2016 Wilmington Hospital Community Health Needs Assessment by ChristianaCare

Wilmington Hospital Community Health Needs Assessment

2016

Contents Introduction .............................................................................................................................. 4 Background......................................................................................................................... 4 Christiana Care Health System ........................................................................................... 4 Service Area Description..................................................................................................... 5 New Castle County Demographics...................................................................................... 6 Population Information ........................................................................................................ 6 City of Wilmington Zone â&#x20AC;&#x201C; Zip Codes 19801, 19802, 19805, 19806 .................................... 7 Language Spoken in the Home ........................................................................................... 8 Methods .................................................................................................................................... 8 Secondary Data .................................................................................................................. 8 Primary Data Collection and Community Input ...................................................................10 Social and Economic Factors ................................................................................................11 Poverty Level .....................................................................................................................11 Poverty Among Children Under Age 18 .............................................................................11 High School Graduation Rates ...........................................................................................11 Unemployment ...................................................................................................................12 Incarceration ......................................................................................................................12 Supplemental Income Benefits...........................................................................................12 Food/Nutrition ....................................................................................................................................... 13 Free and Reduced-Price Lunch Program ...........................................................................13 Food Stamps/SNAP ...........................................................................................................13 Ease of Accessing Fruits or Vegetables in Neighborhood ..................................................14 Food Insecurity ..................................................................................................................14 Health Access .........................................................................................................................14 Insurance Coverage...........................................................................................................14 Unmet Medical Need Due To Cost .....................................................................................15 Access Problems Due To Transportation ...........................................................................16 Usual Source of Care .........................................................................................................16 Dental Access ....................................................................................................................17 Primary Care Physicians - National Data ...........................................................................17 Dentists ..............................................................................................................................18 Hospital Facilities ...............................................................................................................18 1

Federally Qualified Health Centers.....................................................................................18 Birth Characteristics ...............................................................................................................20 Births .................................................................................................................................20 Teen Birth Rate ..................................................................................................................20 Prenatal Care.....................................................................................................................20 Low Birth Weight ................................................................................................................20 Infant Mortality ...................................................................................................................21 Premature Death, Injury and Safety .......................................................................................22 Premature Death................................................................................................................22 Unintentional and Intentional Injury ....................................................................................22 Violent Crimes ...................................................................................................................22 Homicide ............................................................................................................................23 See or Hear Violence .........................................................................................................23 Adverse Childhood Conditions ...........................................................................................23 Racial/Ethnic Discrimination ...............................................................................................24 Chronic Disease ......................................................................................................................25 Health Status .....................................................................................................................25 Diabetes ............................................................................................................................25 Asthma ..............................................................................................................................26 Health Behaviors.....................................................................................................................27 Overweight and Obesity .....................................................................................................27 Infectious Diseases .............................................................................................................................. 27 Sexually Transmitted Diseases ..........................................................................................27 HIV/AIDS ...........................................................................................................................28 Tobacco, Alcohol and Other Drugs ................................................................................................... 28 Tobacco Use......................................................................................................................28 Alcohol Use........................................................................................................................29 Drug Use............................................................................................................................29 Substance Abuse Diagnosis ..............................................................................................30 Mental and Behavioral Health ................................................................................................32 Diagnosis ...........................................................................................................................32 Treatment ..........................................................................................................................32 Vaccines and Screenings .......................................................................................................33 2

Vaccines ................................................................................................................................................ 33 Flu Vaccines ......................................................................................................................33 Pneumonia Vaccination .....................................................................................................33 Preventive Screening........................................................................................................................... 33 Mammograms and Pap Tests ............................................................................................33 Colonoscopy/Sigmoidoscopy .............................................................................................34 Nearly three-quarters if adults age 50 and older in New Castle County have had the recommended colonoscopy/sigmoidoscopy screening. ......................................................34 Prostate Cancer Screening ................................................................................................34 Mortality ...................................................................................................................................35 Death Due to Breast Cancer ..............................................................................................35 Death Due to Prostate Cancer ...........................................................................................35 Death Due to Lung Cancer ................................................................................................35 Death Due to Colorectal Cancer ........................................................................................36 Death Due to Cerebrovascular Disease or Stroke ..............................................................36 Death Due to Heart Disease ..............................................................................................36 Death Due to Influenza and Pneumonia .............................................................................37 Death Due to Diabetes .......................................................................................................37 Primary Data ............................................................................................................................38 Community Interviews ......................................................................................................................... 38 Interview Findings ..............................................................................................................38 Community Survey Findings ..............................................................................................39 Prioritized Significant Health Needs ......................................................................................41 Process and Criteria Used to Prioritize Health Needs ..........................................................41 Potential Resources to Address Prioritized Health Needs...................................................42 Evaluation of Actions Taken Since Last Assessment ..........................................................45 Navigation and Access to Health Care ............................................................................................. 45 Electronic Health Records & Improved Coordination ..................................................................... 46 New Models of Care ............................................................................................................................ 46 Enhanced Mental Health Services .................................................................................................... 47 Attachment 1: Benchmark Comparisons ..............................................................................48 Attachment 2: Listing of Key Informants ..............................................................................49 Attachment 3: About Community Health Advisors, LLC ......................................................50 3

Introduction Background Christiana Care Health System conducted this community health needs assessment (CHNA) to better understand and meet the needs of residents in its service area. This assessment was conducted in accordance with the requirements of Section 501(r) of the Internal Revenue Code as defined by the final regulations issued in December 2014. All non-profit hospitals across the country must comply with Section 501(r) requirements in order to maintain federal tax-exempt status. The requirement that hospitals conduct assessments a minimum of every three years and develop implementation strategies, or health improvement plans, is the federal governmentâ&#x20AC;&#x2122;s effort to ensure that community benefit investments focus on documented needs. The information from this community health needs assessment will be used by Christiana Care to focus on selected community needs. Federal regulations require tax-exempt hospitals to report annually on actions taken that benefit the community they serve. Christiana Care will report to the Internal Revenue Service on the community benefit programs and activities that aim to address selected health needs identified through its most recent CHNA. These community benefit investments aim to improve the health of residents in the communities served by Christiana Care hospitals. Christiana Care Health System Christiana Care Health System is headquartered in Wilmington, Delaware. It is a notfor-profit, non-sectarian health system and is one of the country's largest health care providers, ranking 21st in the nation for hospital admissions. Christiana Care is a major teaching hospital with two campuses and more than 250 Medical-Dental residents and fellows. Christiana Care is recognized as a regional center for excellence in cardiology, cancer and women's health services. The system is home to Delaware's only Level I trauma center, the only center of its kind between Philadelphia and Baltimore. Christiana Care also features a Level III neonatal intensive care unit, the only delivering hospital in the state to offer this level of care for newborns. Two hospitals comprise Christiana Care Health System with more than 1,100 beds combined and a variety of outpatient services including home health care services, preventive medicine, rehabilitation services, a network of primary care physicians and 4

an extensive range of outpatient services. The Systemâ&#x20AC;&#x2122;s two hospitals are Wilmington Hospital, located in Wilmington, and Christiana Hospital, located in Newark. With more than 11,100 employees, Christiana Care is the largest private employer in Delaware. In fiscal year 2015, Christiana Care had $1.6 billion in total patient revenue and provided the community with $16.9 million in charity care (at cost). Christiana Care Health Systems services are available at: Christiana Hospital 4755 Ogletown-Stanton Rd., Newark, DE 19718 Wilmington Hospital 501 W. 14th St., Wilmington, DE 19801 Helen F. Graham Cancer Center & Research Institute 4701 Ogletown-Stanton Road, Newark, DE 19713 Concord Health Center 161 Wilmington-West Chester Pike, Chadds Ford, PA 19317 Healthcare Center at Christiana 200 Hygeia Dr., Newark, DE 19713 Middletown Emergency Department 621 Middletown Odessa Rd., Middletown, DE 19709 Smyrna Health & Wellness Center 100 S. Main St., Smyrna, DE 19977 Christiana Surgicenter 4755 Ogletown-Stanton Rd., Newark, DE 19718 Eugene Du Pont Preventive Medicine & Rehabilitation Institute 3506 Kennett Pike, Wilmington, DE 19807 Roxana Cannon Arsht Surgicenter 12th & Jefferson Sts., Wilmington, DE 19801 Wilmington Annex 1400 Washington St. Wilmington, DE 19801 Service Area Description Approximately 80% of patients served by Christiana Careâ&#x20AC;&#x2122;s two hospitals originate from New Castle County. New Castle County will be considered the primary service area

for purposes of this assessment since the residents of New Castle County are most likely to be influenced by the services and initiatives of Christiana Care hospitals. New Castle County Demographics New Castle County is the northernmost and most populous county in the State of Delaware. Its population of approximately 549,543 represents an increase of slightly less than 4% between 2011 and 2015. Wilmington is the largest city in New Castle County with a population of 92,399 residing in four zip codes â&#x20AC;&#x201C; 19801, 19802, 19805, 19806. The median age of 38 in New Castle County is younger than that for the State of Delaware. The percentage the population over age 65 in the County is less than the state-wide percentage. The median household income for New Castle County is greater than that of the State of Delaware. Population Information Population 2015

Annual Growth Percentage

Median Age

Age 65+ Percentage

Median Household Income

Delaware

938,607

0.9%

16.3%

$62,768

New Castle County

549,543

0.7%

13.9%

$68,651

Area

Truven Health Analytics Inc. 2015

The racial/ethnic composition of the New Castle County service area is predominantly white Caucasian. In the service area population about 25% is black non-Hispanic, about 10% is Hispanic and about 5% is Asian. New Castle County, Racial/Ethnic Composition 2015

White NonHispanic

Population

325,917

Percentage

59.3%

Black NonHispanic

Asian NonHispanic

128,715

27,782

53,226

13,903

Total New Castle County 549,543

23.4%

5.1%

9.7%

2.5%

100%

Hispanic

All Others

Truven Health Analytics Inc. 2015 Data

The racial/ethnic composition of the City of Wilmington zone is predominantly Black/Non-Hispanic. Just under half of the service area population is Black/ NonHispanic; one-third is white Caucasian; and nearly one-sixth is Hispanic. City of Wilmington Zone â&#x20AC;&#x201C; Zip Codes 19801, 19802, 19805, 19806 2015

White NonHispanic

Population

30,882

Percentage

33.4%

Black NonHispanic

Asian NonHispanic

Hispanic

All Others

Total City of Wilmington Zone

44,111

1,080

14,200

2,126

92,399

47.7%

1.2%

15.4%

2.3%

100%

Truven Health Analytics Inc. 2015 Data

Language Spoken in the Home Fifteen percent of New Castle County residents, five years of age or older, speak a language other than English in their home. This includes both people who speak English well and those who do not. Adults Reporting Language Other Than English Spoken in Their Home Area

Percentage

New Castle County

15%

Delaware

13%

United States

21%

Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates Delaware Focus

A recent survey found approximately 10% of New Castle County adults speak Spanish at home, the largest linguistic group for those reporting that a language other than English is spoken in their home. Adults Reporting Language Spoken in Their Home Area

Spanish

English

Chinese (i.e. Mandarin, Cantonese)

Other

City of Wilmington

83.3%

12%

4.1%

Non-urban New Castle County

80.8%

9.3%

1.7%

8.2%

New Castle County

81.3%

9.9%

1.4%

7.4%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Methods Christiana Care Health System contracted with Community Health Advisors, LLC (CHA) (see Attachment 3) for assistance with this assessment; they were responsible for conducting research and analyzing secondary and primary data. Secondary Data Secondary data was collected from a variety of sources to present community demographics, social and economic factors, health access, birth characteristics, leading causes of death, chronic disease and health behaviors. Analysis was conducted using data from:

•

The annual American Community Survey, conducted by the U.S. Census Bureau, provides vital information about our nation and its people.

•

The County Health Rankings Program provides data measuring vital health factors in nearly every county in America.

•

Delaware Focus, an initiative of the Delaware Community Foundation, is a common source of information on critical topics that affect the health and progress of Delaware and monitor quality of life.

•

Delaware Health Tracker, an initiative of Delaware hospitals, is coordinated by the Delaware Healthcare Association. Health Tracker provides data to help communities set goals and evaluate progress. Delaware Health Tracker data is updated whenever source data is updated.

•

The 2015 Delaware Household Health Survey Data was conducted by the Delaware Public Health Institute. Data is based on a survey of randomly selected households and with topics including personal health behavior, access to care, preventive screenings and adverse childhood experiences.

•

KIDS COUNT in Delaware 2014 Fact Book is a collaborative project of the State of Delaware and the Center for Community Research and Service at the University of Delaware.

•

Various health data sets and statistics from the Delaware Department of Health and Social Services, Division of Public Health were used in this assessment.

•

Truven Health Analytics, Inc., data was also used in this assessment.

When possible, these data sets are presented in the context of the State of Delaware, framing the issue as it relates to the entire state. The data sets are sometimes segmented by race/ethnicity, when such breakouts are possible and significant differences exist across these groups. Some data sets are cross-tabulated by geography using the designations of City of Wilmington and non-urban New Castle County. This enables examination of differences that may exist between the urban core of the City of Wilmington and the non-urban areas of New Castle County that may otherwise be masked by county-wide data. The report includes benchmark comparison data that measures New Castle County data findings with Healthy People 2020 objectives (Attachment 1). Healthy People 2020 9

(HP 2020) objectives are a national initiative to improve the publicâ&#x20AC;&#x2122;s health by providing measurable objectives and goals that are applicable at national, state and local levels. Primary Data Collection and Community Input Primary data collection efforts included interviews with key stakeholders and community leaders, as well as a brief community survey administered to area residents. The stakeholder interviews were conducted both in person and by phone by Mark Rukavina during March 2016. Interviewees were representatives from the state public health department, area health and human service organizations, public officials, civic and religious leaders, agencies serving low-income and minority populations, law enforcement and others to gather information directly from those serving residents of New Castle County. Thirty-four individuals were interviewed through this process. A community health survey was administered using a convenience sample of 55 people visiting the New Castle Farmers Market in February 2016.

Social and Economic Factors Poverty Level Eleven percent of New Castle County residents live at or below the Federal Poverty Level and the rate is much higher in the City of Wilmington. Racial/ethnic disparities exist with 8% of the White/Non-Hispanic population, 18% of the Black population and 23% of the Hispanic population living at or below the Federal Poverty Level. Living at or Below 100% of the Federal Poverty Level, 2010-2014 Area

Percent

City of Wilmington

26%

New Castle County

11%

Delaware

12%

Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates Delaware Focus

Poverty Among Children Under Age 18 The percentage of families with children living at or below the poverty rate in New Castle County is slightly lower than that of Delaware. Certain zip codes show much higher rates of children living in poverty: The three zip codes with the highest poverty rates are within the City of Wilmington. Poverty Levels for Children under Age 18, 2010-2014 New Castle Zip Code

Children Under 18 Years of Age

19801

46.6%

19802

39.3%

19805

32.2%

Delaware

17.4%

Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates

High School Graduation Rates High school graduation rates are determined by the percent of ninth grade students in public schools who graduate in four years. The Healthy People 2020 target for students who graduate high school within four years of enrollment in 9th grade to 82.4%. Two school districts in New Castle County have graduation rates lower than the HP 2020 target and the state rate. Racial and ethnic data show further disparities, with the graduation rate in the Christina School District at 71% for Black/African American students and 70% for Hispanic students. 11

High School Graduation Rate, 2014 School District

Percent

Christina School District

75%

Smyrna School District

78%

Delaware

84% Source: Delaware Departments of Education 2014

Unemployment Residents of the City of Wilmington are far more likely to be unemployed than the residents of non-urban areas of New Castle County. New Castle Count Adults Reporting on Main Wage Earners Employment Status Area City of Wilmington Non-urban New Castle County New Castle County

Unemployed, Looking For Work

Unemployed, Not Looking For Work

4.9%

2.4%

0.4%

2.6%

0.8%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Incarceration Nearly one in ten adult residents of New Castle County said that a household member had been sent to prison. Adults Reporting, When Growing Up, Household Member Incarcerated Area City of Wilmington

Percent 14.6%

Non-urban New Castle County

7.5%

New Castle County

9.1%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Supplemental Income Benefits Five percent of adults in New Castle County report receiving Supplemental Security Income, which provides financial support to low-income people who are 65 or older, blind, or disabled.

Adults Reporting Someone in Household Receiving SSI Area

Percent

City of Wilmington

7.5%

Non-urban New Castle County

6.9%

New Castle County

5.2%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Seventeen percent of New Castle County residents filing income taxes qualified for the Earned Income Tax Credit (EITC), a federal tax credit for low- and moderate-income working people. More than 30% of filers in Wilmington qualified for the EITC. Household Supportive Benefits Area City of Wilmington

EITC Tax Year 2013 31%

New Castle

17%

Delaware

18%

United States

20%

Source: The Brookings Institution 2013, Delaware Focus

Food/Nutrition Free and Reduced-Price Lunch Program The percentage of students enrolled in the free and reduced-price lunch program is one indicator of socioeconomic status. The percentage of enrolled students in New Castle County compares to state-wide enrollment. Public School Students Enrolled in Free Lunch Program Area New Castle County Delaware

Percent 50% 52%

Source: Delaware Department of Education 2012-2013 Accessed on KIDS COUNT in Delaware 2014 Fact Book

Food Stamps/SNAP One-fifth of New Castle County adult residents reported that someone in the household was receiving SNAP or food stamp benefits. The percentage of residents of the City of

Wilmington reporting receiving benefits was more than twice the number for residents of the non-urban areas of New Castle County. Someone in Household Receiving Food Stamps or SNAP Area

Percent

City of Wilmington

35.2%

Non-urban New Castle County

15.5%

New Castle County

19.7%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Ease of Accessing Fruits or Vegetables in Neighborhood Residents of the City of Wilmington were far more likely to report difficulty finding access to fresh fruit and vegetables than the residents of non-urban New Castle County. Finding Fruits or Vegetables in Neighborhood Area

Difficult or Very Difficult

City of Wilmington

16%

Non-urban New Castle County

New Castle County

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Food Insecurity Food Insecurity is the percentage of the population lacking access to a reliable source of food during the past year. New Castle County and the state have a similar ranking on the food index. Food Insecurity Area

Percentage

New Castle County

12%

Delaware

13% Source: County Health Rankings, 2016

Health Access Insurance Coverage In 2014, the most recent year for which insurance coverage information is available, the percent of adult residents of New Castle County with health insurance coverage was 14

90.2%. The rate for children with health insurance in New Castle County was 94.5%. These are similar to coverage rates across the state. Data on race and ethnicity shows disparities with Hispanic and Asian adults in New Castle County less likely to have health insurance coverage than White Caucasian or Black/African American residents. Adults with Health Insurance by Race/Ethnicity Race/Ethnicity

Percent With Insurance 2014

Asian (New Castle County) Black/African American (New Castle County) Hispanic (New Castle County)

81.3%

79.3%

White (New Castle County)

92.9%

New Castle Overall Rate

90.2%

Delaware

89.5%

90.1%

Source: American Community Survey, 2014 Delaware Health Tracker

A recent survey found differences when comparing insurance coverage for adult residents of the City of Wilmington to those in non-urban areas of New Castle County. The percentage of uninsured adult residents in the City of Wilmington is significantly higher than in other parts of New Castle County. Adults Reporting Having No Health Insurance Area City of Wilmington

Percent 12%

Non-urban New Castle County

New Castle County

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

When people were asked why they did not have insurance coverage, more than onethird (35%) of the uninsured New Castle residents said the primary reason was high cost. More than one-fifth (22%) of uninsured New Castle residents had been without health insurance for more than two years. (Data Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey.) Unmet Medical Need Due To Cost One in ten residents of New Castle County had an unmet medical need for which they did not see a doctor in the previous year due to the cost of care.

Adults with Unmet Medical Need Due to Cost Area

Percent

New Castle County

10%

Delaware

10%

Source: Behavioral Risk Factor Surveillance System 2006-20012 Accessed on County Health Rankings, 2015

Residents in the City of Wilmington were more likely than other New Castle residents to report that they did not seek health care in the previous year if they were sick or injured, due to cost. Adults Reporting Not Seeking Care Due to Cost Area

Percent

City of Wilmington

14.2%

Non-urban New Castle County

10.7%

New Castle County

11.4%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Nearly 20% of residents in the City of Wilmington did not fill a prescription due to cost, compared to 15% of the non-urban residents of New Castle County. (Data Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey)

Access Problems Due To Transportation One in ten New Castle County residents reported that in the previous year they canceled a doctor's appointment or did not schedule one when it was needed because of transportation problems. Residents of the City of Wilmington experienced this problem at twice the rate of New Castle County residents. Adults Reporting Transportation Problems Area

Percent

City of Wilmington

20%

Non-urban New Castle County

8.5%

New Castle County

11%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Usual Source of Care According to a recent survey, 85% of New Castle County residents have a person or place where they usually go for care if they are sick or want advice about their health. 16

Of those who said they have a regular place where they go for care, the residents of the City of Wilmington are significantly more likely to go to a hospital emergency room for care. Adults Reporting Usual Source of Care Private Physician, Community Health Center, or Public Clinic

Hospital Emergency Room

Hospital Out Patient Clinic

Other

Area City of Wilmington

82%

Non-urban New Castle County

89%

New Castle County

88%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Dental Access Three-quarters of New Castle Countyâ&#x20AC;&#x2122;s adult residents have seen a dentist within the past two years. But there are differences in access and more than one-third of Wilmington residents report not having seen a dentist in more than two years. Adults Reporting More Than Two Years Since Last Dental Visit Area

Percent

City of Wilmington

34%

Non-urban New Castle County

20%

New Castle County

23%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Health and Human Service Providers Primary Care Physicians - National Data A sufficient availability of primary care physicians is essential for timely access to preventive and primary care. According to County Health Rankings data, New Castle County had 460 primary care physicians in 2013. The ratio of the population to primary care physicians in New Castle County is 1,195:1. One benchmark figure for this indicator is the ratio at the 90th percentile for all counties nationally, which is 1,040:1. When compared against this benchmark, New Castle residents may have more difficulty accessing the care of a primary care physician than is the case in other parts of the country. The figures above includes practicing physicians (M.D. and D.O.) under the age of 75 years and specializing in general practice medicine, family medicine, internal medicine 17

and pediatrics. This information is based on data obtained from the Health Resources and Services Administration (HRSA). Dentists County Health Rankings data on the New Castle County ratio of population to dentists for 2013 was 1,733:1. Again, a benchmark for this indicator is the ratio at the 90th percentile for all counties nationally, which is 1,340:1. Given the number of dentists in New Castle County, some residents may experience difficulties accessing dental care due to a demand for services that exceeds the dental capacity of the county. Hospital Facilities The following hospitals are located in New Castle County: Nemours/Alfred I. DuPont Hospital for Children 1600 Rockland Rd., Wilmington, DE 19899 Christiana Care Health System - Christiana Care Hospital 4755 Ogletown-Stanton Rd., Newark, DE 19718 Christiana Care Health System - Wilmington Hospital 501 West 14th St., Wilmington, DE 19801 HealthSouth Rehabilitation Hospital of Middletown 250 E. Hampden Rd., Middletown, DE 19709 Rockford Center - Rockford Center 100 Rockford Dr., Newark, DE 19713 Saint Francis Healthcare - St. Francis Hospital 701 N Clayton St., Wilmington, DE 19805 Wilmington VA Medical Center 1601 Kirkwood Hwy., Wilmington, DE 19805 Federally Qualified Health Centers Federally Qualified Health Centers (FQHC), funded with Section 330 federal grants, provide primary care (including medical, dental and mental health services) for uninsured and medically underserved populations. ZIP Code Tabulation Area data for New Castle County and information from the Uniform Data System (UDS) 1, were used to qualify the number of New Castle patients served by these centers. Two Federally

The UDS is an annual reporting requirement for grantees of HRSA primary care programs.

Qualified Health Centers (Henrietta Johnson Medical Center at Claymont and Westside Family Healthcare, Inc.) serve the county at multiple sites. Low-Income Patients Served by FQHC Low-Income Population 142,788

New Castle residents served by Section 330 Grantees

Penetration among LowIncome Patients

Penetration of Total Population

30,970

21.7%

5.42%

Source: UDS Mapper, 2014

The following are Federally Qualified Health Center sites: Henrietta Johnson Medical Center 601 New Castle Ave., Wilmington, DE 19801 Henrietta Johnson Medical Center at Eastside 600 N. Lombard St., Wilmington, DE 19801 Henrietta Johnson Medical Center at Claymont 3301 Green St., Claymont, DE 19703 Westside Family Healthcare, Inc., Wilmington 1802 W. 4th St., Wilmington, DE 19805 Westside Family Healthcare, Inc., Northeast 908-B E. 16th St., Wilmington, DE 19802 Westside Family Healthcare, Inc., Newark 27 Marrows Rd., Newark, DE 19713 Westside Family Healthcare, Inc., Bear / New Castle 404 Fox Hunt Dr., Fox Run Shopping Center, Bear, DE 19701

Birth Characteristics Births In 2012, there were 6,479 live births in New Castle County. Teen Birth Rate The teen birth rate of 32.3 per 1,000 live births in New Castle County was less than the rate of 36.6 per 1,000 live births for the State of Delaware. The birth rate among African American teens greatly exceeds the overall county rate and is twice the rate of White/Caucasian teens in New Castle County. Births to Teenage Mothers (Under Age 20) Rate/1,000 Live Births Area

Black/African American

White/ Caucasian

Overall

New Castle County

52.5%

26%

32.3%

Delaware

56.4%

31%

36.6%

Source: Delaware Department of Health and Social Services, Division of Public Health, 2007-2011

Prenatal Care More than eight in ten pregnant women in New Castle County received prenatal care in the first trimester of their pregnancy, though there are disparities across race and ethnicity. Additionally, a lower percentage of teenage mothers received prenatal care. The Healthy People 2020 national target is to increase the percentage of pregnant women who receive prenatal care in the first trimester to 77.9%. First Trimester Entry Into Prenatal Care Area New Castle County Delaware

Black/African American

Hispanic

White/ Caucasian

Overall

77%

73.1%

85%

82.6%

71.2%

55.2%

76.7%

75.3%

Source: Delaware Department of Health and Social Services, Division of Public Health, 2007-2011

Low Birth Weight Low birth weight is a negative birth indicator. Babies born at a low birth weight are at higher risk for disease, disability and possibly death. The Healthy People 2020 national target is to reduce the proportion of infants born with low birth weight to 7.8%. In New Castle County the rate of low birth weight babies was 9.1%, with the Black/African American babies being more likely to be born at a low birth rate.

Low Birth Weight (under 5.5 lbs.) Black/African American

Area

Hispanic

Overall

White

New Castle County

13.8%

7.8

9.1%

Delaware

13.2%

8.8%

Source: Delaware Department of Health and Social Services, Division of Public Health, 2007-2011

Infant Mortality The mortality rate measures deaths of infants in their first year of life. This continues to be one of the most widely used measures of the overall health status of a community. The leading causes of death among infants are birth defects, pre-term delivery, low birth weight, Sudden Infant Death Syndrome (SIDS) and maternal complications during pregnancy. The infant mortality rate in New Castle County was 9.1 per 1,000 live births. The rate among Black/African Americans was more than twice the rate for White/Caucasian infants (county level data on Hispanic births not available for reporting). The Healthy People 2020 national target is to reduce the infant mortality rate to 6 deaths or fewer per 1,000 live births. According to data from the Centers for Disease Control and Prevention, the actual number of infant deaths within the first year of life in New Castle County has declined in recent years: 73 in 2011 (10.6); 59 in 2012 (8.5); and 48 in 2013 (6.9). Infant Mortality Rate/1,000 Live Births Area

Black/Africa American

White/ Caucasian

Overall

New Castle County

15.6

6.2

9.1

Delaware

13.8

5.8

8.1

Source: Delaware Department of Health and Social Services, Division of Public Health, 2007-2011 Accessed - Delaware Health Tracker

Premature Death, Injury and Safety Premature Death Premature death is the number of deaths that could have been prevented among persons less than 75 years of age. Every death occurring before the age of 75 contributes to the total number of years of potential life lost. The rate of 7,200 in New Castle County is slightly lower than the state-wide rate. Premature Death, before Age 75, per 100,000 Persons Years of Potential Life Lost Rate 7,200 7,300

Area New Castle County Delaware Source: National Vital Statistics System 2011-2013 Accessed - County Health Snapshots, 2016

Unintentional and Intentional Injury Injury deaths is the number of deaths from intentional and unintentional injuries per 100,000 people in a population. The leading causes of death by unintentional injuries are: motor vehicle, poisoning and falls. The leading causes of intentional injury deaths are: suicide by firearm, homicide by firearm and suicide suffocation. The Healthy People 2020 national target is to reduce the deaths caused by unintentional injuries to 36.4 deaths per 100,000 people in the population. Deaths Due to Injury per 100,000 Persons Area

Injury Death Rate

New Castle County

Delaware

Source: County Health Snapshots, Measurement Period 2009-2013

Violent Crimes The violent crime rate is the number of violent crimes reported per 100,000 people in a population. Violent crimes are defined as offenses that involve face-to-face confrontation between the victim and the perpetrator, including homicide, forcible rape, robbery and aggravated assault. High levels of violent crime compromise physical safety and psychological well-being. High crime rates can also deter residents from pursuing healthy behaviors such as exercising outdoors. The rate of violent crimes in New Castle County (616 per 100,000) is greater than the state rate (576 per 100,000). 22

Number of Violent Crimes Reported per 100,000 Persons Area

Violent Crime Rate

New Castle County

616

Delaware

576

Source: County Health Snapshots, 2010-2012

Homicide The homicide rate is the number of deaths due to homicide per 100,000 people in a population. The homicide rate in New Castle County was 8 compared to a rate of 6 for the State of Delaware (County Health Rankings, 2016). Delaware’s homicide rate in recent years has outpaced that of every other state (Centers for Disease Control and Prevention, 2015). Wilmington, as the largest city in Delaware, affects this rate. The CDC reported: “Indeed, although Wilmington is a moderately-sized city of approximately 71,525 residents, when compared to all large cities in the United States, its homicide rate in recent years has been reported to be as high as fourth overall.” See or Hear Violence More than 1 in 10 adult residents of New Castle County report seeing or hearing violence in their neighborhood or community “many times” and triple the number of adult residents in the City of Wilmington said that this was the case for them. Adults Reporting How Often They Have Seen or Heard Violence in Community Area City of Wilmington Non-urban New Castle County New Castle County

Many Times

A Few Times

30.3%

32.6%

5.2%

21.8%

10.6%

24.2%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Adverse Childhood Conditions Adult residents of New Castle County report that during the first 18 years of their lives: •

•

Nearly one in six (15.2%) residents said that a parent or other adult in the household “often” or “very often” pushed, grabbed, slapped, threw something; or hit them you so hard that it left marks or they were injured. Nearly one in ten (8.9%) said that an adult or person at least five years older than them touched or fondled them, had them touch their body in a sexual way; or attempted or actually have oral, anal, or vaginal intercourse with them. 23

(Data source: Delaware Public Health Institute, 2015 Delaware Household Health Survey) Racial/Ethnic Discrimination One in five adult residents of the City of Wilmington said they had been discriminated against due to race or ethnicity “often” or “very often” during the first 18 years of life -double the number in non-urban New Castle County. Adults Reporting Discrimination Area

Very Often/ Often

Not Very Often/ Never

City of Wilmington

20.3%

79.7%

Non-urban New Castle County

10.1%

89.9%

New Castle County

12.3%

87.7%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Chronic Disease Health Status When asked to self-report on health status, 13% of adults in New Castle County indicated they were in fair or poor health. Fair or Poor Health, Adults, Age-Adjusted Area

Percent

New Castle County Delaware

13% 15%

Source: Behavioral Risk Factor Surveillance System 2014 Accessed on County Health Rankings, 2016

Diabetes Diabetes is a leading cause of death in the United States and people with diabetes are at increased risk for ischemic heart disease and stroke. It is a frequent cause of endstage renal disease, non-traumatic lower-extremity amputation and a leading cause of blindness among working-age adults. The percentage of adults diagnosed with diabetes was 8.3% in New Castle County. Women who were diagnosed with diabetes only during the course of their pregnancy (gestational diabetes) were not included in this count. This is lower than the state rate. Adult Diabetes Prevalence, Age-Adjusted, By County/State Area

Percent

New Castle Delaware

8.3% 11.1%

Source: CDC, National Diabetes Surveillance System, 2012 Delaware Health Tracker

A higher rate of adults in the City of Wilmington was told they had diabetes than adults in other parts of the county. Adults Told By Health Professional They Have Diabetes Area

Percentage

City of Wilmington

16%

Non-urban New Castle County

12%

New Castle County

12%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Asthma The percentage of children in grades 6 through 8 in New Castle County who have ever been diagnosed with asthma compares to the state rate. Percentage Children in 6-8th Grades, Diagnosed with Asthma Area New Castle Delaware

Percent 26% 26.3%

Source: Delaware Youth Risk Behavior Survey 2011 Delaware Health Tracker

Health Behaviors Overweight and Obesity Of adults in New Castle County, more than one-quarter report a BMI of 30 or greater and about the same report no leisure time physical activity. The Healthy People 2020 target is to decrease the percentage of adults engaged in no leisure-time physical activity to 32.6% or lower. Adult Obesity Percent Obese

Area

Percent Inactive

New Castle County

27%

23%

Delaware

29%

25%

Source: National Diabetes Surveillance System 2012 Accessed on County Health Rankings, 2016

When combining adults in the county who are overweight (BMI of 25 to 30) with those who are obese (BMI of 30 or greater), two-thirds of adults report weighing more than what is considered to be a healthy weight. Overweight or Obese Adults by Area Area

Combined Percentage Overweight or Obese

City of Wilmington

66%

Non-urban New Castle County

60%

New Castle County

62%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Infectious Diseases Sexually Transmitted Diseases Chlamydia is the sexually transmitted disease that is most prevalent in New Castle County, similar to the state rate. STD Cases, Rate per 100,000 Persons Area

Chlamydia

Gonorrhea

Syphilis

New Castle County

480

143

Delaware

479

137

Source: Delaware Department of Health and Social Services, Division of Public Health 2014

HIV/AIDS In New Castle County, the incidence of both HIV and AIDS is greater than for the State of Delaware. HIV/AIDS Incidence Rate per 100,000, 2014 HIV (new infections)

Area

AIDS

New Castle County

14.3%

9.6%

Delaware

12.5%

7.8%

Source: Delaware Department of Health and Social Services, Division of Public Health 2014

According to the Division of Public Health of the Delaware Department of Health and Social Services, the HIV/AIDS mortality has disproportionately affected Delawareâ&#x20AC;&#x2122;s Black/African American population. Statewide, though Blacks/African Americans made up only 23% of the total Delaware population in 2007 through 2011, they accounted for 76% of all deaths due to HIV/AIDS during that time.

Tobacco, Alcohol and Other Drugs Tobacco Use The percentage of youth and adults using tobacco products is reported in the tables below. Among youth, the rate is for those who said they smoked cigarettes on at least one day during the 30-day period prior to the survey. Youth Tobacco Use

New Castle County

Students in the th 11 grade 11%

Delaware

11%

Area

Students in the th 8 grade

Source: Delaware School Survey 2013 Accessed on KIDS COUNT in Delaware 2014 Fact Book

The rate of adults in New Castle County who smoke cigarettes is similar to the state rate. The Healthy People 2020 national target is to reduce the percentage of adults who smoke cigarettes to 12% or less. Adult Cigarette Smoking, 2013 Area

Percent

New Castle County

18.6%

Delaware

19.6%

Source: Behavioral Risk Factor Surveillance System 2013 Delaware Health Tracker

Nearly one-third of adult residents of the City of Wilmington smoke tobacco, significantly higher than for other parts of the county. Adults Reporting Currently Smoking Tobacco Products Area

Yes

City of Wilmington

29%

Non-urban New Castle County

18%

New Castle County

21%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Alcohol Use Among youth, the rate is for those who said they used alcohol on at least one day during the 30-day period prior to the survey. Youth Alcohol Use

New Castle County

14%

Students in the th 11 grade 36%

Delaware

14%

35%

Area

Students in the th 8 grade

Source: Delaware School Survey 2013 Accessed on KIDS COUNT in Delaware 2014 Fact Book

The following table describes adults binge drinking. Male binge drinking is defined as five or more drinks on one occasion and female binge drinking is four or more drinks on one occasion. One in five adults in New Castle County binge drink, which is slightly higher than the state rate, but both compare rates favorably to the Healthy People 2020 national target to reduce the proportion of adults aged 18 years and older engaging in binge drinking during the past 30 days to 24.4%. Adult Binge Drinking, 2006-2012 Area New Castle County Delaware

Percent 19.9% 17%

Source: Behavioral Risk Factor Surveillance System 2013 Delaware Health Tracker

Drug Use Among youth, the rate is for those who said they used marijuana on at least one day during the 30-day period prior to the survey. 29

Youth Marijuana Use Students in the th 8 grade

Area New Castle County Delaware

10%

Students in the th 11 grade 28%

26%

Source: Delaware School Survey 2013 Accessed on KIDS COUNT in Delaware 2014 Fact Book

The percentage for residents in the City of Wilmington using an illicit drug in the 30 days prior to the survey is higher than for New Castle residents. Illicit drugs include marijuana, cocaine, heroin, hallucinogens, inhalants and prescription-type psychotherapeutics used non-medically. Illicit Drug Use Area

Percent

City of Wilmington

12.5%

New Castle County

8.7%

Delaware

8.5%

Source: National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration 2010-2012 (Delaware Focus)

Substance Abuse Diagnosis Six percent of New Castle County adult residents said they have, at some time, been told by a doctor or other health professional that they have a substance abuse problem. Adults Told By Health Professional They Have Substance Abuse Problem Area

Percent

City of Wilmington

Non-urban New Castle County

New Castle County

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

An even greater percentage of New Castle County adult residents were told, at some time, by a peer, a friend, or a loved one that they have a substance abuse problem.

Adults Told By a Peer, Friend, or Loved One That They Have Substance Abuse Problem Area City of Wilmington Non-urban New Castle County New Castle County

Percent 14% 9% 10%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Among those told they had a problem, more than one-third of New Castle County residents said that they never received any form of treatment for substance abuse. More than half said the reason they did not receive treatment was because they did not need help or did not have a problem and one-fifth said they were able to handle it or could quit on their own.

Mental and Behavioral Health When asked about mental health, which includes stress, depression and problems with emotions, residents of New Castle County reported an average of 3.5 days during the past 30 days when their mental health was not good. This rate is similar to that of the State of Delaware. Poor Mental Health Days, Adults Area

Average Days

New Castle County

3.5

Delaware

3.6

Source: Behavioral Risk Factor Surveillance System 2014 Accessed on County Health Rankings, 2016

Diagnosis Nearly one-fifth of New Castle County residents have been diagnosed with a mental health condition including clinical depression, anxiety disorder or bipolar disorder. Diagnosis is more common among City of Wilmington residents than among the residents of non-urban areas of New Castle County. Adults Reporting Diagnosis for Mental Health Condition Area

Percent

City of Wilmington

26%

Non-urban New Castle County

16%

New Castle County

18%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Treatment Nearly two-thirds of New Castle County residents with a mental health condition are in treatment. Those not in treatment say they are no longer experiencing the problem or that treatment is not necessary. Some raise cost or lack of insurance coverage as the reason for not receiving treatment for their mental health condition. Adults with Mental Health Diagnosis, Reason for Not Being in Treatment No longer a problem/treatment not necessary

Cost barriers/Insurance does not cover

14%

30%

Non-urban New Castle County

51%

New Castle County

44%

Area City of Wilmington

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Vaccines and Screenings Vaccines Flu Vaccines Nearly two-thirds (63.7%) of the adults in New Castle County received an influenza vaccination in the past year, which is slightly lower than the state-wide figure. Adults Receiving Flu Vaccine Geographic Area

Percent

New Castle County Delaware

63.7% 65.8%

Source: Behavioral Risk Factor Surveillance System 2013 Delaware Health Tracker

Pneumonia Vaccination Two-thirds (66.5%) of adults aged 65 years and older in New Castle County have received a pneumococcal (pneumonia) vaccine. This is lower than the state rate of 72.4%. The Healthy People 2020 national target is to increase the proportion of adults aged 65 years and older who receive a pneumonia vaccination to 90% or higher. Adults Receiving Pneumonia Vaccine Area

Percent

New Castle County

66.5%

Delaware

72.4%

Source: Behavioral Risk Factor Surveillance System 2013 Delaware Health Tracker

Preventive Screening Mammograms and Pap Tests Among women ages 50 and over in New Castle County, most have had a screening mammogram and most women age 18 and older had a Pap test, on par with state figures. Adult Preventive Screenings Geographic Area

Mammograms Women 50+

New Castle County Delaware

84.2% 83.8%

Pap Test Women 18+ 82.6% 82.8%

Source: Health Indicators Warehouse, BRFSS, 2006-2012

Colonoscopy/Sigmoidoscopy Nearly three-quarters if adults age 50 and older in New Castle County have had the recommended colonoscopy/sigmoidoscopy screening. Adult Preventive Screenings

New Castle County

Colonoscopy/Sigmoidoscopy Adults 50+ 70.9%

Delaware

70.6%

Geographic Area

Source: Health Indicators Warehouse, BRFSS, 2006-2012

Prostate Cancer Screening When asked about their last PSA test or rectal exam for prostate cancer, nearly one-fifth of adult males in New Castle County said they have never had one. One-quarter of male adults in the City of Wilmington said they have never been screened. Adult Males Reporting Never Having Had PSA Test or Rectal Exam Area

Never Had PSA Test or Rectal Exam

City of Wilmington

26%

Non-urban New Castle County

15%

New Castle County

17%

Source: Delaware Public Health Institute, 2015 Delaware Household Health Survey

Mortality Death Due to Breast Cancer The age-adjusted death rate from breast cancer for females in New Castle County was 20.9 per 100,000 females, slightly less than the state rate. The Healthy People 2020 target is to reduce the breast cancer death rate to 20.7 deaths per 100,000 females. The rate among African American, non-Hispanic females is higher than both the HP 2020 rate, and the overall county rate. Age-Adjusted Death Rate Due to Breast Cancer, per 100,000 Females Area New Castle County Delaware

Black/African American 23.6 25.6

White

Overall Rate 20.8

20.9

21.7

Source: Source: Health Indicators Warehouse, BRFSS, 2009-2013

Death Due to Prostate Cancer The age-adjusted death rate due to prostate cancer in New Castle County was 24 per 100,000 males, slightly higher than the state rate. The Healthy People 2020 national health target is to reduce the prostate cancer death rate to 21.8 deaths per 100,000 males. The rate among African American males is notably higher than the HP 2020 target, the overall rate or the rate for white males. Age-Adjusted Death Rate Due to Prostate Cancer, per 100,000 Males Area New Castle County Delaware

Black/African American 36.2 39.2

White

Overall Rate 22.4

20.7

22.7

Source: National Cancer Institute Measurement period 2008-2012 Delaware Health Tracker

Death Due to Lung Cancer According to the American Lung Association, more people die from lung cancer each year than any other cancer. The greatest risk factor for lung cancer is duration and quantity of smoking. The age-adjusted death rate due to lung cancer in New Castle County compares to the state rate. The Healthy People 2020 national target is to reduce the lung cancer death rate to 45.5 deaths per 100,000 persons.

Age-Adjusted Death Rate Due to Lung Cancer, per 100,000 Persons Area New Castle County Delaware

Black/African American 50.6 50

Hispanic 20.3 14.2

White

Male

53.7

63.8

55.5

66.4

Female 43.9 45.2

Overall Rate 52.3 54.2

Source: National Cancer Institute Measurement period 2008-2012 Delaware Health Tracker

Death Due to Colorectal Cancer The age-adjusted death rate due to colorectal cancer in New Castle County was 14.7 per 100,000 persons. This represents a decrease from a rate of 16 in the reporting period 2007-2011. The Healthy People 2020 national target is to reduce the colorectal cancer death rate to 14.5 deaths per 100,000 persons. Age-Adjusted Death Rate Due to Colorectal Cancer, per 100,000 Persons Area

Overall Rate

New Castle County

14.7

Delaware

14.3

Source: Source: Health Indicators Warehouse, BRFSS, 2009-2013

Death Due to Cerebrovascular Disease or Stroke The age-adjusted death rate due to cerebrovascular disease and stroke per 100,000 people in New Castle County was 43.4, higher than the state rate. The Healthy People 2020 national target is to reduce the stroke death rate to 34.8 deaths per 100,000 population. Age-Adjusted Death Rate Due to Cerebrovascular Disease (Stroke), per 100,000 Persons Area

Overall Rate

New Castle County

43.3

Delaware

37.7

Source: National Cancer Institute Measurement period 2007-2011 Delaware Health Tracker

Death Due to Heart Disease This indicator shows the age-adjusted death rate per 100,000 persons due to heart disease. It includes deaths due to acute myocardial infarction, other ischemic heart disease, hypertensive heart disease, heart failure and all other heart disease. The rate of 165.4 per 100,000 people in New Castle County is slightly lower than the state rate. 36

Both the state and county rate exceed the Healthy People 2020 target of reducing death due to heart disease to 103.4 deaths per 100,000 population.

Age-Adjusted Death Rate Due to Heart Disease, per 100,000 Persons Area New Castle County Delaware

Overall Rate Age-Adjusted 165.4 172.6

Source: Delaware Department of Health and Social Services, Division of Public Health Measurement Period 2007-2011 Delaware Health Tracker

Death Due to Influenza and Pneumonia This indicator shows the age-adjusted death rate per 100,000 persons due to influenza and pneumonia. The rate of 13.4 per 100,000 people in New Castle County is greater than the state rate. Age-Adjusted Death Rate Due to Influenza and Pneumonia, per 100,000 Persons Area New Castle County Delaware

Overall Rate Age-Adjusted 13.4 12.4

Source: Delaware Department of Health and Social Services, Division of Public Health Measurement Period 2007-2011 Delaware Health Tracker

Death Due to Diabetes This indicator shows the age-adjusted death rate per 100,000 persons due to diabetes. The rate of 21.9 in New Castle County exceeds the state rate, as well as the Healthy People 2020 target of 66.6 deaths per 100,000 population due to diabetes. Age-Adjusted Death Rate Due to Diabetes, per 100,000 Persons Area New Castle County Delaware

Overall Rate Age-Adjusted 21.9 20.7

Source: Delaware Department of Health and Social Services, Division of Public Health Measurement Period 2007-2011 Delaware Health Tracker

Primary Data Community Interviews Key informant interviews were conducted in person and through telephone interviews by Mark Rukavina, of Community Health Advisors, LLC. These interviews were designed to gain perspective into the community health needs of the New Castle County service area. A total of 34 individuals were interviewed, the majority being external stakeholders from the area. Attachment 2 includes the names, organizational affiliation and community for each of the stakeholders interviewed for this assessment. People were interviewed during the month of March 2016. Community Health Advisors conducted community interviews using structured questions with key stakeholders asked to discuss community health issues, broader social determinants of health, availability of services to meet community needs and recommendations for improving community health. CHA reviewed and analyzed the interviews to identify the most frequently mentioned community health issues. Interview Findings The following health issues are considered to be of greatest concern based on the interviews with key informants. They are arranged in alphabetical order, not order of significance. Cost â&#x20AC;&#x201C; It was widely acknowledged that health insurance coverage gains have been made over the past few years. However, it is felt that cost is a problem for many residents in the area. Many interviewees referenced that their clients have difficulty paying for their medications, in particular due to high co-payments or deductibles. Cultural Competency And Diversity Among Providers â&#x20AC;&#x201C; Many stakeholders raised concern about the shortage of providers from the same racial/ethnic background as the people they serve. Some cited language and other cultural barriers that interfere with effective medical treatment. Often the interviewees saw cultural competency as going beyond racial/ethnic and linguistic groups, with several people raising concerns regarding the competency of providers when treating people with disabilities or the elderly. The perceived shortage of mental health services is exacerbated by the lack of culturally competent or racially/ethnically diverse providers. Mental Health â&#x20AC;&#x201C; Interviewees identified the need for more mental health services in the area, especially addressing trauma, depression and substance abuse. It was noted that there was some confusion or perceived disruption of services resulting from the recent integration at Christiana Care of mental health into primary care. While generally thought to be a good idea, there was also broad agreement that this integration should 38

be done while maintaining and effectively coordinating with community-based mental health services. Opiate/Heroin Addiction – There is widespread agreement that opiate and heroin addiction is a serious problem in New Castle County. Numerous stakeholders said that this problem affects people of all races, ethnicities and socio-economic classes. There was great interested in more community education, prevention and treatment services to address this problem. Other Priority Health Issues – In addition to those noted above, the health issues of most concern to the community stakeholders included cancer, HIV/AIDS, diabetes, obesity, cardiovascular health, care self-management, elder health, prevention and dental care. Addressing health disparities, especially as they relate to the African American community, was also a concern for many of the people interviewed. Social Determinants of Health – There is broad recognition of the importance of social determinants of health to good health across the community. Among the social determinants raised by many stakeholders were high rates of poverty, the lack of nutritional or food security, safety, violence and the trauma related to it. Other social determinants of health identified included homelessness and the challenge related to the lack of stable housing and quality education, teens feeling disenfranchised and the lack of safe social activities for youth. Teen Pregnancy and Infant Mortality – Several community leaders said that the high teen pregnancy and birth rates and infant mortality are serious community health problems. They expressed an interest in doing more work in this area and noted existing programs such as the Alliance for Adolescent Pregnancy Prevention and the Delaware Adolescent Program, Inc., which serve teenagers. Community Survey Findings Fifty-five people completed a survey administered at the Wilmington Farmers Market in February 2016. The vast majority of respondents were female (73%); had health insurance coverage (84%); and said that they had a doctor or nurse practitioner that they visit regularly (78%). Slightly more than one-third of respondents said they were Hispanic and just under twothird said Non-Hispanic. Thirty-five percent (35%) described themselves as being of two or more races; 29% African American; 27% White Non-Hispanic; and the remainder being of other races.

When asked the top five health issues in the community, respondents named: Diabetes – 73% 39

Obesity – 58% Heart Disease – 55% Substance Abuse – 40% Dental Health – 40% Asthma – 38% Mental Health – 35% Unprotected Sex – 33% When asked the top five health-related issues in their community, respondents named: Affordable Care - 69% Affordable Nutritious Food - 56% Lack of Exercise - 55% Affordable Housing - 53% Providers Speaking Language/Understanding Culture of Patient - 45% Tobacco Use - 38% Poverty - 33% Violence - 31%

Prioritized Significant Health Needs The health of New Castle County residents is influenced by many factors. The factors may include barriers to needed care that are due to financial, cultural, or transportation issues. Health is also influenced by nutritional, social, environmental, and behavioral factors. In prioritizing the health needs for the residents of our service area, we grouped the needs into three main categories: access to care, social determinants of health, and priority health issues. The process used to prioritize the needs is described in the section below. After reviewing the information gathered through this process, we have identified the following prioritized significant health needs for our area. 1. Prevalence of Poverty and Other Factors Including Food Insecurity, Housing, Affordability of Care, and Employment/Job Security 2. Mental Health and Substance Abuse 3. Violence and Public Safety Issues 4. Women and Childrenâ&#x20AC;&#x2122;s Health, In Particular Prenatal Care & Infant Mortality

Process and Criteria Used to Prioritize Health Needs To help with the process of prioritizing significant health needs, we surveyed nearly three dozen community leaders and stakeholders who helped us identify the significant health needs in our area. This group included people with community and health expertise, as well as representatives of public health, medically underserved populations, racial/ethnic populations, low-income and medically underserved groups. Members of the Christiana Care leadership team were also asked to prioritize the significant health needs. Using a brief web-based survey, we received responses from a total of 35 community stakeholders and Christiana Care leadership team members. There was noteworthy overlap in terms of the perceived priority needs. Senior leaders at Christiana Care examined this information in combination with the analysis of secondary data. Consideration was given to the Christiana Care and community resources available to address particular needs. Needs were prioritized based on severity and urgency, community perception of the importance, and any disparities associated with the needs. All of this information was factored into the decision made by the Christiana Care leadership team in prioritizing the significant health needs. 41

Christiana Care will consider these priorities needs, as well as available resources, feasibility and the effectiveness of possible interventions to design an implementation strategy to address selected needs.

Potential Resources to Address Prioritized Health Needs Prevalence of Poverty and Other Factors Including Food Insecurity, Housing, Affordability of Care, and Employment/Job Security Christiana Care Health System has programs that help to address social determinants of health needs, including the following: Food Insecurity Food assistance for children at Wilmington Hospital Pediatrics Camp FRESH Affordability of Care Christiana Care Financial Assistance Policy Employment/Job Security Program focused on the hiring of military personnel Christiana Care partner organizations and other resources offering related programs in the service area include: United Way 211 Line Food pantries, clothing closets, day programs and shelters operated by local churches and non-profit organizations. Mental Health and Substance Abuse Christiana Care Health System has various programs to address these needs including the following: Behavioral health integrated with primary care Crisis and Psychiatric Emergency Services Perinatal Mental Health program Outpatient Psychiatry Adolescent Bridge Program Adult Bridge Program Transgender counseling Project Engage Substance Abuse Counseling Project Recovery 42

Christiana Care partner organizations and other resources offering related programs in the service area include: Brandywine Counseling Delaware Mental Health Association NAMI Delaware Delaware Psychiatric Center MeadowWood Rockford Center Violence and Public Safety Christiana Care Health System has various programs to address these needs including the following: We are the Why Program Choice Road You Only Live Once Cease Violence Forensic Nurse Examiners Ripple Effect Say Something ThinkFirst for Teens Christiana Care partner organizations and other resources offering related programs in the service area include: Delaware Coalition for Injury Prevention: Gun Violence Delaware Commission for Women Delaware Coalition Against Domestic Violence (Delaware Men) Wilmington HOPE Commission Wilmington Peacekeepers Association

Women and Children’s Health – Prenatal Care and Infant Mortality Christiana Care Health System has various programs to address these needs including the following: Alliance for Adolescent Pregnancy Prevention Healthy Beginnings Center for Women’s Emotional Wellness LARC Long-Acting Reversible Contraception Program Neonatal Abstinence 43

Administrator of the Women Infants and Children (WIC) Breastfeeding Peer Counseling Program Health Ambassadors Christiana Care partner organizations and other resources offering related programs in the service area include: Delaware Adolescent Program, Inc. (DAPI) WIC Program Westside Family Healthcare Henrietta Johnson Medical Center

Evaluation of Actions Taken Since Last Assessment Navigation and Access to Health Care Market Place Guides: Christiana Care has devoted resources to improve access to insurance coverage, as well as navigation and access to health care services. In conjunction with other non-profit groups in the area, Christiana Care helped to increase the number of Delaware residents with health insurance coverage. During the 2015 federal open enrollment period, Christiana Care marketplace guides consulted about insurance options with 8,729 people at community events and on a one-on-one basis. They directly enrolled 317 individuals in health insurance coverage during the 2015 enrollment period. Health Ambassador Program: Christiana Care’s Health Ambassador Program promotes good health before pregnancy and provides information to help prevent premature births, a leading cause of death in newborn babies. The health ambassadors also promote key maternal and child health messages including the benefits of breastfeeding and the importance of safe sleep. They work in targeted high risk zip codes to connect pregnant women and young families to health care, social services, home visiting and educational programs. The health ambassadors work with community partners including Henrietta Johnson Medical Center, St. Francis Healthcare, Westside Family Healthcare and the Wilmington Hospital Health Center. Christiana Care leads a city-wide team of health ambassadors in partnership with other local partners. During Fiscal Year 2015, Health Ambassadors referred pregnant women and new parents to the following programs and services: • Medical home: 7,947 • Parenting support: 5,323 • Breastfeeding support: 666 • Food: 378 • Housing: 326 • Safe sleep: 177 • Clothing: 144 Blood Pressure Ambassador Program: The Blood Pressure Ambassador Program increases awareness of hypertension in the African-American community, using a model of peer education and camaraderie. In the last year, 82 ambassadors conducted more than 2,000 free hypertension screenings. Christiana Care’s Helen F. Graham Cancer Center & Research Institute’s Annual Free Skin Screening: Partnering with the Academy of Dermatology, The Cancer Center offers annual free skin cancer screenings. In May 2015, health care providers screened 132 people for skin cancer. Health Info On The Go: This effort reaches residents by using community health outreach and education staff to provide health education and routine health screenings 45

in cholesterol, glucose and blood pressure with cancer awareness, prevention and early detection at the local farmers market. Since the program’s inception in 2009, it has provided education to more than 3,500 shoppers and conducted screenings for more than 1,300 people. Breast Health Programs: Christiana Care Breast Health Programs reached more than 14,000 high-risk women in Fiscal Year 2015. They offer support to the underserved community. The program deploys bilingual navigators to improve access to mammograms, assistance with transportation, reminder notices, escorts for patients, and funding for screenings. They also provide community education to promote breast health, cancer prevention and early detection. Christiana Care’s community health and outreach staff work with the Hispanic community to train promotoras, who promote wellness and help connect other members of the Hispanic community with health services, particularly preventive screenings. The Healthy Latin Families Program helps New Castle County residents make their families and homes healthier. This serves those who need screenings and preventive care, those with chronic diseases and children with asthma. An annual Latinas Fuertes Y Saludables program, presented entirely in Spanish, brings health information, screenings and resources to more than 300 members of the Hispanic community. Electronic Health Records & Improved Coordination Christiana Care worked to increase use of electronic health records to improve care coordination and communication among providers and their patients. To do so, Christiana Care established Care Link, an expansive information technology-enabled network. Care Link case managers help patients with chronic illness navigate and coordinate hospital, physician, community and support services. This virtual hub of interdisciplinary professionals contributes to significant reductions in re-hospitalizations. Of 650 surgical patients managed by the Care Link team, fewer than 2 percent returned for observation or emergency department visits. The seven-day readmission rate was lower than for elective surgical patients not managed by Care Link. New Models of Care Christiana Care’s integration of mental health therapists into specialty and family medicine practices is opening mental health doors to children, adolescents and adults who might otherwise never seek help. The model follows an established national and international movement to align behavioral health with primary care in an effort to prevent or reduce the impact of mental health issues. Christiana Care’s 15 school-based wellness centers provided health services including physical exams, screenings, drug and alcohol abuse counseling and individual, family and group counseling to more than 23,000 adolescents in Fiscal Year 2015.

Care Link case managers help patients with chronic illness navigate and coordinate hospital, physician, community and support services. An interdisciplinary team of professionals contributes to significant reductions in re-hospitalizations. Of 650 surgical patients managed by the team, fewer than 2 percent returned for observation or emergency department visits. The seven-day readmission rate was lower than for elective surgical patients not managed by Care Link. The Medical Home Without Walls program, part of Care Link, reaches hospital and emergency department “superusers,” a group that includes fewer than 10 percent of all patients but accounts for more than 20 percent of all visits to the hospital (many of them homeless with complex medical problems). A case management team visits patients at their home or shelter, accompanies them to medical appointments and addresses social ills such as hunger, addiction and domestic violence. The program provides coordinated care to people who might otherwise only receive care through frequent visits to the emergency department.

Enhanced Mental Health Services Integrated Care Model: A shortage of mental health providers and treatment centers in our community has created significant access problems. To help address this problem, Christiana Care implemented a model of integrating mental health therapists in primary care and specialty practices. It was intended to improve access to mental health services for children, adolescents and adults who might otherwise not seek help. Therapists embedded in our cancer program, heart and vascular services, women’s health, primary care and pediatrics practices offer real-time collaboration among the patient, primary-care provider and behavioral health specialist. The approach follows an evidence-based national and international movement to align behavioral health with primary care in an effort to prevent or reduce the impact of mental health issues. Project Engage is a unique addiction recovery program based on a peer model and in collaboration with a non-profit counseling center in New Castle County. Since its inception, Project Engage has connected some 3,000 people with specially trained intervention counselors, known as engagement specialists, onsite at the hospital to work one-on-one with patients addicted to drugs or alcohol. Of 1,123 patients with substance-use disorder offered help through Project Engage, 27 percent accepted substance-abuse treatment. Christiana Care’s Center for Women’s Emotional Wellness provides specialized clinical care for women experiencing postpartum depression and other mood disorders that impact a mother’s bond with her baby and her entire family. The center offers outpatient therapy for individuals and couples, evaluation and management of medications and streamlined access to therapy services for women coping with behavioral health challenges before, during and after pregnancy. In addition, the team provides education to primary care professional to raise awareness about perinatal mood and anxiety disorders. In 2015, the team consulted with 240 new mothers in the hospital immediately following delivery and conducted 2,750 outpatient visits. Christiana Care screens all new mothers for mood and anxiety symptoms after childbirth, before they leave the hospital. 47

Attachment 1: Benchmark Comparisons Where data were available, indicators in New Castle County were compared to Healthy People 2020 objectives.

New Castle County Data

Healthy People 2020 Objectives

Child health insurance rate 94.5% Adult health insurance rate 90.2% Prenatal Care In First Trimester 82.6% Infants Born With Low Birth Weight 9.1%

Child Health Insurance Rate 100% Adult Health Insurance Rate 100% Prenatal Care In First Trimester 77.9% Infants Born With Low Birth Weight 7.8% Infant Mortality Rate 9.1 Per 1,000 Live Infant Mortality Rate 6 Per 1,000 Live Births Births Deaths Caused By Unintentional Injuries 58 Deaths Caused By Unintentional Deaths Per 100,000 People Injuries 36.4 Deaths Per 100,000 People Adults No Leisure Time Activity 23% Adults No Leisure Time Activity 32.6% Adults Who Smoke Cigarettes 18.6% Adults Who Smoke Cigarettes 12.0% Adults Binge Drinking During 19.9%. Adults Binge Drinking During 24.4%. Adults 65 + Pneumonia Vaccination 66.5% Adults 65 + Pneumonia Vaccination 90% Breast Cancer Death Rate 20.9 Deaths Per Breast Cancer Death Rate 20.7 100,000 Females Deaths Per 100,000 Females Prostate Cancer Death Rate 24 Deaths Per Prostate Cancer Death Rate 21.8 100,000 Males Deaths Per 100,000 Males Lung Cancer Death Rate 52.3 Deaths Per Lung Cancer Death Rate 45.5 Deaths 100,000 Persons Per 100,000 Persons Colorectal Cancer Death Rate 14.7 Deaths Colorectal Cancer Death Rate 14.5 Per 100,000 Persons Deaths Per 100,000 Persons Stroke Death Rate 43.3 Deaths Per Stroke Death Rate 34.8 Deaths Per 100,000 Population 100,000 Population Heart Disease Death Rate 165.4 Deaths Heart Disease Death Rate 103.4 Per 100,000 Population Deaths Per 100,000 Population Diabetes Death Rate 66.6 Deaths Per Diabetes Death Rate 66.6 Deaths Per 100,000 Population 100,000 Population

Attachment 2: Listing of Key Informants 1. Linda Brittingham, Christiana Care Director of Social Work 2. Kathy Cannatelli, Eugene du Pont Preventative Medicine & Rehabilitation Institute & Center for Community Health 3. Paul Calistro, West End Neighborhood House 4. Dr. Chris Cannon, Arsht Cannon Foundation 5. Reverend Tamika Cobb, Beautiful Gates Outreach Center 6. Vicky Cooke, Delaware Breast Coalition 7. Chief Bobby Cummings, City of Wilmington Police 8. Pastor Gerdts, First and Central Presbyterian Church in Wilmington 9. Susan Getman, Wilmington Senior Center 10. Allison Gill, American Cancer Society 11. Jim Grant, Delaware Department of Health and Social Services 12. Rich Heffron, Delaware State Chamber of Commerce 13. Judith Herrman, University of Delaware School of Nursing 14. Joe Hickey, St Patrickâ&#x20AC;&#x2122;s Center 15. Pastor Andy Jacob, Hanover Presbyterian Church 16. Lynn Jones, Christiana Care Visiting Nurse Association 17. Tyrone Jones, United Way of Delaware 18. Nora Katurakes, Christiana Care Cancer Outreach and Education 19. Omar Khan, M.D., Eugene duPont Preventive Medicine & Rehabilitation Institute, and Center for Community Health 20. Jim Lafferty, Mental Health Society 21. Secretary Rita Landgraf, Delaware Department of Health and Social Services 22. Reverend Tom Layman, Sunday Breakfast Mission 23. Lolita Lopez, Westside Family Health 24. Maria Matos, Latin American community Center 25. Dr. Karyl Rattay, Director of the Delaware Division of Public Health 26. Jill Rogers, Delaware Division of Developmental Disabilities 27. Colonel Elmer Setting, New Castle Police 28. Hanifa Shabazz, Wilmington City Councilwoman 29. Eileen Sparling, UD Center for Disabilities Studies 30. Michelle Taylor, United Way of Delaware 31. LaVaida White, retired public health nurse and active community resident 32. Emily Vera, Mental Health Society 33. Two members of the Christiana Care Patient Advisory Committees

Attachment 3: About Community Health Advisors, LLC Christiana Care Health System contracted with Community Health Advisors, LLC (CHA) for assistance with this assessment. Community Health Advisors provides customized service to hospitals and other health care providers seeking to improve community health. Specializing in assisting non-profit hospitals in their community health needs assessments, health improvement efforts and community benefit programming, CHA works with clients to ensure compliance with Section 501(r) regulatory requirements. Community Health Advisors was established in Massachusetts in 2012 by Mark Rukavina. Mr. Rukavina has more than two decades of experience working in the nonprofit health care sector, including directing a national, non-profit, research and advocacy organization and managing a hospital-based, community health demonstration program sponsored by the American Hospital Associationâ&#x20AC;&#x2122;s Health Research and Educational Trust. He holds an MBA from Babson College and a BS from of the University of Massachusetts in Amherst.