in each of the 50 states are ranked according to summaries of a variety of health measures. Counties are ranked relative to the health of other counties in the same state. RWJF calculates and ranks four summary composite scores used in this report:

Overall Health Outcomes Overall Health Delivery Factors Health Factors – Health behaviors Health Factors – Social and economic factors

This is a nationally recognized data set for measuring key social determinates of health. RWJF is committed to continually measuring these metrics.

Data in this evaluation is also supplemented with sources from state and local agencies in Washington. Unless otherwise noted all data cited in this section is from RWJF or the following sources:

Behavioral Risk Factor Surveillance System; Washington Healthy Youth Survey; Washington Department of Health, Vital Statistics; US Census Bureau; The University of Washington’s Alcohol and Drug Abuse Institute; WA Office of the Superintendent for Public Instruction; Feeding America; Enroll America; Centers for Medicare & Medicaid Services; Community Commons and Skagit County Public Health WIC.

Next to each local indicator we've shown whether the local rate (percentage) is less than, greater than, or equal to the state rate (percentage). With any indicator, there is a range of possible 'true' values because data collection always entails some error. Often, percentages that appear different are rated as 'equal.' This is because, statistically speaking, there is a large chance that the 'true' value of the data at the state and county level is equal, rather than different, due to error inherent in the data collection process.


Healthy, Active Living: Skagit County Health Indicators, 2016

What is Healthy, Active Living?

Healthy, Active Living is a key pillar of a healthy community. We envision a community where the environment and resources of that community allow adults, teens, and children to be physically active, to eat nutritious meals, to be free of the burdens of substance abuse and chronic disease, and to live with an ample sense of wellbeing and connection to others.

How Does Skagit County Compare to Other Counties?

Skagit County is ranked 17 out of 39 Washington Counties for its food and physical activity environment, as well as the adult behavioral health indicators like excessive drinking and smoking. This means we’re doing well compared to over half of counties in Washington.

Healthy, Active Living Profile

Adults: Adult obesity: 28% (=WA: 27%) Adult physical inactivity: 19% (=WA: 18%) Adult diabetes: 9% (=WA: 9%)

Youth: 10th graders who are obese: 13.2% (=WA: 11.2%) 10th graders reporting physical inactivity: 11.3% (=WA: 12.0%)

Environment: Reasonable access to exercise opportunities: 73% of residents (<WA: 88%) Food environment index: 2016: 7.6 (=WA: 7.5)

Substance abuse: Opiate use:

Deaths attributed to any opiate: 11.6 per 100,000 population (>WA: 8.6 per 100,000 population)

Publicly funded treatment admissions involving any opiate: 585.3 per 100,000 population (>WA: 176.3 per 100,000 population)

Adult excessive drinking: 19% (=WA: 19%) Adult smoking: 15% (=WA: 15%) 10th graders smoking cigs in past 30 days: 7.2% (=WA: 7.9%)


Closer Look

Growth in Opiate Abuse Opiate abuse, including heroin and prescription opiates, has grown steadily in the past fifteen years. Several measures, including the rate of Skagit crime lab results related to an opiate, the rate of residents treated for opiate addiction and the rate of deaths attributed to any opiate, have increased significantly in Skagit County between 2002-2004 and 2011-2013. Opiate use and abuse is a significant health and political issue in Skagit County that requires cross-sector collaboration in order to alleviate its negative health and social consequences for our community.

Figure 2, Opiate use and abuse growth over time, Washington State, 2002-2004 to 2011-2013

Source: Alcohol & Drug Abuse Institute, University of Washington

Of Note:

Caregiver Wellness As one of the largest employers in the community, PeaceHealth is working to support Active Healthy living in its workforce by offering an employee wellness program. Workplace wellness programs are evidence-based strategies to improve physical fitness and risk factors. At PeaceHealth, we can make an impact on community wellness by improving our employees’ wellness, but there are differences based on income levels:

67.1% of eligible United General employees participate in a wellness program.

27.3% of eligible United General employees earning $25,000 - $40,000 participate in a wellness program.


Youth Alcohol Abuse Tenth graders in Skagit County are significantly more likely than tenth graders in Washington to report drinking alcohol and binge drinking. Alcohol abuse in teens leads to permanent cognitive and developmental changes, as well as put them at risk for alcohol abuse throughout the life course.

Additional Indicators with Trend Data

The Behavioral Risk Factor Surveillance System is used to measure chronic diseases and health behaviors among a population of adults in all 50 states at the county level. The Washington Healthy Youth Survey measures health risk behaviors and outcomes among 6th, 8th, 10th, and 12th graders in Washington State. The Washington Department of Vital Statistics measures causes of death and circumstances of prenatal outcomes and birth. The Robert Wood Johnson Foundation County Health Rankings aggregates BRFSS, Vital Statistics, US Census, and business data to provide an overview of measures that matter for health. The University of Washington’s Alcohol and Drug Abuse Institute measures markers of opiate abuse over time in Washington counties.

Table 4. Healthy, Active Living: Skagit County vs. Washington State, 2016 Better Equal Worse

Chronic Conditions

Adult diabetes ●

Heart disease death rate ●

Adult obesity ●

Risk behaviors

Adult physical inactivity ●

Adult excessive alcohol use ●

Adult smoking ●

Deaths due to any opiate ●

Suicide death rate ●

Environment

Grocery availability & food insecurity ●

Access to exercise opportunities ●


Table 5. Healthy, Active Living: Skagit County 10th Graders, Health Indicators vs. Washington State, 2014 and Trend Since 2010

Better Equal Worse Trend

Chronic Conditions

Obesity ● stasis

Depression ● stasis

Risk behaviors

Smoking cigarettes ● improving

Drinking alcohol ● improving

Using marijuana/hashish ● stasis

Binge drinking ● improving

Eat 5+ fruits/vegetables per day* ● stasis Consumed no sugar-sweetened beverages in past 7 days

● **

Reports no leisure-time physical activity for 60 min/day in past 7 days

● stasis

Reports ‘seriously considering suicide’ ● stasis

Environment

Bought sugar-sweetened beverages at school ● improving *trend since 2012 **no trend data available due to methodology change

Key Take-Aways

Abuse of opiates and negative effects of that abuse has grown in Skagit County since the early 2000s; deaths from any opiate in Skagit County have grown 42% since 2002-2004. The rate of treatment for opiate addiction is by far the highest in the state, suggesting that Skagit County is responding to the opiate abuse epidemic.

Skagit County teens are more likely to drink alcohol and binge drink than teens in Washington state overall, which imperils the health of the community.


Child & Family Wellbeing: Skagit County Health Indicators, 2016

What is Child & Family Wellbeing?

Child & Family Wellbeing is a key pillar of a healthy community. Circumstances in pregnancy through early childhood are key predictors of health and wellbeing later in life. We envision a community where all pregnant women and families with children are well-fed, safe, and equipped with resources and knowledge to succeed in school, from kindergarten to high school graduation.


In social and economic factors, including the percentage of adults who have completed high school and have some college education, as well as the percentage of babies born to single mothers, Skagit County is ranked 22nd of 39 counties in Washington.

Child & Family Wellbeing Profile

Percent of students who demonstrate expected skills in 6 of 6 domains: 30.1% (<WA: 39.5%) Childhood food insecurity: 23.4% (=WA: 21.0%) Graduation rate: 71.4% (<WA: 77.2%) Maternal smoking in third trimester of pregnancy: 8.1% (=WA: 7.3%) Low birth weight: 5% (<WA: 6%) Prenatal care beginning in first trimester: 72.6% (=WA: 74.7%) 19-35-month olds up-to-date with vaccinations: 40% (<WA: 56%) Teens up-to-date with vaccines: 23% (<WA: 34%) WIC infants fully or partially breastfed: 36.5% (Skagit County Community Action Agency) (=WA:

41.3%)

Closer Look

Readiness to Learn In the Mount Vernon School District, as in Washington State, children from low-income families and children with limited English are significantly less ready for kindergarten than their peers as measured by skills in six domains of ability of average 5-year olds. These domains include social/emotional functioning, physical functioning, language ability, and cognitive, literacy, and math abilities. These kindergarten deficits are difficult to make up over time and can lead to lower levels of high school completion and a host of vulnerabilities later in life.


Figure 3. Percentage of entering kindergarteners demonstrating kindergarten-level skills in 6 of 6 domains, 2014-2015

Adverse Childhood Experiences (ACEs) Adverse Childhood Experiences, or ACEs, are traumatic events that occur in childhood and cause stress that changes a child’s brain development. Exposure to ACEs has been shown to have a dose-response relationship with adverse health and social outcomes in adulthood, including but not limited to depression, heart disease, COPD, risk for intimate partner violence, and alcohol and drug abuse. Adverse Childhood Experiences include emotional, physical, or sexual abuse, emotional or physical neglect, seeing intimate partner violence inflicted on one’s parent, having mental illness or substance abuse in a household, enduring a parental separation or divorce, or having an incarcerated member of the household.

Figure 4. Association between ACEs and Negative Outcomes

Source: Centers for Disease Control & Prevention, "Association between ACEs and negative outcomes"

We can examine ACEs reported by adults in Washington and see that many Skagit County adults are bearing childhood traumas that put them at risk for poor health and social outcomes in adulthood.

30%

24%

16%

40%

31%

21%

0%5%

10%15%20%25%30%35%40%45%

All Low-income Limited English

Mt. Vernon School District WA State

Of Note:

70% of kindergarteners entering school are not ready for kindergarten in at least one domain in the Mt. Vernon School District.

Nearly 75% of teens in Skagit County are not up-to-date with vaccinations.

23% of Skagit County children lack access to adequate, nutritious food.

https://www.cdc.gov/violenceprevention/acestudy/about_ace.html


Figure 5. Adverse Childhood Experiences reported by adults in Skagit County and Washington State, 2011

Source: Washington State Behavioral Risk Factor Surveillance System

Child and Teen Vaccination Rates The percentage of toddlers and teens in Skagit County that have completed the recommended vaccine series is lower than Washington State overall. Lack of vaccination puts children and teens, as well as immunocompromised people in Skagit County like pregnant women, newborns, and the elderly at risk of serious infectious diseases like pertussis and measles.

Figure 6. Rate of Vaccine Completion, Toddlers and Teens, 2014

Source: Washington State Department of Health

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1+ ACEs 2+ ACEs 3+ ACEs 4+ACEs

Skagit County WA State

0%

10%

20%

30%

40%

50%

60%

19-35-month olds 13-17-year olds



Child Food Insecurity Food insecurity is more complicated than simply going hungry; in fact, some families are food insecure without being hungry because they are forced by their limited resources of time, money, and availability to subsist on cheap convenience foods with little nutritional value. Low-income families that are food insecure often live in a nexus of environmental factors that impede their ability to adopt healthy lifestyles. According to the Food Research & Action Center, food insecure households tend to “lack access to healthy, affordable foods,” be vulnerable to “cycles of food deprivation and overeating” due to the instability of their financial and other resources, and are often at “greater exposure to marketing of obesity-promoting products,” such as billboards and other advertisements.

Due to these and other environmental factors typical of the neighborhoods of low-income, food-insecure families, childhood food insecurity has been shown by many studies to be related to childhood overweight and obesity, in addition to children’s performance in school and social and emotional development. Food insecurity is therefore a crucial, justice-oriented metric of childhood wellbeing that affects their development and opportunities throughout the life course.

23% of all children in Skagit County are food insecure, slightly higher than the rate in Washington.

Figure 7. Childhood food insecurity rate, all counties, Washington, 2013

Child & Family Wellbeing Data Sources

The Washington Department of Vital Statistics measures causes of death and circumstances of prenatal outcomes and birth. The Washington Department of Health measures vaccine rates and conducts the BRFSS, which compiles rates of Adverse Childhood Experiences. The Robert Wood Johnson Foundation County Health Rankings aggregates BRFSS, Vital Statistics, US Census, and business data to provide an overview of measures that matter for health. The Office of the Superintendent for Public Instruction measures “Readiness to Learn” among entering kindergarteners in Washington State in 6 domains:

http://frac.org/pdf/frac_brief_understanding_the_connections.pdf


social-emotional, physical, language, cognitive, literacy, and math. The USDA Women, Infant, and Children nutrition program measures breastfeeding among its program recipients by individual WIC site—the numbers for Skagit County come from the Skagit County Community Action Agency WIC site. Low birth weight is compiled in a seven-year period by RWJF County Health Rankings from WA State Vital Statistics data (2007-2013). Childhood food insecurity is measured by the USDA and Feeding America, and is characterized by a lack of consistent, sufficient, and varied nutrition.

*Data aggregated from 2007-2013 **no trend data available

Key Take-Aways

Inequities in readiness for kindergarten make it harder for children of low-income families and children with limited English skills to do well in school.

Over half of adults in Skagit County endured in childhood at least one Adverse Childhood Experience that puts them at greater risk of poor health outcomes, negative health behaviors, and poor social outcomes.

Rates of vaccine completion are low in Skagit County relative to the state and imperil the health of the community; not only are children and teens affected, but vulnerable populations like newborns, pregnant women, and the elderly are at increased risk for serious infectious diseases when vaccine rates are low.

Low rates of low birth weight demonstrate exceptional health outcomes for newborns and pregnant women and are an important source of health resilience.

Table 6. Child & Family Wellbeing: Skagit County Health Indicators vs. Washington State, 2016


Social Indicators

High school graduation rate ● worsening

Childhood food insecurity ● stasis Entering kindergarteners demonstrating Readiness to Learn in 6 of 6 domains*

● worsening

Health Indicators

Prenatal care in 1st tri. of pregnancy ● worsening

Maternal smoking in 3rd tri. of pregnancy ● improving

Low birth weight* ● **

WIC infants partially or fully breastfed ●

Toddlers up-to-date with vaccines ● **

Teenagers up-to-date with vaccines ● **


Health Delivery Systems: Skagit County Health Indicators, 2016

What are Health Delivery Systems?

Health Delivery Systems are a key pillar of a healthy community. Access to quality, affordable, comprehensive care throughout the life course is an important facet of community wellness. We envision a community where all people have access to quality, affordable preventive and acute care, including mental health and dentistry, throughout the life course.


In health delivery factors including the ratio of physicians, dentists, and mental health providers to the population, as well as certain measures of quality of care like the percentage of Medicare recipients that receive mammograms and diabetic monitoring, Whatcom County ranks 16th out of 39 counties in Washington—near the median score of Washington counties.

Health Delivery Systems Profile

Ratio of residents to care providers: Primary care: 1,050:1 (=WA: 1,190:1) Dentists: 1,370:1 (=WA: 1,290:1) Mental health: 360:1 (=WA: 380:1)

Uninsured rate among adults below age 65: 9% (=WA: 8%) 10th graders who saw a doctor for a physical in the past year: 63.4% (=WA: 66.1%) 10th graders who saw a dentist for a checkup, exam, teeth cleaning, or other dental work:

76.2% of 10th graders in 2014 (=WA: 79.0%)

Closer Look

Health Insurance Inequities Though Skagit County’s overall insurance rate is improving, there are significant inequities in health insurance rate by race/ethnicity, with Hispanic/Latino adults being much less likely to have insurance than other groups.


Figure 8. Uninsured Rate Among Adults <65 Years, 2015

Preventive Hospital Stays Preventable Hospital Stays is the hospital discharge rate for ambulatory care-sensitive conditions per 1,000 fee-for-service Medicare enrollees. Ambulatory care-sensitive conditions include: convulsions, chronic obstructive pulmonary disease, bacterial pneumonia, asthma, congestive heart failure, hypertension, angina, cellulitis, diabetes, gastroenteritis, kidney/urinary infection, and dehydration. This measure is age-adjusted.

Hospitalization for diagnoses treatable in outpatient services suggests that the quality of care provided in the outpatient setting was less than ideal. The measure may also represent a tendency to overuse hospitals as a main source of care.

Lower numbers on this measure are the goal. Skagit County ranks well below the nation but above the State of Washington average, ranking 36th out of 39 counties. The data suggest that there are opportunities to improve primary care.

Figure 9. Rate of Preventable Hospital Stays by County, Washington State

Of Note:

Skagit County Medicare beneficiaries have a rate of 39 preventable hospital stays per 1,000 beneficiaries per year, similar to WA State (36 preventable hospital stays per 1,000 beneficiaries per year).

Racial/ethnic disparities in access to insurance exist in Skagit County.

Source: Robert Wood Johnson County Health Rankings

9%8% 8%

14%

10%

8% 8%7%

13%

8%

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All Black White Hispanic orLatino

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Figure 10. Preventable Hospital Stays, Skagit County, WA

Emergency Room Use Treating patients with low-acuity conditions in the ED is an issue, because it is not the best care setting for those conditions and it contributes to unnecessary overcrowding and increased cost. For PeaceHealth United General, nearly 30% of emergency room visits could be considered avoidable given their low acuity. When viewed by payer, Medicare patients have the lowest rate of these visits, representing nearly 15% of all Medicare emergency room encounters. Medicaid patients have the highest rates, 37%.

Figure 11. ED Visits by Acuity, United General Medical Center, 2016

Source: PeaceHealth Internal Data, trend data is not available due to electronic health system transitions.

31.91%37.18%

14.73%

Commercial/All Other Medicaid Medicare


Health Delivery Systems Data Sources:

The Washington Healthy Youth Survey measures health risk behaviors and outcomes among 6th, 8th, 10th, and 12th graders in Washington State, including health care access. The Robert Wood Johnson Foundation County Health Rankings aggregates provider and US Census data to provide an overview provider to resident ratios and overall clinical care relative measures. Enroll America aggregates measures of insurance across all 50 states at the county and state level. The Centers for Medicare & Medicaid Services Office of Minority Health Disparities Mapping Tool shows measures of health inequities at the county level across the US for different health delivery indicators.

Table 7. Health Delivery Systems: Skagit County Health Indicators vs. Washington State, 2016 and Local Trend since 2010


Primary Care Provider to resident ratio ● stasis

Dentists to resident ratio ● stasis

Mental Health Providers to resident ratio ● stasis

Uninsured adults below age 65 ● improving Saw a doctor for a physical in the past year (10th graders)

● improving

Saw a dentist for checkup, cleaning, or other work in past year (10th graders)

● stasis

Key Take-Aways

Overall access to care in Skagit County appears similar to Washington State as a whole.

Significant disparities in insurance rate exist along racial/ethnic gradients in Skagit County.

Over a third of Skagit County 10th graders did not have a physical in the past year, and nearly a quarter did not see the dentist.


Equity: Skagit County Health Indicators, 2016

What is Equity?

Equity is a key pillar of a healthy community. Health equity will be achieved when everyone is given the opportunity to reach their full health potential. Affordable, safe housing, and employment that allows sufficient resources to meet a household budget are important facets of equity.


In social and economic factors, including the percentage of children in poverty, violent crime, and income inequality, Skagit County is ranked 22nd of 39 counties in Washington. This means that we’re in the lower half of counties in Washington.

Equity Profile

Individuals living below the Federal poverty level: 15% (=WA: 14%) Individuals in poverty or ALICE (Asset-Limited, Income Constrained, Employed): 36% (>WA: 32%) Linguistic isolation: 6% (<WA: 8%) Households with ‘severe housing problems,’ including cost-burdened housing: 19% (=WA: 18%) Unemployment rate: 9% (=WA: 9%) Veteran population: 13% (=WA: 11%) Income inequality (ratio of income at the 80th percentile to income at the 20th percentile): 4.3

(=WA: 4.5)

Closer Look

Cost-burdened Housing Affordable housing is a key component of financial wellbeing and stability, and forms the basis of good health. Skagit County residents in nearly every area have high rates of high housing costs. The United Way ALICE report cites the housing affordability prospects in Skagit County as ‘poor.’

Figure 12. Percentage households where housing costs exceed 30% of household income, Skagit County, 2010-2014

Source: Community Commons


High Percentage of Households Struggling Economically Over a third—36%--of Skagit County residents either live in poverty or are Asset Limited, Income Constrained, Employed (ALICE), meaning that they are employed and make a wage above the poverty line but below the threshold of a stable household budget for housing, food, transportation, health care, and childcare.

Lack of economic resources imperils the health of these families and is a significant detriment to their wellbeing.

Equity Data Sources

The US Census measures the percentages of individuals living in poverty, in linguistic isolation, and adults who are unemployed. The Robert Wood Johnson County Health Rankings provide estimates of individuals who have ‘severe housing problems,’ meaning individuals who live with at least 1 of 4 conditions: overcrowding, high housing costs relative to income, or lack of kitchen or plumbing, as well as a measure of income inequality at the county and state level, which is the ratio of household income at the 80th percentile to income at the 20th percentile. Community Commons provides maps of census-tract level data, including housing cost burden.

Table 8. Equity: Skagit County Health Indicators vs. Washington State, 2016 and Local Trend since 2012


Individuals living below the poverty line ● worsening

ALICE Households ● *

Individuals over age 5 in linguistic isolation ● stasis

Households with ‘severe housing problems’ ● stasis*

Unemployment rate ● stasis

Income inequality ● worsening *no trend data available **baseline trend data aggregated from 2006-2010

Key Take-Aways

Skagit County does poorly in measures of affordability—over a third of Skagit residents cannot afford a basic household budget.

Levels of income inequality are similar to overall Washington state income inequality levels.

A high percentage of cost-burdened housing in certain areas of Skagit County imperils the wellbeing of affected households and the community as a whole.

Of Note: Changing demographics call for employers to monitor their workforce so that it reflects the composition and diversity of the community. Increasing racial and ethnic diversity among licensed health professionals is particularly important because evidence indicates that among other benefits, it is associated with improved access for non-majority patient groups, increased patient satisfaction and an overall decrease in health care disparities.


VI. COMMUNITY CONVENING

Method Following the wide-ranging and inclusive community convenings associated with the recently completed 2015 CHNA, it was decided to limit participation in this “refresh” to a number of key organizations in the region representing public health and medically underserved and vulnerable groups. Participating organizations are noted below.

Table 9. Organizations to which Convening Participants belong, 2016 CHNA

Organization Population Served

PeaceHealth Low income, seniors, adults, children, undocumented, homeless, racial/ethnic minorities

Skagit County Public Hospital District No. 304 Community Health Outreach Programs

All Hospital district residents; medically underserved

Medical Information Network – North Sound (MIN-NS)

Founded by Skagit Valley Hospital, Island Hospital and Whidbey Health, provides high quality, secure, HIPAA compliant HIT environments for improved communication and care coordination across organizational boundaries.

Skagit County Public Health and Community Services

All Skagit County residents and residents in need of behavioral health services and/or child/family services

Community Convening

On May 27, 2016, community representatives were convened for a three hour conversation and provided with an update of the 2015 CHNA priorities. Participants were asked to affirm that these priorities should remain a focus area. Based on the 2016 secondary data gathering relative to each community health pillar, attendees were then asked to consider and discuss whether there are any significant gaps or opportunities beyond the 2015 priorities that need to be considered and to understand possible solutions that local experts support.


Table 10. Summary of health and social gaps/needs and strategy opportunities according to key community stakeholders, by community health pillar, May 2016

Healthy, Active Living Child & Family Wellbeing

Needs/Gaps

Obesity, diabetes, hypertension

Low fruit and vegetable consumption

Youth marijuana use Opioid use Chlamydia rate Lack of places to exercise

Childhood immunization Prenatal care Adverse Childhood experiences Domestic violence Youth violence Youth depression and suicide

Strategic Opportunities


Food security initiative Employee wellness Physical activity

Community Health Workers

Enhance primary care and behavioral health integration and coordination.


Tax levy to support early childhood services

Pregnancy supports

Health Delivery Systems Equity

Needs/Gaps

Unaffordable health care Lack of mental and behavioral

health care providers Lack of preventive medical care

and primary care Too little case

management/care coordination

Cost-burdened housing Living wage jobs Racial/ethnic health disparities

Strategic Opportunities

Effective information exchange and care coordination

Population Health Trust programs

More primary care and dental providers that accept Medicaid and Medicare

Incentives for providers to accept Medicaid patients

Integration of medical care with dental and mental health

Create a diverse workforce

Culturally-appropriate care

Access to health care for vulnerable and rural populations


VII. IMPLEMENTATION PLAN

Introduction

The CHNA is a report based on epidemiological, qualitative and comparative methods that assesses the health issues in a hospital organization’s community and that community’s access to services related to those issues.

The Implementation Plan is a list of specific actions that demonstrate how PeaceHealth United General plans to meet the CHNA-identified health needs of the residents in the service area. This Implementation Strategy was approved by the local PeaceHealth Community Health Board.

IRS Implementation Strategy Requirements

The Implementation Strategy which is developed and adopted by each hospital must address the needs identified in the CHNA by either describing how the hospital plans to meet the need or identifying it as a need not to be addressed by the hospital and why. Each need addressed must be tailored to that hospital’s programs, resources, priorities, plans and/or collaboration with governmental, non-profit or other health care organizations. If collaborating with other organizations to develop the implementation strategy, the organizations must be identified.

PeaceHealth Process for Establishing Implementation Plan

In 2016, PeaceHealth reconfigured its ten local governing boards into “Community Health Boards” with the dual responsibility of overseeing the quality of hospital care and furthering community health. Accordingly, each board established two standing committees, one dedicated to monitoring and improving quality and the other focused on local CHNA implementation.

When the CHNA was published in late June 2016, the document included a set of relatively high level strategies for consideration by the CHNA committees. These committees were asked to consider the identified CHNA strategies in relation to hospital competencies, community partnerships that would be required and available resources, and to settle on a final set of strategies that would inform the development of the CHNA implementation plan. This document outlines those final strategies2.

Health Priorities and Implementation Plan Structure

The Implementation plan outlined below is for a three-year period and will guide the development of an annual plan that operationalizes each initiative. The needs that are being addressed correspond to the prioritized needs identified in the CHNA. For each need, a set of initiatives are noted, along with the outcome measures, necessary community partners, and the degree of PeaceHealth engagement.

2 This section was amended on November 14, 2016 to replace the interim implementation strategies published with the CHNA adopted in June 2016 with the final implementation strategies approved by the United General Board in November 2016.


It should be noted that the listing of community partners is not intended to imply firm organizational commitment on behalf of those listed nor limit involvement by organizations not listed. The degree of PeaceHealth engagement is framed in terms of “lead,” “co-lead” or “support.”

Table 11. 2016 PeaceHealth United General CHNA Implementation Plan Overview

Focus Area Needs Initiatives Indicators/Measures

Behavioral Health

Lack of ED diversion, triage and acute intervention Lack of sub-acute and transitional facilities for people with behavioral health problems Proliferation of opioids in the community

Develop ED assessment and tele-psych service

Complete regional behavioral health assessment that builds on CHNA findings and develop local improvement plan that includes treatment options and transition services for district residents

Support the opioid intervention plans being developed by the Population Health Trust Opioid Workgroup Leadership Team (OWLT)

Rate of ED visits that are BH (psych and/or SA) related

Rate of drug overdose deaths

Care Coordination for Complex Patients

Prevent and treat food insecurity and chronic diet-related diseases

Initiate and implement food prescription program within community

Clinical measures (Hemoglobin A1C and BP) for participating patients

Maternal Child Health & Childhood Development

Lack of primary care access

Provide school-based health care for students of Sedro-Woolley High School

Number of students lacking access to care who are served


Table 12. 2016 PeaceHealth United General Initiatives

Needs Not Addressed

In this CHNA, PeaceHealth United General addressed a significant number of health needs that were prioritized with input from the community and where we were able to leverage our resources and expertise to address these issues. However, in prioritizing some issues, others are not directly addressed. The issues not addressed included domestic and youth violence, cost burdened housing, and dental access. Though we recognize their importance and impact on the overall health of the community, in most of these cases PeaceHealth United General lacks the expertise to address these issues and we do not feel we are in a position to deploy specific strategies around these broader socio-environmental issues. We also feel these needs are being addressed by other facilities or organizations in the community.

Initiatives Target Population Potential Partners PeaceHealth Engagement

Behavioral Health

Develop ED assessment and tele-psych service

Complete regional behavioral health assessment that builds on CHNA findings and develop local improvement plan that includes treatment options and transition services for district residents

Support the plans being developed by the Population Health Trust Opioid Workgroup Leadership Team (OWLT)

Underserved within ED Individuals with mental health instabilities Individuals with substance abuse issues

PHMG; Emcare Skagit County Health Department; BHO; Compass Health County Health Department and wide range of Population Trust members

Lead

Lead

Support

Care Coordination for Complex Patients

Initiate and implement food prescription program within community

Individuals with food insecurities and identified chronic disease states (i.e. diabetes, cardiovascular disease)

District #304 Community Outreach Programs; UGMC Auxiliary; Community Vendors

Lead

Maternal Child Health & Childhood Development



Skagit County Health Department; SW school district; Behavioral Health Organization

Lead