sierra nevada memorial hospital - dignity health...service area lies within nevada county, ca, known...

Sierra Nevada Memorial Hospital

2013 Community Health Needs Assessment Summary Implementation Strategy and Community Benefit Plan

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Table of Contents

I. 2013 Sierra Nevada Memorial Hospital Community Health Needs Assessment Summary: An assessment of the Hospital’s Service Area in Nevada County conducted jointly by Sierra Nevada Memorial Hospital, Valley Vision and Community Stakeholders

Description of the Community Served by the Hospital 3 The Assessment Team 4 How the Assessment was Conducted 5 Health Needs Identified 9 Community Assets Identified 20

II. Sierra Nevada Memorial Hospital Implementation Strategy and Community Benefit Plan Summary

Summary 21 Target Areas and Population 21

How the Implementation Strategy Was Developed 22 Major Needs and How Priorities Were Established 22

Description of What Sierra Nevada Memorial Hospital Will Do to Address Community Needs 24 Action Plans 24 Next Steps for Priorities 26 Priority Needs Not Being Addressed and the Reasons 26 Approval 26

Appendices Appendix A: List of Key Informants for Sierra Nevada Memorial Hospital CHNA Appendix B: Health Assets Table for Sierra Nevada Memorial Hospital Service Area Attachment: 2013 Sierra Nevada Memorial Hospital Community Needs Assessment

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2013 Sierra Nevada Memorial Hospital Community Health Needs Assessment Summary: An Assessment of the Hospital’s Service Area in Nevada County conducted jointly by Sierra Nevada Memorial Hospital, Valley Vision and Community Stakeholders

Beginning in early 2012 through February 2013 an assessment of the health needs of residents living in the service area of Sierra Nevada Memorial Hospital, a member of Dignity Health, was completed by the Hospital, Valley Vision, Inc., and Community Stakeholders. The Hospital’s service area lies within Nevada County, CA, known for its rural atmosphere and small town way of life, and comprised of an estimated 75,000 residents. Except for Tahoe Forest Hospital in Truckee, CA, which is located 70 miles away and provides only critical access, Sierra Nevada Memorial Hospital is the sole hospital serving this region. Description of Community Served by the Hospital Defining the Hospital Service Area (HSA). Sierra Nevada Memorial Hospital’s HSA was determined by analyzing patient discharge data. Dignity Health hospitals define the community as the geographic area served by the hospital, considered its primary service area. This is based on a percentage of hospital discharges and is also used in various other departments of the system and hospital, including strategy and planning. The HSA identified for the focus of the needs assessment is depicted in the map below.

Map of Sierra Nevada Memorial Hospital service area

Description of the Community. Nevada City, Grass Valley, Truckee and nine other unincorporated cities make up Nevada County. National forests and state parks account for 63%

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of all land in the county. Nevada County ranks 36th among the most populated counties in California. Agriculture, forestry and fishing companies represent the largest business sectors in the county, with small businesses of one to four employees most representative of the economy. Of the estimated 75,000 residents, a large percentage is retired. There is a higher percentage (20.6%) of residents 65 years of age, or older, living in Nevada County than in California’s overall percentage (11.2%) of residents in this age demographic. Community Demographics. Within Sierra Nevada Memorial Hospital’s primary service area demographics are as follows:

• Population o Under 18 = 18.8% o 18-34 = 16.3% o 35-64 = 44.4% o 65+ = 20.6%

• Diversity o Caucasian: 87.7% o Hispanic: 7.0% o Asian: 1.2% o African American: 0.4% o American Indian/Alaska Native & Other: 3.7%

• Average Income: $70,877 • Uninsured: 16.56% • Unemployment: 5.0% • No High School Diploma: 5.4% • Renters: 21.9% • Medicaid Patients: 10.42%

The Assessment Team The Community Health Needs Assessment (CHNA) was conducted through a participatory team process led by community benefit staff of Sierra Nevada Memorial Hospital, and Valley Vision, Inc., a community service organization dedicated to improving quality of life in the greater Sierra, Sacramento, and San Joaquin regions. Valley Vision (www.valleyvision.org) is a non-profit 501(c)(3) research and consulting firm serving a broad range of communities across Northern California. The organization’s mission is to improve quality of life through the delivery of high-quality research on important topics such as healthcare, economic development, and sustainable environmental practices. Using a community-based participatory orientation to research, Valley Vision has conducted multiple CHNAs across an array of communities for over seven years.

A team of experts from multiple sectors within the Hospital’s service area was assembled to conduct the assessment, including: 1) a local public health expert with over a decade of experience in conducting CHNAs; 2) a geographer with expertise in using GIS technology to

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map health-related characteristics of populations across large geographic areas, and 3) local public health practitioners and consultants to collect and analyze data. Community-Based Participatory Research Approach. The assessment followed a community-based participatory research approach for identification and verification of results at every stage of the assessment. This orientation built capacity and enabled beneficial change within the Hospital CHNA workgroup, and the community members for which the assessment was conducted. Including participants in the process allowed for a deeper understanding of the results. CHNA Workgroup. The CHNA workgroup, comprised of Hospital community benefit representatives, other health system, and Sierra Health Foundation, was an active contributor to the CHNA process. Using the community-based participatory research approach, monthly meetings were held with the workgroup at each critical stage in the assessment process. This data, combined with demographical data, informed the location and selection of key informants that participated in the assessment. Key informants included health and community experts such as the Nevada County Public Health Officer, the Nevada County School District Superintendent, and physicians and leaders of community health and social service organizations. How the Assessment was Conducted “Health Need” and Objectives of the Assessment. The CHNA was anchored and guided by the following objective:

In order to provide necessary information for the Sierra Nevada Memorial Hospital community health improvement plan, identify communities and specific groups within these communities experiencing health disparities, especially as these disparities relate to chronic disease, and further identify contributing factors that create both barriers and opportunities for these populations to live healthier lives.

The World Health Organization defines health needs as “objectively determined deficiencies in health that require health care, from promotion to palliation.” Building from this, the CHNA used the following definitions for health need and driver:

Health Need: A poor health outcome and its associated driver.

Health Driver: A behavioral, environmental, and/or clinical factor, as well as more upstream social economic factors that impact health

Methodology. The assessment used a mixed method data collection approach that included primary data such as key informant interviews, community focus groups, and a

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community assets assessment. Secondary data included health outcomes, demographic data, behavioral data, and environmental data. Unit of Analysis and Study Area. The study area of the assessment included Sierra Nevada Memorial Hospital’s service area. A key focus was to show specific communities (defined geographically) experiencing disparities as they related to chronic disease and mental health. To this end, zip code boundaries were selected as the unit-of-analysis for most indicators. This level of analysis allowed for examination of health outcomes at the community level that are often hidden when data are aggregated at the county level. Some indicators (demographic, behavioral, and environmental in nature) were included in the assessment at the census tract, census block, or point prevalence level, which allowed for deeper community level examination. Selection of Data Criteria. Criteria were established to help identify and determine all data to be included for the study. Data were included only if they met the following standards:

• All data were to be sourced from credible and reputable sources • Data must be consistently collected and organized in the same way to allow for future

trending • Data must be available at the zip code level or smaller

County, state, and Healthy People 2020 targets (when available) were used as benchmarks to determine severity. All rates are reported per 10,000 of population. Health outcome indicator data were adjusted using Empirical Bayes Smoothing, where possible, to increase the stability of estimates by reducing the impact of the small number problem. To provide relative comparison across zip codes, rates of Emergency Department (ED) visits and hospitalization for heart disease, diabetes, hypertension, and stroke were age adjusted to reduce the influence of age. Primary Data - The Community Voice. Primary data collection included qualitative data gathered in four ways:

• Input from the Dignity Health community benefit team • Key informant interviews with area health and community experts • Focus groups with area community members • Community health asset collection via phone interviews and website analyses

Key Informants. Key informants are health and community experts familiar with populations and geographic areas residing within the Sierra Nevada Memorial Hospital’s service area. To gain a deeper understanding of the health issues pertaining to chronic disease and populations living in more vulnerable communities, seven key informants participated in the CHNA process. Interviews were conducted with these informants using a theoretically grounded interview guide. Each interview was recorded and content analysis was conducted to identify key themes and important points pertaining to each HSA geographic area. Findings from these interviews were also used to help identify communities most appropriate for focus groups. (See Appendix A for a list of key informants, including professional title, and description of their knowledge and expertise).

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Focus Groups. Members of the community representing subgroups, defined as groups with unique attributes (race and ethnicity, age, sex, culture, lifestyle, or residents of a particular area of the HSA), were recruited to participate in a focus group. A standard protocol was used for the focus group to understand the experiences of these community members as they relate to health disparities and chronic disease. One focus group was conducted that included 12 community member participants. Content analysis was performed on the focus group interview notes to identify salient health issues affecting these community residents. Secondary Quantitative Data. Secondary quantitative data used in the assessment are listed below in Tables 1 and 2. Table 1: Health outcome data used in the CHNA reported as ED visits, hospitalization, and mortality

ED and Hospitalization Mortality Accidents Hypertension* All-Cause Mortality* Infant Mortality Asthma Mental Health Alzheimer’s Disease Injuries Assault Substance Abuse Cancer Life Expectancy

Cancer Stroke* Chronic Lower Respiratory Disease Liver Disease

Chronic Obstructive Pulmonary Disease Unintentional Injuries Diabetes Renal Disease

Diabetes* Self-inflicted injury Heart Disease Stroke

Heart Disease* Hypertension Suicide *Age adjusted by 2010 California standard population Table 2: Socio-demographic, behavioral, and environmental data profiles used in the CHNA

Socio-Demographic Total Population Limited English Proficiency Family Make-up Percent Uninsured

Poverty Level Percent over 25 with No Nigh School Diploma Age Percent Unemployed

Race/Ethnicity Percent Renting Behavioral and Environmental Profiles

Safety Profile • Major Crime • Assault • Unintentional Injury • Fatal Traffic Accidents • Accidents

Food Environment Profile • Percent Obese/Percent Overweight • Fruit and Vegetable Consumption (≥5/day) • Farmers Markets • Food Deserts • modified Retail Food Environment Index

(mRFEI) Active Living Profile

• Park Access

Physical Wellbeing Profile • Age-adjusted Overall Mortality • Life Expectancy • Infant Mortality • Health Care Professional Shortage Areas • Health Assets

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Data Analysis - Identifying Vulnerable Communities. The first step in the process was to examine socio-demographics in order to identify areas of the HSA with high vulnerability to chronic disease disparities and poor mental health outcomes. Race/ethnicity, household make-up, income, and age variables were combined into a vulnerability index that described the level of vulnerability of each census tract. This index was then mapped for the entire HSA. A tract was considered more vulnerable, or more likely to have higher unwanted health outcomes than others, in the HSA if it had higher: 1) percent Hispanic or non-White population; 2) percent single parent headed households; 3) percent below 125% of the poverty level; 4) percent under five years old; and 5) percent 65 years of age or older living in the census tract. This information was used in combination with input from the CHNA workgroup to identify prioritized areas for which key informants would be sought. The vulnerability index for the HSA is shown below.

Sierra Nevada Memorial Hospital service area map of vulnerability Where to Focus Community Member Input? Focus Group Selection. The selection for the focus group was determined by feedback from key informants and analysis of health outcome indicators (ED visits, hospitalization, and mortality rates). Due to the barriers of low population density and lack of spaces for community members to congregate, qualitative data collection emphasized key informants that serve area residents over focus groups.

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Identifying “Communities of Concern”: the First step in Prioritizing Area Health Needs. To identify Communities of Concern, primary data from key informant interviews, detailed analysis of secondary data, health outcome indicators, and socio-demographics were examined. Zip code communities with rates that exceeded county, state, or Healthy People 2020 benchmarks for ED utilization, hospitalization, or mortality were considered. The health outcome data analysis was triangulated with primary data and socio-demographic data to identify specific Communities of Concern.

What is the Health Profile for Communities of Concern? What are the Prioritized Health Needs of the Area? Data on socio-demographics of residents living in these communities, which included socio-economic status, race and ethnicity, educational attainment, housing status, employment status, and health insurance status, were examined. Area health needs were determined via in depth analysis of qualitative and quantitative data, and then confirmed by socio-demographic data. As noted earlier, a health need was defined as a poor health outcome and its associated driver. A health need was included as a priority if it was represented by rates worse than the established quantitative benchmarks or was consistently mentioned in the qualitative data. Health Needs Identified

Analysis of data revealed two Communities of Concern listed in Table 3.

Table 3: Identified Communities of Concern for Sierra Nevada Memorial Hospital Service Area Zip Community Name County 2010 Population*

95945 Grass Valley Nevada 25,199 95975 Rough and Ready Nevada 1,769

Total population 26,968 (*Source: 2010 Census data) The Sierra Nevada Memorial Hospital service area is made up of six zip codes in the western part of Nevada County and is home to approximately 75,000 residents. Based on an analysis of socio-demographic characteristics and health outcome data at the zip code level, 95945 and 95975 were identified as Communities of Concern. Nearly 27,000 residents live in these two zip code Communities of Concern. While many of the socio-demographic characteristics and health outcome variables indicate that these areas as highly vulnerable and have high rates of negative health outcomes, there are pockets within other zip codes in the HSA that display similar characteristics and health outcomes. Therefore, it should be stated that other Communities of Concern exist outside of these two zip codes and are dispersed throughout the HSA, but are not easily identified by zip code boundaries (e.g. elderly who may live in or near of Nevada City or low-income families that reside in or near Penn Valley).

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Socio-demographic Profile of Communities of Concern. Table 4 below displays data that serve to describe the socio-demographic profile of the two zip code Communities of Concern. Values and rates in bold indicate those that exceed any of the reported benchmarks. Table 4: Socio-demographic characteristics for Sierra Nevada Memorial Hospital Communities of Concern compared to national and state benchmarks

% H

ouse

hold

s in

pove

rty

over

65

head

ed

% F

amili

es in

pov

erty

w/

kids

% F

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pov

erty

fe

mal

e he

aded

% o

ver 2

5 w

ith n

o h

igh

scho

ol d

iplo

ma

% N

on-W

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His

pani

c

% o

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ge 5

with

lim

ited

Engl

ish

% U

n-

empl

oyed

%

No

heal

th in

sura

nce

%

Ren

ting

95945 7.4 13.9 30.9 7.6 14.9 0.9 8.1 24.6 49.7 95975 12.0 16.2 26.1 6.0 18.7 0.1 15.5 23.5 19.8

National 8.7 15.1 31.2 12.9 -- 8.7 7.9 16.3 -- State -- -- -- 19.4 -- -- 9.8 21.6 --

(Source: Dignity Health Community Benefit, CNI data, 2011) An examination of social determinants of health indicated that both zip codes displayed rates that exceeded certain benchmarks. For example, 95975 had 16% unemployment, surpassing both the state and national rates. Zip code 95975 had 12% of households over 65 living in poverty and 16% of households of families living in poverty, both higher than national benchmarks. Both zip codes had a higher rate of residents without health insurance compared to the state and national benchmarks, with 95945 at 25% and 95975 at 23%. Priority Health Needs. The health needs identified through analysis of both quantitative and qualitative data are listed below. All needs are noted as a “health driver,” or a condition or situation that contributed to a poor health outcome. Health outcome results follow the list below. See Appendix G for a detailed list of health needs, including health outcomes and their associated drivers, identified within the HSA.

• Lack of access to primary care and preventive services • Lack of integration of behavioral health and primary care • Transportation issues and limitations • Limited access to healthy foods, food security • Lack of access to specialty care • Lack of dental care • Lack of access to mental health services • Eligibility requirements for Medi-Cal and other social services • Lack of access to outdoor and recreational activities • Lack of access to physical therapy

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Health Outcomes - Diabetes, Heart Disease, Stroke, and Hypertension. Diabetes, heart disease, stroke, and hypertension were consistently mentioned in the qualitative data as conditions affecting many area residents. When asked about the biggest health issues within the community, one key informant stated, “… diabetes, hypertension, heart disease are big players for us. As you get into folks from financially disadvantaged areas you start to get higher incidents of things like diabetes, obesity, those kind of things” (KI_Nevada_1). An examination of health outcome data related to these conditions is shown in Tables 5-8 below. Table 5: Mortality, ED visit, and hospitalization rates for diabetes compared to county, state and Healthy People 2020 benchmarks (rates per 10,000 population)

Diabetes

Zip Code Mortality ED Visits Hospitalization 95945 1.9 228.9 153.8 95975 2.1 111.3 99.9

Nevada County 1.6 126.9 95.1 CA State 1.8 188.4 190.9

Healthy People 2020 6.6 -- -- (Sources: Mortality, CDPH 2010; ED visits and hospitalization, OSHPD, 2011) An examination of mortality due to diabetes reveals both zip codes have rates higher than county and state benchmarks. Zip code 95945 had a rate of ED visits due to diabetes of 228.9 per 10,000, clearly higher than Nevada County rate of 126.9 per 10,000. Rates in 95945 were drastically higher in Blacks at 2260.0 diabetes related ED visits per 10,000 compared to Whites at 309.4 visits, and Hispanics at 197.4 visits. Whites were the only group to have a rate of ED visits related to diabetes in 95975 at 144.0 visits per 10,000, above the county benchmark. The rate of hospitalizations due to diabetes in 95945 was highest in Blacks at 451.4 per 10,000, a rate more than twice the state benchmark. The rate for ED visits in Whites was 267.0 per 10,000 in this zip code. Again Whites were the only group to have a rate of hospitalizations due to diabetes in the 95975 zip code of 141.2 per 10,000. Table 6: Mortality, ED visit and hospitalization rates for heart disease compared to county, state and Healthy People 2020 benchmarks (rates per 10,000 population)

Heart Disease



Healthy People 2020 10.1 -- --

(Sources: Mortality, CDPH 2010; ED visits and hospitalization, OSHPD, 2011) Mortality due to heart disease was more than twice the county rate in zip code 95945, at 33.4 per 10,000 compared to 15.2 per 10,000. Zip code 95945 also had higher rates of ED visits and hospitalizations due to heart disease compared to county and state benchmarks. Rates for ED visits related to heart disease in 95945 were highest in Whites at 205.6 visits followed by Asian Pacific Islanders at 47.2 visits, and Native Americans at 40.7 visits. Whites were the only group to have a rate of ED visits related to heart disease in 95975 at 118.6 visits per 10,000. The rate of

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hospitalizations due to heart disease in 95945 was highest in Whites at 291.6 per 10,000, compared to the rate in Hispanics at 112.0 per 10,000. Table 7: Mortality, ED visits, and hospitalization rates for stroke compared to county, state and Healthy People 2020 benchmarks (rates per 10,000 population)

Stroke



Healthy People 2020 3.4 -- --

(Sources: Mortality, CDPH 2010; ED visits and hospitalization, OSHPD, 2011) While both Communities of Concern demonstrated mortality rates due to stroke that surpassed the state benchmark, zip code 94945 had a mortality rate due to stroke that was three times the state rate. An examination of rates of ED visits and hospitalizations for stroke showed that rates in 95945 exceeded Nevada County rates. Table 8: ED visit and hospitalization rates for hypertension compared to county and state benchmarks (rates per 10,000 population)

Hypertension

Zip Code ED Visits Hospitalization 95945 308.6 395.8 95975 210.4 251.2

Nevada County 192.6 275.0 CA State 365.6 380.9

(Source: OSHPD, 2011) Both Communities of Concern had rates of ED visits for hypertension higher than the Nevada County rate. Zip code 95945 also had a rate of hospitalization for hypertension that surpassed the state rate.

Mental Health and Substance Abuse. Area experts and community members consistently reported the struggle HSA residents had at maintaining positive mental health and accessing treatment for mental illness. Such struggles ranged from overall daily coping in the midst of personal and financial pressures, to the management of severe mental illness requiring needed in-patient treatment and medications for care. Table 9 provides data on ED visits and hospitalizations related to mental health.

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Table 9: ED visit and hospitalization rates due to mental health issues compared to county and state benchmarks (rates per 10,000 population)

Mental Health (overall)



(Source: OSHPD, 2011) Community of Concern zip code 95945 had rates of ED visits and hospitalizations for mental health issues that nearly twice exceeded county and state benchmarks.

In addition to mental health issues, rates of ED visits and hospitalization due to self-inflicted injury were examined. Table 10: ED Visit and hospitalization rates due to self-inflicted injury compared to specific county and state benchmarks (rates per 10,000 population)

Self-Inflicted Injury



(Source: OSHPD, 2011) Area experts mentioned isolation as a concern for people at risk of suicide. Zip code 95945 had rates of ED visits and hospitalizations due to self-inflicted injury higher than the county and state benchmarks. Key informants identified areas such as Penn Valley, the outskirts of Nevada City, and North San Juan as having populations of elderly individuals who may not have family in the area and who might have minimal contact with other area residents. It was discussed that this lack of social interaction could be a contributing factor for mental health issues and suicide.

Area experts and focus group participants also mentioned the lack of public space and areas where the community can gather and engage with others, which might also contribute to isolation and related negative health outcomes. As Table 11 shows, rates of substance abuse-related ED visits and hospitalization were clearly elevated in the Communities of Concern. Table 11: ED visit and hospitalization rates due to substance abuse issues compared to county and state benchmarks (rates per 10,000 population)

Mental Health- Substance

Abuse



(Source: OSHPD, 2011)

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Both Communities of Concern had rates of ED visits and hospitalizations due to substance abuse that were above county and state benchmarks. The rates for substance abuse in zip code 95945 were more than three times the state benchmark for ED visits and more than two times the state benchmark for hospitalizations. Qualitative data supported these findings, with one key informant stating, “We also recognize a significant impact on health from substance abuse issues, be it opiates or pain meds. Marijuana, alcohol, always a big one” (KI_Nevada_1). Respiratory Illness: Chronic Obstructive Pulmonary Disease (COPD) and Asthma. In an effort to understand the impact of tobacco use and respiratory illness in the Communities of Concern, rates of ED visits and hospitalization related to chronic obstructive pulmonary disease (COPD), asthma, and bronchitis were examined and are displayed in Table 12. Rates of ED visits and hospitalization due to asthma are examined independently in Table 13. Table 12: ED Visits and Hospitalization due to COPD, asthma, and bronchitis compared to county and state benchmarks (rates per 10,000 population)

COPD, Asthma, Bronchitis



(Source: OSHPD, 2011) Table 13: ED Visit and hospitalization rates due to asthma compared to county and state benchmarks (rates per 10,000 population)

Asthma



(Source: OSHPD, 2011) In zip code 95945, rates of ED visits and hospitalizations related to COPD and asthma were higher than the county and state benchmarks. The hospitalization rate for COPD, asthma, and bronchitis in 95945 was double the state rate, at 322.6 per 10,000 compared to 156.8 per 10,000. The ED visit rate due to asthma in 95945 was nearly double the Nevada County rate. Behavioral and Environmental - Safety Profile. Examination of safety indicators included examining local law enforcement data reported by police and sheriff’s departments in the area. In addition, rates of ED visits and hospitalizations due to assault and unintentional injury were examined.

Crime Rates. The following map shows major crimes by municipality as reported by various jurisdictions. Darker colored areas denote higher rates of major crime, including homicide, forcible rape, robbery, aggravated assault, burglary, motor vehicle theft, larceny, and arson.

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Major crimes by municipality as reported by California Attorney General’s Office, 2010 Zip codes 95945 and 95959 are located in two separate municipalities which include the Grass Valley Police Department and the Nevada City Police Department. The crime rate for the City of Grass Valley is 477.4 crimes per 10,000 residents compared to Nevada City at 436.8. Portions of 95945 and 95959 are also included in the Nevada County Sheriff’s Department with a crime rate of 107.7 per 10,000 residents, which is also lower than the neighboring counties of Placer and Yuba with rates of 193.6 and 212.6 per 10,000 residents, respectively. Assault and Unintentional Injury. As an additional indicator of safety within the Communities of Concern, ED visit and hospitalization rates for assault were examined. Table 14: ED visits and hospitalization rates due to assault compared to county and state benchmarks (rates per 10,000 population)

Assault



(Source: OSHPD, 2011)

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Both Communities of Concern had rates of ED visits due to assault that surpassed the Nevada County benchmark. As Table 14 indicates, zip code 95945 exceeded the county benchmarks for both rates of ED visits and hospitalizations due to assault.

Unintentional Injury. As the fifth leading cause of death in the nation and the first leading cause in those under the age of 35, examining rates of unintentional injuries was important. Table 15: Mortality, ED visits and hospitalization rates due to unintentional injury compared to county and state benchmarks (rates per 10,000 population)

Unintentional Injury

Zip Code Mortality ED Visits Hospitalization

95945 4.1 1466.7 369.5 95975 3.1 919.6 183.3


Healthy People 2020 3.6 -- -- (Sources: Mortality, CDPH 2010; ED visits and hospitalization, OSHPD, 2011) As Table 15 displays, both zip code Communities of Concern surpassed the state rates of mortality, ED visits, and hospitalization due to unintentional injury. The rate of ED visits due to unintentional injury was notably high in 95945, at 1,466.7 per 10,000, more than double the state rate. The hospitalization rate for unintentional injury in 95945 was twice the state rate. Fatality/Traffic Accidents. The following map displays the locations of traffic accidents that resulted in a fatality. Only those locations of traffic accidents resulting in a fatality located within HSA are noted, and accidents beyond the HSA boundaries are not shown. Table 16 shows bicycle accidents and accidents involving a motor vehicle versus a pedestrian or bicyclist. Accidents resulting in a fatality, especially those on city streets, contribute to the perception of safety area residents feel when traveling through their community, particularly for area residents that rely on public, pedestrian, and/or bicycle travel. Both area experts and community members in the HSA stated that access to services and care is largely dependent on adequate transportation and many residents’ access services by walking, biking, or taking local, sporadically available public transportation.

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Traffic accidents resulting in fatalities as reported by the National Highway Transportation Safety Administration, 2010 As shown in map above, most fatal traffic accidents in the HSA took place on the highways in the area; however two accidents occurred on smaller streets close to town centers. Table 16: ED visit and hospitalization rates for accidents compared to county and state benchmarks (rates per 10,000 population)

Accidents



(Source: OSHPD, 2011) Zip code 95975 had rates of ED visits and hospitalization due to bicycle accidents and accidents involving an automobile and a bicyclist or pedestrian which exceeded county and state benchmarks. Food Environment. An examination of the food environment in the Communities of Concern is shown in Table 17. Approximately 50% of residents within the Communities of Concern reported not eating at least five servings of fruits or vegetables daily as recommended by the state. While zip code 95945 had one farmers’ market, it also contains a federally designated food desert tract. Such tracts are designated by the federal government as census tracts in which 33% of the population or more than 500 people have low access to healthy food.

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Table 17: Percent obese, percent overweight, percent not eating at least five fruits and vegetables daily, presence (X) or absence (-) of federally defined food deserts, and number of farmers markets

Food Environment

Zip Code % Obese

% Overweight

% no 5-a-day

Food Desert

Farmers Markets

95945 20.0 34.7 50.3 X 1 95975 21.2 36.1 49.3 - 0

CA State 24.8 -- -- -- -- [Sources: % Obese & overweight, fruit & vegetable consumption: Healthy City (www.healthycity.org), 2003-2005; Food deserts: Kaiser Permanente CHNA Data Platform/US Dept. of Agriculture, 2011; Farmers markets: California Federation of Certified Farmers Markets, 2012] Residents and area experts stated that accessing healthy foods may be an issue due to affordability and difficultly of getting to and from markets. Long drives and limited public transit become increasing issues the further away residents live from the town centers of Grass Valley or Nevada City. The following map shows the modified Retail Food Environment Index (mRFEI), which is the proportion of healthy food outlets to all available food outlets by census tract. Lighter areas indicate greater access to health foods and the darkest areas indicate no access to healthy foods.

Modified Retail Food Environment Index (mRFEI) by census tracts for HSA An examination of mRFEI data indicated that much of the area within the Communities of Concern is categorized as having good access to healthy food. However, other areas within the HSA are categorized as having no healthy retail outlets.

http://www.healthycity.org/

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Active Living. One of the largest barriers to engagement in physical activity is access to recreational areas. The following map profiles the percent of the population in census tracts that live within one-half mile of a recreational park.

Percent population living in census tract within one-half mile of park space (per 10,000) Zip code 95945 had the census tract with the highest percent of residents, over one-third, living within one-half mile of a park. However, the vast majority of the HSA has very limited access to parks. The HSA is surrounded by recreational activities and very close to the Tahoe National Forest. Despite this, area experts stated that these recreational opportunities are not accessible to low-income families or the elderly, who may not have the equipment to enjoy activities such as hiking, biking, or kayaking. Physical Wellbeing. Age-adjusted all-cause mortality rates are a significant indicator of the health of a community. Zip code 95945 had the highest age-adjusted overall mortality rate in the SNMH HSA at 67.6 deaths per 10,000. Life expectancy data showed that the Communities of Concern had a lower life expectancy at birth compared to other zip codes in the HSA; however, the overall life expectancy was comparable or slightly better than that of the state benchmark. The infant mortality rate of zip code 95945 matched that of the state, at 5.2 deaths per 1,000 live births.

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Table 18: Age-adjusted all-cause mortality rate, life expectancy at birth, and infant mortality rate (all-cause mortality rate per 10,000 populations; infant mortality rate per 1,000 live births)

Zip Code Age-Adjusted

All-Cause Mortality

Life expectancy Infant Mortality

95945 67.6 78.5 5.2 95975 60.3 80.2 0.0

Nevada County 61.5 -- 3.6 CA State 63.3 78.6 5.2 National -- 80.4 --

Healthy People 2020 -- -- 6.0 (Sources: 2010 CDPH and 2010 Census data; rates calculated) Community Assets Identified

Communities require resources in order to maintain and improve their health. These include health related assets such as access to health care professionals and community-based organizations. An assessment of these resources revealed nearly 40 assets that provide Sierra Nevada Memorial Hospital opportunities for partnership in addressing some of the health needs identified in this report. A listing of health assets in the HSA can be found in Appendix B.

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Sierra Nevada Memorial Hospital Implementation Strategy and Community Benefit Plan

Summary for FY 2013 – 2015 Sierra Nevada Memorial Hospital has been meeting the health needs of residents in its Nevada County community for over 50 years. A part of western Nevada County since 1958, the Hospital carries out its mission daily, contributing to the wellness of its community through the provision of quality services delivered in a compassionate and cost effective manner, and collaborating with others in the community to improve quality of life.

The Hospital has 870 employees and offers 121 licensed acute care beds and 18 emergency department beds, and has continued to expand services over the years to meet the growing needs of its community. An Ambulatory Treatment Center was added in the 1990s, created specifically for patients with chronic illnesses and other ongoing outpatient care needs. In more recent years, the Hospital opened the Sierra Nevada Diagnostic Center. The Hospital’s Cancer Center is nationally accredited by the Commission on Cancer of the American College of Surgeons as a Community Cancer Program, and its Primary Stroke Center has earned the Gold Seal of Approval from the Joint Commission for Primary Stroke Centers.

This report summarizes the plans for Sierra Nevada Memorial Hospital to sustain and build upon community benefit programs that address priority health needs identified in the 2013 Community Health Needs Assessment (CHNA), and to engage with the community in developing new offerings that respond to needed care and services.

Target Areas and Populations Specifically, the 2013 CHNA identified two of the six zip codes within Sierra Nevada Memorial Hospital’s service area as Communities of Concern. Nearly 27,000 residents live within these two zip codes - 95975 and 95945 – which encompass the communities of Grass Valley and Rough and Ready. Both zip codes displayed rates for unemployment that surpassed state and national rates, and both were higher than national benchmarks for poverty. More residents in these zip codes had no health insurance as compared to state and national benchmarks. Higher rates of chronic illness were identified within both zip codes. There were more than double the number of emergency department visits and hospitalizations in these two zip codes as compared to zip codes in the service area due to diabetes and heart disease. Stroke, hypertension, COPD and asthma were also greater concerns for residents in these two communities. Mental health illness in these two zip codes was significantly higher, with cases that nearly twice exceeded county and state benchmarks. The problems of substance abuse, self-inflicted injury, and suicide were also greater. Within these two zip codes, the CHNA also showed that there was low access to healthy foods. A priority for Sierra Nevada Memorial Hospital is to focus on populations with the greatest need; thus more emphasis on addressing health issues in these two zip codes is a target area of focus for community benefit planning and implementation for the Hospital.

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How the Implementation Strategy Was Developed The 2013 CHNA informed Sierra Nevada Memorial Hospital’s implementation plan, along with a review and evaluation of existing community benefit programs and services. In developing the CHNA, the Hospital took a leadership role, engaging the services of Valley Vision, a community-based nonprofit research and consultant group, and involving a variety of experts from the public health field, as well as a geographer with experience using GIS technology to map health-related characteristics of populations across large areas, and other public health practitioners. The assessment followed a community-based participatory research approach for identification and verification of results at every stage of the assessment. This orientation built capacity and enabled beneficial change within the Hospital CHNA workgroup, and the community members for which the assessment was conducted. Including participants in the process allowed for a deeper understanding of the results. Key informants for the CHNA included community leaders with significant knowledge and expertise; Nevada County Public Health Officer, Nevada County School District Superintendent; physicians; and leaders of community health and social service agencies among them. Findings from the new 2013 CHNA, completed in late March 2013, will be presented in various community forums, and shared with health providers, organizations, community leaders and public officials. Sierra Nevada Memorial Hospital established a leadership team to determine how best to enhance services to respond to priority needs, and to develop a plan of action. Major Needs and How Priorities Were Established The 2013 CHNA provided a baseline for establishing priorities. The CHNA process involved a rigorous community-based participatory research approach that engaged both public health experts and community members, utilizing a mixed method data collection methodology that included primary and secondary data collection. Primary data were compiled from key informant interviews, community focus groups, and the community assets assessment process. Secondary data included health outcomes, demographic data, behavioral data, and environmental data. Ten health needs specifically, were identified as priority health needs in the CHNA:

1. Lack of access to primary care and preventive services 2. Lack of integration of behavioral health and primary care 3. Transportation issues and limitations 4. Limited access to healthy foods, food security 5. Lack of access to specialty care 6. Lack of dental care 7. Lack of access to mental health services 8. Eligibility requirements for Medi-Cal and other social services 9. Lack of access to outdoor and recreational activities 10. Lack of access to physical therapy

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The CHNA revealed priority health needs were greatest in two Communities of Concern - zip code 95975 and 9594 - which represent nearly 27,000 residents in the communities of Grass Valley and Rough and Ready. The Leadership Team at Sierra Nevada Memorial Hospital went through a process of review and evaluation to compare the CHNA findings to community benefit programs and services currently being offered by the Hospital, and to determine gaps in services that required attention. Each CHNA priority health need was weighed against criteria that included:

• How does what the Hospital experiences from an Emergency Department and inpatient admissions standpoint correspond to the CHNA

• What is being done currently by the Hospital in response to the identified priority health needs

• What health needs are other community-based provider organizations currently addressing

• Where are there gaps in care • Which gaps reflect the greatest risk for residents • Where are these gaps greatest • In addition to the significant charity care, Medi-Cal, other government-funded programs,

and community services being provided, what level of resources might be available by the Hospital to expand or develop new initiatives to respond to these gaps

• How might the Hospital collaborate with the community to best leverage resources to better meet health needs

• What community provider partners are available • Which priority health needs align most with the clinical expertise of the Hospital

When comparing current community benefit programs and services offered at Sierra Nevada Memorial Hospital to the findings in the CHNA, the Hospital is currently responding to a number of priority health needs. In addition to charity care, care for the indigent, and un-funded care to the Medi-Cal population, the Hospital’s core community services address those priority health needs concerning 1) the need for greater access to primary and preventative services, with major emphasis on chronic disease prevention and self-management; 2) the need to integrate behavioral health and primary care; 3) the need for transportation; and, 4) the need to support residents with eligibility requirements for Medi-Cal and other social services. The Hospital will continue to address these priorities, while implementing plans that:

• Place specific attention on the two Communities of Concern to ensure residents in these communities can access, and benefit from, services and programs

• Expand collaboration within the community’s safety net to increase access to care • Determine community assets and ways to collaborate with community-based nonprofit

mental health providers • Redesign the annual Dignity Health Community Grants Program to build capacity for

greatly needed health and health-related services • Expand community outreach to ensure awareness of, and increase participation in,

chronic disease prevention and self-management educational offerings, particularly diabetes and heart disease

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Description of What Sierra Nevada Memorial Hospital Will Do to Address Community Needs The Sierra Nevada Memorial Hospital leadership team will continue to meet on a regular basis, and identify stakeholders in the community who have expertise in those areas identified as priorities. Specific actions in conjunction with the current community benefit services offered by the Hospital are outlined below.

Action Plans

1. Lack of Access to Primary Care. Sierra Nevada Memorial Hospital has a leadership role on the board of the principle Federally Qualified Health Center in the region, Western Sierra Medical Clinic. The Hospital supports this center’s current efforts to serve as a primary health care home to the underserved. To provide much needed space (one contributor to poor access identified through qualitative data in the CHNA) the Hospital has enabled the Clinic to utilize hospital-owned facilities in Grass Valley for additional capacity at a reduced rate. The Hospital will continue to work closely with Western Sierra Medical Clinic to increase focus on access to care, particularly within the two Communities of Concern. The Hospital also strives to ensure patients in need of a primary care provider are given timely referrals to the Clinic prior to discharge.

A. Satellite Lab and X-Ray Clinic. The Hospital is opening a new satellite lab and x-ray clinic located in Penn Valley, in the vicinity of Rough and Ready, one of the Communities of Concern identified in the CHNA. This outpatient facility will significantly enhance access to medical services. Key informants in the CHNA voiced the difficulties many residents within the community have in obtaining lab and x-ray tests.

2. Lack of Access to Preventative Services. The Hospital is one of the few providers in the

region addressing the need for health education that focuses on disease prevention and management of chronic disease. Through the Hospital’s Wellness Education department, thousands of residents have been served over the past 15 years, receiving the necessary resources and skills to control health conditions and lead healthier lives. In addition, annual blood screenings are provided. The Hospital will continue to provide these priority services, and focus on outreach efforts to increase awareness and participation by residents within the two Communities of Concern. In particular, main conditions that were raised consistently as priority health issues in CHNA qualitative data included diabetes, hypertension, and heart disease. Sierra Nevada Memorial Hospital is working to provide services to address these conditions in several ways:

The best practice health intervention CHAMP® (Congestive Heart Active Management Program) model provides assistance and support to those with heart disease. Sierra

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Nevada Memorial Hospital implemented this program when it was determined to be a health priority in the region some years ago. Heart failure is a major cause of hospitalization for residents within the HSA. The program provides ongoing clinical support to those with heart failure, and provides medication monitoring and education. It aims to help those suffering from heart failure live healthier, more active lives, and reduce avoidable hospital admissions. Complementary to CHAMP®, the Hospital offers cardiac rehabilitation programs and classes specifically focused on the underserved who would not otherwise have access to such services.

Diabetes: Take Control! is an active and growing program focused on education and nutrition counseling to enable residents to better manage this chronic condition, stay healthy, and avoid hospitalizations for uncontrolled symptoms.

Better Breather and Pulmonary Rehabilitation, and Smoking Cessation classes are also offered, responding to the chronic diseases of Chronic Obstructive Pulmonary Disease and Asthma, which was also shown to be prevalent in the CHNA.

A. Building Capacity for Preventative Services Collaborative efforts are underway by the Hospital with Western Sierra Medical Clinic to increase access to preventative services. The Hospital is training key members of the Clinic’s staff to be able to provide education and to facilitate chronic disease self management classes, extending the reach of these programs in the region, and in particular to Communities of Concern.

3. Lack of mental health services and substance abuse treatment. Sierra Nevada

Memorial Hospital recognizes the major gap in services for mental health care, and the high substance abuse problem in the region, and is responding through collaborative measures that build capacity in the community for services addressing these needs.

A. Building Capacity for Mental Health and Substance Abuse Treatment through Collaboration. Sierra Nevada Memorial Hospital is in the process of redesigning its annual Dignity Health Community Grants Program to focus on creating strategic partnership programs within the nonprofit community that target underserved individuals in need of mental health care and/or substance abuse treatment. Through the grants program, agencies will work together to ensure coordinated care and the continuum of support necessary to improve the health and quality of life for those they serve. Emphasis will also be placed on developing methods for measuring program outcomes. 4. Lack of Access to Specialty Care. The Hospital continues to grow its Nurse Navigator and peer support programs within its existing service lines, particularly for stroke victims. Stroke, specifically among the large elderly male population in the region, was identified as a high-risk health issue in the CHNA. The Hospital is also developing a lung cancer screening program to respond to the growing prevalence of lung cancer, which was indicated in the CHNA as an increasing concern.

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5. Unintentional injury. Quantitative data from the CHNA reflected that ED visits for unintentional injury is far greater within the Hospital's service area when compared to state rates. A significant contributing factor for this high rate is due to falls among the large elderly population in the region. Falls prevention classes are offered, and the Hospital is involved in the Falls Prevention Coalition of Nevada County, an organization dedicated to reducing the risk of falls through education. 6. Eligibility Requirements for Medi-Cal and other Social Services. Sierra Nevada Memorial Hospital’s active Enrollment Assistance program is directly aligned with this CHNA priority. The program identifies patients without insurance and navigates them through the complicated and often confusing enrollment process.

Sierra Nevada Memorial Hospital will continue to provide core community benefit services that are directly responding to other priority health needs, including:

1. Transportation and Medication. The Hospital assesses and provides transportation for those with no means to travel, and provides medications to patients who cannot afford to purchase them.

2. Professional Health Education. Sierra Nevada Memorial Hospital provides educational training opportunities for future workforce expansion needed to expand access to care in the region. Student nurses work with preceptors in the Hospitals inpatient unit on a continuous basis.

3. Cancer and Traumatic Brain Injury Support Groups. Support groups offered by the Hospital provide education, and help those in the community and their family members cope with cancer and brain injuries.

4. Alzheimer’s Outreach Program. In response to a growing need to assist patients, their families and caregivers with Alzheimer’s, SNMH’s Home Care Department provides an Alzheimer’s Outreach Program that serves as a community education, resource and support center. Alzheimer’s is particularly prevalent among the growing elderly residents within Nevada County. A licensed Social Worker is dedicated to the program, which offers a variety of services, including ongoing “Yes I Can” courses that teach caregivers and families how to provide quality care for those with Alzheimer’s still living at home, and Caregiver Support Groups. The program provides education and caregiver support via home visits and through consultations and serves to link those in need to important resources and assisted living/care centers.

Next Steps for Priorities For each of the priority areas listed above, Sierra Nevada Memorial Hospital will work with established partners, and build new partnerships with others in the community to create opportunities for collaboration and capacity building. Emphasis will be placed on developing methodologies for measuring goals and objectives in order to more accurately measure health outcomes. Attention will be given to outreach within the two Communities of Concern.

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Priority Needs Not Being Addressed and the Reasons Why The Hospital responds to priority health needs in many ways, and in times that are critical for patients in crisis. In addition to charity care, indigent care, and un-funded care for Medi-Cal patients, a significant number of programs and services offered address the priority needs identified in the 2013 CHNA. The needs of Nevada County are monumental, and as the sole hospital serving this expansive rural region, Sierra Nevada Memorial Hospital does not have the resources available to develop and/or duplicate initiatives to meet every priority need identified, which makes collaboration with community assets critical. The County Public Health Department and other community-based nonprofit organizations for instance, are providing mental health services. Community Recovery Resources directly responds to the issue of substance abuse, and in fact, is building a new inpatient treatment facility. The City of Grass Valley and Nevada City offer weekly farmers markets, making fresh foods available at an affordable cost to residents.

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Appendix A: List of Key Informants for Sierra Nevada Memorial Hospital CHNA Area Name & Title Agency Area of Expertise Nevada County

Dr. Frank J. Lang, Jr., Physician

Miners Community Clinic, Inc.

Community Health

Nevada County

Dr. Karen L. Milman, Public Health Officer

Nevada County Health and Human Services

Community Health

Nevada County

Dr. Dawn Harris, Physician Emergency Medical Physician, Sierra Nevada Memorial Hospital

Community Health

Nevada County

Ariel Lovett, Deputy Director

Community Recovery Resources

Community Health

Nevada County

Kim Parker, Executive Director

Sierra Hospital Memorial Hospital Foundation

Community Health

Nevada County

Holly Hermansen, Superintendent, Nevada County Schools Shelly Sexton, Nevada County SELPA Administrator

Nevada City Unified School District

Community Health, Youth & Adolescent Health

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Appendix B: Health Assets Table for Sierra Nevada Memorial Hospital Service Area

Name Z

ip C

ode

Ast

hma/

Lun

g D

isea

se

Dia

bete

s

Hyp

er-

tens

ion

Men

tal

Hea

lth

Nut

ritio

n

Subs

tanc

e A

buse

Tob

acco

Med

ical

Se

rvic

es

Spec

ialty

Oth

er

Den

tal

A New Day 95945 C Support

groups, free of charge to

people over 13

Freed 95945 E, I, R, A ADA Services Transportation

Hospice of the Foothills 95945 C M End of life management

Western Sierra Medical Group/ Grass Valley

Clinic 95945

M, E, I, C,

P C, P E, I,

P S, M, E,I, C, R, P Teen Clinic Yes

Community Recovery Resources 95945

S, M, E, I, CM, C, R, A, P

S, M, E, I, CM, C, R, A, P

P Substance abuse

Food Bank of Nevada County 95945 E, I,

P Food distribution

Gold Country Community Services 95945 S R, P Senior meals Active classes

for Seniors

Gold Country Telecare Paratransit Service 95945

Transportation to elderly & people with disabilities

KARE Crisis Nursery 95945 R Emergency childcare

RSVP/Help Line/Area 4 Agency on Aging 95945 I, R, A I Senior services

Interfaith Food Ministries 95945 P Food bank

The Last Friday Supper 95945 P Dinner last Friday of mo.

Chapa De Indian Health Program 95945 M, P M, P M, P

S, E, I, CM, C, R,

P E, P

E, I, CM, C, R,

P

I, R

S, M, E, I, CM, C, R,

P

Indian healthcare services

Culturally competent Yes

The Salvation Army of Grass Valley 95945 P Food

distribution

Sierra Nevada Memorial Hospital 95945 E, P E, P E, P E

E, I, P

S, M, E, I, CM, R, P

Full service hospital

Twin Cities Church 95945 P USDA

Commodities Distribution

Mission Beth El 95945 P USDA


Elks Lodge Project Hope 95945 P USDA


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Lunch at the Crossroads 95945 P Nutritional meal, one Friday/mo

Hospitality House 95945 S, E, I, CM, R P I,

CM P Shelter Yes

St Patrick Parish 95945 P Community

Dinner 2nd/4th Monday

Women, Infants & Children 95945

E, I, R,

A, P

Booth Family Center 95945 E, I, C, R

E, I, C, R,

P

E, I, C, R, P

Housing/ transition

American Red Cross, Western Nevada County 95945 C P P Disaster relief

Women of Worth (W.O.W) 95945

E, I, C, R,

P P E, I,

R Domestic violence

prevention and relief

Shelter

S=screening services; M=disease management services; E=education services; I=information available; CM=case management; C=counseling services offered; R=referral services offered; A=advocacy services; P=programs offered

sierra nevada memorial hospital - dignity health...service area lies within nevada county, ca, known...

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