2022 New Castle County Community Health Needs Assessment by ChristianaCare

New Castle County

Community Health Needs Assessment June 1, 2022

TABLE OF CONTENTS TABLE OF CONTENTS......................................................................................................................................................... 2 EXECUTIVE SUMMARY ........................................................................................................................................................4 Introduction ............................................................................................................................................................................4 Community Assessed ......................................................................................................................................................4 Significant Community Health Needs .................................................................................................................. 6 Significant Community Health Needs: Discussion ...................................................................................... 6 Access to Health Services ...................................................................................................................................... 6 Chronic Health Conditions ....................................................................................................................................... 7 Maternal and Child Health ....................................................................................................................................... 7 Mental Health and Substance Use Disorders ............................................................................................. 8 Social Determinants of Health ............................................................................................................................. 8 Violent Crime................................................................................................................................................................... 9 DATA AND ANALYSIS ........................................................................................................................................................ 10 Community Definition ................................................................................................................................................... 10 Secondary Data Summary ......................................................................................................................................... 13 Demographics .............................................................................................................................................................. 13 Socioeconomic Indicators..................................................................................................................................... 13 Other Local Health Status and Access Indicators.................................................................................. 14 Food Deserts ................................................................................................................................................................. 16 Medically Underserved Areas and Populations ...................................................................................... 16 Health Professional Shortage Areas ............................................................................................................... 16 COVID-19 Prevalence and Mortality Findings .......................................................................................... 16 Findings of Other CHNAs ........................................................................................................................................17 Primary Data Summary ................................................................................................................................................ 18 Key Stakeholder Interviews ................................................................................................................................. 18 Community and Internal Hospital Meetings ............................................................................................. 20 OTHER FACILITIES AND RESOURCES IN THE COMMUNITY ....................................................................22 Federally Qualified Health Centers ......................................................................................................................22 Hospitals ...............................................................................................................................................................................23 Other Community Resources...................................................................................................................................23 APPENDIX A – OBJECTIVES AND METHODOLOGY........................................................................................25

Regulatory Requirements ..........................................................................................................................................25 Methodology ......................................................................................................................................................................25 Data Sources ................................................................................................................................................................ 26 Consultant Qualifications....................................................................................................................................... 27 APPENDIX B – SECONDARY DATA ASSESSMENT ..........................................................................................28 Demographics ...................................................................................................................................................................28 Socioeconomic Indicators .........................................................................................................................................34 People in Poverty ....................................................................................................................................................... 35 Unemployment ........................................................................................................................................................... 40 Health Insurance Status ......................................................................................................................................... 41 Crime Rates ....................................................................................................................................................................43 Housing Affordability ...............................................................................................................................................44 Dignity Health Community Need IndexTM ................................................................................................... 47 Centers for Disease Control and Prevention Social Vulnerability Index (SVI) ..................... 50 Other Health Status and Access Indicators .................................................................................................... 57 County Health Rankings ......................................................................................................................................... 57 Community Health Status Indicators ............................................................................................................ 60 COVID-19 Incidence and Mortality ..................................................................................................................63 Causes of Death ..........................................................................................................................................................64 Communicable Diseases ...................................................................................................................................... 69 Maternal and Child Health ................................................................................................................................... 70 Behavioral Risk Factor Surveillance System ............................................................................................. 73 Delaware School Survey ........................................................................................................................................ 78 Food Deserts ................................................................................................................................................................. 81 Medically Underserved Areas and Populations ......................................................................................83 Health Professional Shortage Areas ...............................................................................................................85 Findings of Other Assessments .............................................................................................................................. 87 Delaware State Health Improvement Plan, 2019 Annual Report ................................................. 87 APPENDIX C – COMMUNITY INPUT PARTICIPANTS .................................................................................... 88 APPENDIX D – CHSI PEER COUNTIES .................................................................................................................... 89 APPENDIX E – IMPACT EVALUATION ..................................................................................................................... 91

EXECUTIVE SUMMARY

EXECUTIVE SUMMARY Introduction ChristianaCare conducted this Community Health Needs Assessment (CHNA) to identify significant community health needs and to inform development of an Implementation Strategy to address current needs. ChristianaCare includes two hospital facilities in Delaware: Christiana Hospital in Newark and Wilmington Hospital in Wilmington. Because the two hospitals defined their communities to be the same (New Castle County, Delaware), they are sharing this joint CHNA report. Christiana Hospital is a 906-bed teaching hospital that operates Delaware’s only Level I trauma center and is the only high-risk delivering hospital in the state (with Level III neonatal intensive care services). The hospital’s campus in Newark is home to two Medical Arts Pavilions offering a wide array of outpatient services. Wilmington Hospital is a 321-bed hospital facility. A Wilmington landmark since 1890, Wilmington Hospital serves as ChristianaCare’s corporate headquarters and provides high quality hospital services for residents of Wilmington and New Castle County. Throughout this report, ChristianaCare refers to Christiana Hospital and Wilmington Hospital together. ChristianaCare has a third campus located in Elkton, Maryland. Union Hospital conducted a separate CHNA that assessed community health needs in Cecil County, Maryland. Additional information on ChristianaCare and its three hospital facilities can be found at: https://christianacare.org/about/. This CHNA has been conducted using widely accepted methodologies to identify the significant health needs of a specific community. The assessment also has been conducted to comply with federal and state laws and regulations.

Community Assessed For purposes of this CHNA, the community is defined as New Castle County, Delaware. During the year ended June 30, 2021, New Castle County accounted for 77 percent of Christiana Hospital’s discharges. Ninety-one (91) percent of Wilmington Hospital’s discharges were for New Castle County residents. The total population of New Castle County in 2021 was approximately 553,500 persons. Substantial variation in socioeconomic conditions exists across New Castle County. For example, the poverty rate in ZIP Code 19801 (where Wilmington Hospital is located) was approximately 35 percent, while the rate in ZIP Code 19701 was under 6 percent.1 Recognizing these variations, this CHNA assessed community health needs in two geographic subareas of New Castle County: “Community 1” (ZIP Codes 19801, 19802, 1

https://maps.udsmapper.org/map

EXECUTIVE SUMMARY 19804, 19805, and 19720) and “Community 2” (all other New Castle County ZIP Codes). Community 1 accounted for 28 percent of ChristianaCare discharges in 2021 and Community 2 accounted for 52 percent. The following map portrays the community assessed by ChristianaCare, the separation of the communities into Community 1 (pink) and Community 2 (purple), and the location of the two hospitals, Christiana Hospital (ZIP Code 19718) and Wilmington Hospital (ZIP Code 19801). Map of New Castle County, ChristianaCare Community

Source: Caliper Maptitude, 2021.

EXECUTIVE SUMMARY

Significant Community Health Needs As determined by analyses of quantitative and qualitative data, an overarching focus on advancing health equity, As determined by analyses of quantitative and qualitative data, an overarching focus on advancing health equity, recognizing that racism and poverty contribute to measurable health disparities, has the best potential to improve community health. Within this contextual framework, significant health needs in the community served by ChristianaCare are: • • • • • •

Access to Health Services, Chronic Health Conditions, Maternal and Child Health Mental Health and Substance Use Disorders, Social Determinants of Health, and Violent Crime.

Significant Community Health Needs: Discussion Access to Health Services Accessing health care services is challenging for some members of the community, particularly low-income people, racial and ethnic minorities, those with limited English proficiency, uninsured and underinsured persons, and the LGBTQ+ community. Barriers to accessing care and services are numerous and inter-related. The federal government has designated the low-income population of Newark and Wilmington as a Health Professional Shortage Area (HPSA) for primary care and for dental health. The per capita supply of dental health providers is low in New Castle County compared to national averages. The low-income population of Newark and Stanton also has been designated a HPSA for mental health. Stakeholders who provided input into this CHNA confirmed that community members living in certain geographic regions, living in poverty, and without health insurance have difficulty accessing primary care. Port Penn and Rockland have both had a comparatively high percentage of their population that is uninsured. Three of five Community 1 ZIP Codes are in the bottom quartile nationally for the percent of people who are 18-64 and uninsured. All five ZIP Codes are below average. Stakeholders and interviewees confirmed that accessing health services is most challenging for those with limited financial and transportation resources. The poverty rate in Community 1 has been well above the rate in Community 2. Rates for Black and Hispanic populations have also been above county-wide and U.S.-wide averages. Notably, the county’s senior (65+ years of age) population is projected to grow 30.5 percent between 2020 and 2030, resulting in an increased demand for more seniorsfocused health and social services.

EXECUTIVE SUMMARY Community input participants also emphasized difficulties accessing substance use disorder treatment services and access problems encountered by people who are unemployed.

Chronic Health Conditions According to County Health Rankings, the following New Castle County indicators benchmark unfavorably compared to the U.S.: • •

Percentage of the adult population with BMI >=30 Percentage of adults reporting no leisure time physical activity

Community 1 ZIP Codes have ranked in the bottom quartile nationally for the following measures: • • •

Fair or poor self-rated health status Physical inactivity Core preventive services for older men

Stakeholders and interviewees linked the high prevalence of chronic conditions to poor nutrition, obesity, and physical inactivity. They identified diabetes as a major community health problem, especially in Community 1 ZIP Codes. Access to primary care is difficult for those with low incomes and with limited English language ability.

Maternal and Child Health New Castle County has had a comparatively high prevalence of low birthweight babies compared to the U.S. The rate for the Non-Hispanic Black population (13.7 percent) has been almost double the rate for the Non-Hispanic White population (6.9 percent). According to a benchmarking analysis of County Health Rankings data, New Castle County has been the bottom quartile of peer counties for this indicator. Birth rates also have been comparatively high for teenage Non-Hispanic Black and Hispanic (or Latino) populations (27.3 and 28.8 births per 1,000 females aged 15-19 years, respectively). These rates have been more than three times that of Non-Hispanic Whites (8.1 per 1,000 females aged 15-19 years). County-wide infant mortality rates have been above Delaware and U.S. averages. Rates for Non-Hispanic Blacks (13.1 per 1,000 live births) have been more than double those for the Non-Hispanic Whites (4.3 per 1,000 live births). Community members providing input into this CHNA identified problems with low birthweight births and infant mortality rates as significant. Interviewees described a need for substance use treatment for pregnant women, including hospital-level care for pregnant women needing detox services. The most recent Delaware State Health Improvement Plan (SHIP, published in 2018) identified maternal and child health as an area of priority focus for 2018-2023.

EXECUTIVE SUMMARY

Mental Health and Substance Use Disorders According to County Health Rankings, the average number of mentally unhealthy days have been higher in New Castle County (4.3 days in the last 30 days) than in the U.S. overall (4.1 days). At 43.5 per 100,000 (age adjusted), deaths due to poisoning (including drug overdoses) have been significantly higher in New Castle County than in the U.S. (24 per 100,000). The percent of adults engaging in binge drinking has also been above average (19.8 percent in New Castle County and 17.2 percent in the U.S.). Community input participants (both adults and youth) identified mental health as the top health concern in New Castle County. Substance use, specifically opioid use and both fatal and non-fatal overdoses, were identified as top community health concerns by community input participants. A gap exists in affordable and viable substance use treatment options. Interviewees stressed the need to focus on underlying drivers of substance use, including trauma and mental health problems. The most recent Delaware SHIP also identified mental health and substance use disorders as areas of priority focus.

Social Determinants of Health Many community meeting participants and interviewees mentioned the significance of social determinants of health. Poverty, unemployment, lack of affordable housing, homelessness, inequitable educational attainment, minority status, and limited English language proficiency were described as contributors to poor health outcomes and health disparities. Social determinants of health disproportionately affect Community 1 compared to the rest of New Castle County. Poverty rates have been highest in Community 1 and for Black and Hispanic populations across the county. Community 1 compares unfavorably to New Castle County as a whole and U.S. averages for the following indicators: • • • • • • •

Poverty rate (under 100 percent of the Federal Poverty Level) Low-income (under 200 percent of the Federal Poverty Level) Less than High School Diploma Percent of households rent burdened Community Need Index™ Lack of health insurance (18-64) Limited English

At 4.4, the Community Need Index™ (CNI) score for Community 1 places those ZIP Codes in the “highest need” category nationally. The U.S. median score is 3.0 and the weighted average for New Castle County is 2.8. The CNI is available for every ZIP Code in the U.S. and is comprised of five social and economic indicators.

EXECUTIVE SUMMARY

Violent Crime Both adults and youth who provided input into this CHNA identified violent crime as a significant community health concern. New Castle County crime rates have been above Delaware averages for serious property offenses, other property and social offenses, robbery, burglary, larceny/theft, property destruction/vandalism, and weapons law violations. Stakeholders indicated that crime affects residents’ ability to secure safe, affordable housing and may be inter-related with substance use. According to County Health Rankings, reported violent crime offenses per 100,000 population have been much higher in New Castle County (551.3) than in the U.S. (386.0).

DATA AND ANALYSIS

DATA AND ANALYSIS Community Definition This section identifies the community that was assessed by ChristianaCare’s Delaware hospital facilities. The community was defined by considering the geographic origins of the inpatient discharges during the year ended June 30, 2021. On that basis, the community was defined as New Castle County. The county accounted for approximately 79 percent of the hospitals’ 2021 inpatient volumes (Exhibit 1). Exhibit 1: ChristianaCare Inpatient Discharges, 2021 ZIP Code

City/Town

19720 New Castle 19702 Newark 19713 Newark 19805 Wilmington 19808 Wilmington 19701 Bear 19711 Newark 19709 Middletown 19802 Wilmington 19801 Wilmington 19804 Wilmington 19810 Wilmington 19803 Wilmington 19809 Wilmington 19707 Hockessin 19703 Claymont 19734 Townsend 19806 Wilmington 19807 Wilmington 19706 Delaware City 19730 Odessa 19731 Port Penn 19733 Saint Georges 19736 Yorklyn 19732 Rockland New Castle County Community 1 Community 2 Other Areas All Discharges

Christiana Hospital

Wilmington Hospital

5,091 3,794 3,190 2,207 3,057 3,071 2,940 3,020 1,231 900 1,516 854 764 596 955 536 834 334 248 194 50 28 21 8 3 35,442 10,945 24,497 10,779 46,228

753 222 284 1,184 296 229 246 163 1,644 1,102 270 849 840 574 122 526 55 493 176 12 4 3 1 7 4 10,059 4,953 5,106 1,033 11,092

CCHS Discharges 5,844 4,016 3,474 3,391 3,353 3,300 3,186 3,183 2,875 2,002 1,786 1,703 1,604 1,170 1,077 1,062 889 827 424 206 54 31 22 15 7 45,501 15,898 29,603 11,812 57,320

Source: Analysis of ChristianaCare’s utilization data, 2021.

Percent of Total CCHS Discharges 10.2% 7.0% 6.1% 5.9% 5.8% 5.8% 5.6% 5.6% 5.0% 3.5% 3.1% 3.0% 2.8% 2.0% 1.9% 1.9% 1.6% 1.4% 0.7% 0.4% 0.1% 0.1% 0.0% 0.0% 0.0% 79.4% 27.7% 51.7% 20.6% 100.0%

DATA AND ANALYSIS The total population of New Castle County in 2021 was approximately 553,533 persons. Community 1 was comprised of 158,573 persons and Community 2 was comprised of 394,960 persons (Exhibit 2). Exhibit 2: Community Population by ZIP Code

ZIP Code

Total Population

City/Town

19720 New Castle 19702 Newark 19711 Newark 19709 Middletown 19701 Bear 19808 Wilmington 19805 Wilmington 19713 Newark 19802 Wilmington 19810 Wilmington 19803 Wilmington 19804 Wilmington 19801 Wilmington 19707 Hockessin 19703 Claymont 19809 Wilmington 19734 Townsend 19806 Wilmington 19807 Wilmington 19717 Newark 19706 Delaware City 19716 Newark 19730 Odessa 19731 Port Penn 19732 Rockland 19733 Saint Georges 19736 Yorklyn Community 1 Community 2 Summary

Percent Population

59,410 54,980 53,194 45,005 42,240 38,106 38,061 30,403 26,126 25,273 21,484 17,529 17,447 16,383 15,379 14,827 13,072 9,313 7,369 3,649 1,858 1,426 441 350 81 68 59 158,573 394,960 553,533

Source: U.S. Census, ACS 5-Year Estimates, 2020

10.7% 9.9% 9.6% 8.1% 7.6% 6.9% 6.9% 5.5% 4.7% 4.6% 3.9% 3.2% 3.2% 3.0% 2.8% 2.7% 2.4% 1.7% 1.3% 0.7% 0.3% 0.3% 0.1% 0.1% 0.0% 0.0% 0.0% 28.6% 71.4% 100.0%

DATA AND ANALYSIS Exhibit 3 shows the ZIP Codes that comprise the ChristianaCare community and Community 1 and Community 2 within New Castle County. Christiana Hospital is in Newark (ZIP Code 19718). Wilmington Hospital is in Wilmington (ZIP Code 19801). Exhibit 3: ChristianaCare’s Community

Source: Caliper Maptitude, 2021.

DATA AND ANALYSIS

Secondary Data Summary The following section summarizes principal observations from the secondary data analysis. See Appendix B for more detailed information.

Demographics Demographic characteristics and trends directly influence community health needs. The total population of New Castle County is expected to grow 2.6 percent from 2020 to 2030 (approximately 14,932 persons). The population 65 years of age and older is anticipated to grow much more rapidly (by 30.5 percent, or 27,659 persons) during that time. This development could contribute to greater demand for health services, since older individuals typically need and use more services than younger persons. Substantial variation in demographic characteristics (e.g., age, race/ethnicity, and income levels) exists throughout the county. In two Community 1 ZIP Codes (19801 and 19802), over 75 percent of the population identifies as Black. In Community 1 as a whole, approximately 48 percent of the population identifies as Black; in Community 2, this statistic is 17 percent. Wilmington ZIP Codes 19804 and 19805 have the highest percentage of population that identify as Hispanic (21.0 and 25.2 percent). Approximately 15 percent of the overall population in Community 1 identifies as Hispanic; in Community 2, this statistic is about 8 percent.

Socioeconomic Indicators People living in low-income households generally are less healthy than those living in more prosperous areas. The overall poverty rate in New Castle County has been below Delaware and U.S. averages; however, rates for Black and for Hispanic (or Latino) county residents have been substantially higher than rates for White residents. The poverty rate in Community 1 has been more than double the rate for Community 2 (16.8 percent compared to 8.3 percent). Low-income census tracts are most prevalent in Newark, Wilmington and throughout Community 1. In many of these census tracts, more than one-half of households are “rent burdened,” are categorized as “high need” by the Dignity Health Community Need IndexTM (CNI) and are in the top quartile nationally for “social vulnerability” according to the Centers for Disease Control’s Social Vulnerability Index. The CNI is calculated for every ZIP Code in the United States. The median score for the U.S. is 3.0, and ZIP Codes are assigned to five categories ranging from “Lowest” to “Highest” Need. At 2.8, the weighted average CNI score for New Castle County is below the U.S. median. The weighted average score for Community 1 is 4.4 (indicating “Highest Need”) and the score for Community 2 is 2.5. Between 2016 and 2019, unemployment rates in New Castle County and the United States declined. The COVID-19 pandemic led to significant increases in unemployment in 2020.

DATA AND ANALYSIS In 2021, rates declined as the economy began to recover from the pandemic; however, New Castle County unemployment rates have remained above both Delaware and the U.S. Because many have employer-based health insurance coverage, continued economic recovery will be important to maintaining access to care. In recent years, the county has had a lower percentage (5.1 percent) of the population without health insurance than Delaware (5.8 percent) and the United States (8.7 percent). Delaware expanded Medicaid eligibility effective January 1, 2014. According to an analysis published by the Kaiser Family Foundation, 62,500 uninsured adults became eligible for Medicaid because of the expansion. New Castle County’s crime rates have been higher than Delaware rates for serious property offenses, other property and social offenses, robbery, burglary, larceny/theft, motor vehicle theft, property destruction/vandalism, and weapon law violations.

Other Local Health Status and Access Indicators Delaware is home to three counties. In the 2021 County Health Rankings, New Castle County ranked number one both for Health Outcomes and for Health Factors (above Sussex and Kent counties). Community Health Status Indicators (CHSI) compares County Health Rankings indicators for each county with those for peer counties across the United States. Each county is compared to 30 to 35 of its peers, which are selected based on socioeconomic characteristics such as population size, population density, percent elderly, per-capita income, and poverty rates. In CHSI, New Castle County compared unfavorably to peer counties for 16 of the 34 benchmark indicators. New Castle County was in the bottom quartile compared to peer counties for the following indicators: • • • • • • • • •

Years of potential life lost before age 75 per 100,000 Percent of live births with low birthweight Newly diagnosed chlamydia cases per 100,000 Percent of adults 25-44 with some college Percent unemployed Ratio of income at 80th percentile to 20th percentile Percent of children in single-parent households Reported violent crime offenses per 100,000 Average daily density of fine particulate matter (PM2.5)

Secondary data from Delaware Health and Social Services (DHSS), the Centers for Disease Control, the Health Resources and Services Administration, the United States Department of Agriculture, and others also were assessed. Based on an assessment of available secondary data, the indicators presented in Exhibit 4 appear to be most significant in New Castle County. An indicator is considered significant if it was found to vary materially from a benchmark statistic (e.g., an average value for Delaware, for peer counties, or for the United States). For example, the deaths due to poisoning (including drug overdose) rate in the county was

DATA AND ANALYSIS 43.5 per 100,000, significantly higher than the U.S. average of 24.0 per 100,000. The last column identifies the Exhibit number in this report for each indicator. Exhibit 4: Significant Indicators Indicator

Area

65+ population change, 2020-2030 Poverty rate, Black, 2016-2020 Poverty rate, Hispanic, 2016-2020 Poverty rate Low Income (<200% of FPL) Less than High School Diploma Unemployment Population without health insurance Rent burden (> 30% income on housing) Community Need Index™ Years of Potential Life Lost Before 75 Per 100,000 Average number of mentally unhealthy days Percent of adults who are current smokers Percent of adults reporting no leisure time physical activity Newly diagnosed Chlamydia Cases per 100,000 Ratio of population to dentists Rate of hospital stays for ambulatory-care sensitive conditions Percent Children in Single-Parent Households Reported Violent Crime Offenses per 100,000 Deaths Due to Injury Per 100,000 Average daily density of fine particulate matter (air pollution) Percent of workforce that drives alone to work Percent of adults with some college Income Inequality (ration of income 80th to 20th percentile) Percent of live births with low birthweight Mortality due to accidental poisoning and exposure to noxious substances (per 100,000) Cancer Mortality (all cancer sites), per 100,000 Death due to poisoning (including drug overdose), per 100,000 Infant Mortality per 1,000 live births Binge drinking

Value

Benchmark Value Area 2.6% Community total 12.8% U.S., All races/ethnicities 12.8% U.S., All races/ethnicities 11.2% New Castle County 24.0% New Castle County 8.4% New Castle County 5.3% United States 8.7% United States 8.7% United States 49.1% United States 49.1% United States 49.1% United States 3.0 United States 6,900 United States 4.1 United States 17.0% United States 23.0% United States 627.7 United States 1,400:1 United States 4,236 United States 27.9% United States 386.0 United States 72.0 United States 7.2 United States 76.0% United States 69.9% Peer counties 4.2% Peer counties 7.9% Peer counties

New Castle County New Castle County New Castle County Community 1 Community 1 Community 1 New Castle County Port Penn Rockland Community 1 Hockessin Newark Community 1 New Castle County New Castle County New Castle County New Castle County New Castle County New Castle County New Castle County New Castle County New Castle County New Castle County New Castle County New Castle County New Castle County New Castle County New Castle County

30.5% 16.7% 16.3% 16.8% 35.2% 12.5% 6.3% 12.9% 24.7% 51.5% 54.3% 56.7% 4.4 7,918 4.3 18.4% 24.7% 643.1 1,639:1 4,896 28.1% 551.3 82.0 9.4 79.9% 63.9% 4.6% 9.0%

New Castle County

45.3

26.9 United States

New Castle County New Castle County New Castle County New Castle County

161.3 43.5 7.8 19.8%

152.4 United States 24.0 United States 5.7 United States 17.2% United States

32 33 39 40

Source: Verité Analysis.

When available New Castle County community health data are arrayed by race and ethnicity, significant differences are observed for: • • • • • •

Exhibit

Poverty rates Uninsured rates Educational achievement Low birthweight babies (per 1,000 live births) Teen birth rates Infant mortality rates

These differences indicate the presence of racial and ethnic health inequities and disparities.

7 13 13 15 15 15 17 18 18 20 20 20 22 28 28 28 28 28 28 28 28 28 28 28 28 29 29 29

DATA AND ANALYSIS

Food Deserts The U.S. Department of Agriculture’s Economic Research Service identifies census tracts that are considered “food deserts” because they include lower-income persons without supermarkets or large grocery stores nearby. Food deserts are present in the cities of Newark and New Castle, and elsewhere in Community 1.

Medically Underserved Areas and Populations Medically Underserved Areas and Populations (MUA/Ps) are designated by the Health Resources and Services Administration based on an “Index of Medical Underservice.” Several census tracts in New Castle County have been designated as Medically Underserved Areas (in Community 1 proximate to Wilmington Hospital and in the northeastern area of Community 2).

Health Professional Shortage Areas A geographic area can receive a federal Health Professional Shortage Area (HPSA) designation if a shortage of primary medical care, dental care, or mental health care professionals is present. Certain types of health facilities also are HPSAs. • • •

The low-income population of Newark and Wilmington have been designated as Primary Care and Dental Health HPSAs. The low-income population of Newark and Stanton have been designated as Mental Health HPSAs. Both Westside Family Healthcare and Henrietta Johnson Medical Center were HPSA designated Federally Qualified Health Centers (FQHC) for primary care, mental health, and dental health professionals.

COVID-19 Prevalence and Mortality Findings The Centers for Disease Control and Prevention (CDC) provides information, data, and guidance regarding the COVID-19 pandemic. The pandemic has been a public health emergency for the New Castle County, the nation, and the world. The pandemic also has exposed the significance of problems associated with long-standing community health issues, including racial health inequities, chronic disease, access to health services, mental health, and related issues. Part of the CDC’s work has included identifying certain populations that are most at risk for severe illness and death due to the pandemic. Based on that work, many at-risk people live in the community served by Union Hospital. Populations most at risk include: • • • •

Older adults; People with certain underlying medical conditions, including cancer, chronic kidney disease, COPD, obesity, serious heart conditions, diabetes, sickle cell disease, asthma, hypertension, immunocompromised state, and liver disease; People who are obese and who smoke; Pregnant women; and,

DATA AND ANALYSIS •

Black and Hispanic (or Latino)

According to the CDC, “long-standing systemic health and social inequities have put some members of racial and ethnic minority groups at increased risk of getting COVID-19 or experiencing severe illness, regardless of age.” As of April 2022, COVID-19 mortality rates in New Castle County have been lower than U.S. averages. However, there have been 148,107 cases and 252 deaths since the pandemic began.

Findings of Other CHNAs The 2018-2023 Delaware State Health Needs Assessment (DSHNA) and State Health Improvement Plan (SHIP) identified and prioritized local and statewide strategies that address critical health needs. The DSHNA and SHIP named four areas of priority focus: chronic disease; maternal and child health; substance use disorders; and mental health. Fourteen recommendations were provided to address these four priority areas: Chronic Disease 1. Reduce obesity by promoting healthy diet and exercise 2. Increase access to healthy foods 3. Improve the built environment 4. Promote access to remote patient monitoring for patients with chronic conditions 5. Increase access to community health workers and care coordination 6. Reduce lung disease (e.g., asthma, lung cancer, chronic obstructive pulmonary disease) 7. Increase the number of primary care physicians in underserved areas 8. Increase the number of Medicaid dental providers in underserved areas 9. Develop a focused effort to “make the healthy choice the easy choice” Maternal & Child Health 10. Embed education for pre- and inter-conception care in schools Substance Use Disorders 11. Reduce tobacco and tobacco-substitute use 12. Reduce substance use Mental Health 13. Improve access to behavioral and mental health services System-wide Recommendations 14. Adopt a Policy, Systems, and Environmental (PSE) change approach to promoting health in all policies, incorporating a social marketing approach, and addressing the social determinants of health. This CHNA has found that several of the above issues remain problematic in New Castle County.

DATA AND ANALYSIS

Primary Data Summary Primary data were gathered through interviews and community meetings. Six online community input meetings and two interviews (with three individuals) were conducted. See Appendix C for information regarding those who participated in the community meetings and interviews.

Key Stakeholder Interviews Interviews were conducted with three stakeholders to learn about community health issues in New Castle County. Participants included the Cabinet Secretary and Deputy Secretary for Delaware Health and Social Services and the Director for the Delaware Division of Substance Abuse and Mental Health. Questions focused first on identifying and discussing health issues in the community before the COVID-19 pandemic began. Interviews then focused on the pandemic’s impacts and on what has been learned about the community’s health given those impacts. Stakeholders also were asked to describe the types of initiatives, programs, and investments that should be implemented to address the community’s health issues and to be better prepared for future risks. The interviewees most frequently identified the following issues as significant before the COVID-19 pandemic began. •

Access to Health Services. Interviewees noted a persistent lack of primary care as a significant issue in the community. They reported an undersupply of primary care providers and community members not establishing a medical home as key drivers of this issue. Interviewees identified cost of care, lack of health insurance or underinsurance, distrust in healthcare, and transportation challenges as contributing factors. They stated that many community members also lack dental care, especially those without employer-based dental coverage. As a result, people rely on emergency departments for significant dental issues.

•

Mental Health. A lack of community-based resources exists for people with persistent and serious mental health issues. In recent years, a Delaware settlement required mental health inpatients be deinstitutionalized and housed in the community. Although some programs with differing levels of support exist, there are not enough programs, services, or housing to meet growing demand. An increasing number of patients have serious and persistent mental illness and are exhibiting aggressive behavior. Not enough mental health providers and other trained professionals are available to care for this population. There has also been a rise in the aging population within this group and thus, more medical issues along with mental illness. Interviewees noted the difficulty meeting the significant needs of this population with lack of human and other resources.

•

Chronic Disease Management. Chronic disease management, especially diabetes, was raised by interviewees as a major community health problem. Issues with access to primary care, discussed above, has played a role. Some areas of the

DATA AND ANALYSIS county are more impacted than others, specifically the city of Wilmington, the Route 9 corridor, and ZIP Codes 19720, 19804, and 19805. These areas are lower income, lack culturally competent providers, and have residents that are marginally employed and unable to qualify for Medicaid or employer-based insurance. •

Health Disparities. Health disparities are recognized as a significant public health issue. Interviewees noted that certain areas of the county have experienced the impacts of systemic racism. Racial and ethnic minorities have been left behind and experience lower incomes, less home ownership, and lower access to loans and jobs. These factors play a role in health behaviors and poor health outcomes. There is a lack of cohesiveness across dividing lines and districts which creates difficulty in delivering services equitably. Some areas lack care resources and investment, specifically Wilmington.

•

Housing. Lack of affordable, safe housing is noted as a significant community health issue. Rent has escalated and there is a lack of group homes and apartment housing which has precipitated homelessness in the community. Interviewees noted that lack of safe housing affected the ability to discharge patients from inpatient care in a timely manner. There was also a reported issue with landlords being unwilling or reluctant to serve those with known mental illness.

•

Substance Use. Substance use, specifically opioid use, is identified as a foremost community health concern. Concerns with both fatal and non-fatal overdoses are reported. There is a reported gap in affordable and viable substance use treatment options. Interviewees identified a need to focus on underlying drivers of substance use, such as trauma and self-medication, as well as dual diagnosis (mental illness and substance use disorder).

Interviewees were asked to describe the impacts of the COVID-19 pandemic on providers, social service organizations, and the community. They responded as follows. •

Healthcare Workforce. A strong need to invest in the healthcare workforce was identified as key to meeting the ongoing health needs of the community. Adequate pay and how healthcare workers are treated is key to retaining staff. The COVID-19 pandemic exacerbated an already existing staffing shortage amongst clinical and frontline staff. Many left healthcare jobs for other industries that paid better and offered better benefits.

•

Telehealth Expansion. Expanded telehealth services were described as a positive development. Increased flexibility on both the side of provider and patient has increased access to care and ease of use.

•

Distrust of Healthcare System and Messaging. Interviewees noted that many marginalized residents lack trust in the healthcare system and providers. Some of this stemmed from experience with culturally incompetent care or lack of sensitivity and attention to minority populations. It was related that the messenger matters and that utilizing place-based interventions and community health workers may improve this issue.

DATA AND ANALYSIS •

Fragmentation of Health and Social Services. Fragmentation and a low level of coordination of care were named as major issues in provision of care, especially with COVID-19 testing and vaccination roll-out. Interviewees identified a gap in coordination between state services and healthcare services. Also noted, was a need to help patients navigate the very complex medical and social services that exist.

Interviewees identified several types of programs and initiatives that would help fill gaps and improve community health. These include a need to integrate mental health services into neighborhoods with a key priority of making services culturally appropriate and accessible. Interviewees identified a need for more mobile services for opioid and other substance use disorders. There is a particular need for substance use treatment for pregnant women, especially hospital level care for pregnant women who need detox services.

Community and Internal Hospital Meetings Six community meetings were conducted in March 2022 to obtain community input. Four community stakeholder meetings were held. Thirty-five (35) individuals participated. These individuals represented organizations including Delaware Health and Social Services, non-profit organizations, local businesses, healthcare providers, local policymakers, and school systems. Forty-five (45) individuals participated in meetings with Christiana Hospital and Wilmington Hospital staff. Individuals from administration, nursing, case management, social services, project management, and health equity participated. A meeting was also held with one hundred ten (110) students from William Penn High School, health classes. That meeting focused on needs pertaining to New Castle County youth. Each meeting began with a presentation that discussed the CHNA process and the purpose of the meetings. Secondary data were presented including a summary of unfavorable community health indicators. Meeting participants then were asked for feedback on the secondary data analysis and to identify community health issues that may not have been found based on the data. Participants then were asked to complete an online survey and to identify “three to five” community health issues they consider to be most significant. Through this process, meeting participants identified the following community health needs as most significant in New Castle County: • • • • • •

Access to care Chronic conditions Dental health Mental health Obesity, poor nutrition, and physical inactivity Sexually transmitted infections (youth)

DATA AND ANALYSIS • • • • •

Smoking, tobacco, and vape product use (youth) Social determinants of health Substance use disorders Violent crime Preventive services and screenings

OTHER FACILITIES AND RESOURCES IN THE COMMUNITY

OTHER FACILITIES AND RESOURCES IN THE COMMUNITY This section identifies other facilities, clinics, and resources available in the ChristianaCare community that are available to address community health needs.

Federally Qualified Health Centers Federally Qualified Health Centers (FQHCs) are established to promote access to ambulatory care in areas designated as “medically underserved.” These clinics provide primary medical care and can offer mental health and dental services for lower-income members of the community. FQHCs receive enhanced reimbursement for Medicaid and Medicare services and most also receive federal grant funds under Section 330 of the Public Health Service Act. There currently are nine FQHC sites operating in New Castle County (Exhibit 5) according to 2022 HRSA data. Exhibit 5: Federally Qualified Health Centers, 2022 Health Center Name

Address

City

ZIP Code

Westside Family Healthcare - Administration Office

300 Water St STE 200

Wilmington

19801

Westside Family Healthcare - Administrative/Service Delivery Site

404 Foxhunt Dr

Bear

19701

Westside Family Healthcare - Ancillary Administration Office

13 Reads Way STE 102

New Castle

19720

Westside Family Healthcare - Service Delivery Site

1802 W 4th St

Wilmington

19805

Westside Family Healthcare - Service Delivery Site

908 E 16th St STE B

Wilmington

19802

Westside Family Healthcare - Service Delivery Site

27 Marrows Rd

Newark

19713

Henrietta Johnson Medical Center at Eastside - Service Delivery Site

600 N Lombard St

Wilmington

19801

Henrietta Johnson Medical Center at Claymont - Service Delivery Site 2722 Philadelphia Pike

Claymont

19703

Henrietta Johnson Medical Center - Service Delivery Site

Wilmington

19801

601 New Castle Ave

Source: Health Resources and Services Administration, 2022.

According to 2020 data published by Health Resources and Services Administration (HRSA), FQHCs served twenty-three (23) percent of uninsured persons and nine (9) percent of Medicaid recipients in New Castle County. Nationally, FQHCs served 22 percent of uninsured patients and 19 percent of the Medicaid recipients.2

See: http://www.nachc.org/research-and-data/research-fact-sheets-andinfographics/chartbook-2020-final/ and https://www.udsmapper.org/. 2

OTHER FACILITIES AND RESOURCES IN THE COMMUNITY

Hospitals Exhibit 6 presents information on hospital facilities that operate in New Castle County. Exhibit 6: Hospital Facilities, 2022 Hospital Name

Address

City

ZIP Code

Number of Beds

Nemours Children's Hospital Delware

1600 Rockland Road

Wilmington

19803

260

ChristianaCare Health Services, Christiana Hospital

4755 Ogletown-Stanton Road

Newark

19718

906

ChristianaCare Health Services, Wilmington Hospital

501 West 14th Street

Wilmington

19801

321

Delaware Psychiatric Center

1901 North duPont Highway

New Castle

19720

200

Encompass Health Rehabilitation Hospital of Middletown250 East Hampden Road

Middletown

19709

MeadowWood Behavioral Health System

575 South duPont Highway

New Castle

19720

120

Rockford Center

100 Rockford Drive

Newark

19713

140

Select Specialty Hospital of Wilmington

701 N Clayton Street, Fifth Floor Wilmington

19805

St. Francis Healthcare

701 N Clayton Street

19805

395

Wilmington

Source: Delaware Health and Social Services (DHSS), 2022

Other Community Resources A wide variety of health and social service resources are available to assist New Castle County residents. Delaware 2-1-1 provides one central resource for access to the health and human service organizations that offer support in the community. Delaware 2-1-1 is provided by the United Way of Delaware in partnership with Delaware Health and Social Services, ChristianaCare, Always Best Care Senior Services and Help is Here Delaware. Delaware 2-1-1 is free, confidential, and easily accessible online at www.delaware211.org or by phone Monday through Friday from 8 a.m. to 9 p.m. Residents may also text their ZIP Code for assistance. Services are available in the following categories: • • • • • • • • • • • • • • • • •

Employment Job Training Family Issues Volunteer Opportunities Financial Assistance Social Services Public Assistance Mental Health Counseling Emergency Housing Food Transportation Healthcare Dental Services Senior Services Clothing Affordable Housing Education

OTHER FACILITIES AND RESOURCES IN THE COMMUNITY • •

Legal Services Crisis Preparedness

Additional information about these resources and participating providers can be found at: www.delaware211.org. In addition to Delaware 2-1-1, ChristianaCare’s Office of Health Equity (OHE) partners with Unite Us, to provide a technology platform that enables impactful social care coordination. Unite Us leverages existing community resources to address social determinants of health. Unite Us eases the process of referrals to community-based organizations and allows for efficient connection between client’s healthcare and social services. Participating providers can view, coordinate, and collaborate on their clients’ care across organizations and types of service. Unite Us connects clients with resources and services in the following categories: • • • • • • • • • • • • • • • • • • • •

Benefits navigation Clothing and household goods Education Employment Entrepreneurship Food assistance Housing and shelter Income support Individual and family support Legal Mental and behavioral health Money Management Physical health Social enrichment Spiritual enrichment Sports and recreation Substance use Transportation Utilities Wellness

APPENDIX A – OBJECTIVES AND METHODOLOGY

APPENDIX A – OBJECTIVES AND METHODOLOGY Regulatory Requirements Federal law requires that tax-exempt hospital facilities conduct a CHNA every three years and adopt an Implementation Strategy that addresses significant community health needs.3 In conducting a CHNA, each tax-exempt hospital facility must: • • • • •

Define the community it serves; Assess the health needs of that community; Solicit and take into account input from persons who represent the broad interests of that community, including those with special knowledge of or expertise in public health; Document the CHNA in a written report that is adopted for the hospital facility by an authorized body of the facility; and, Make the CHNA report widely available to the public.

The CHNA report must include certain information including, but not limited to: • • •

A description of the community and how it was defined, A description of the methodology used to determine the health needs of the community, and A prioritized list of the community’s health needs.

Methodology CHNAs seek to identify significant health needs for particular geographic areas and populations by focusing on the following questions: • • • •

Who in the community is most vulnerable in terms of health status or access to care? What are the unique health status and/or access needs for these populations? Where do these people live in the community? Why are these problems present?

The focus on who is most vulnerable and where they live is important to identifying groups experiencing health inequities and disparities. Understanding why these issues are present is challenging but is important to designing effective community health improvement initiatives. The question of how each hospital can address significant community health needs is the subject of the separate Implementation Strategy (Community Health Implementation Plan). Federal regulations allow hospital facilities to define the community they serve based on “all of the relevant facts and circumstances,” including the “geographic location” served by the hospital facility, “target populations served” (e.g., children, women, or the aged), and/or the hospital facility’s principal functions (e.g., focus on a particular specialty area or 3

Internal Revenue Code, Section 501(r).

APPENDIX A – OBJECTIVES AND METHODOLOGY targeted disease).” 4 Accordingly, the community definition considered the geographic origins of the hospital’s patients and also the hospital’s mission, target populations, principal functions, and strategies. Data from multiple sources were gathered and assessed, including secondary data5 published by others and primary data obtained through community input. Input from the community was received through key stakeholder interviews and online community meetings (including a meeting conducted with internal hospital staff). Stakeholders and community meeting participants represented the broad interests of the community and included individuals with special knowledge of or expertise in public health. See Appendix C. Considering a wide array of information is important when assessing community health needs to ensure the assessment captures a wide range of facts and perspectives and to increase confidence that significant community health needs have been identified accurately and objectively. Certain community health needs were determined to be “significant” if they were identified as problematic in at least two of the following three data sources: (1) the most recently available secondary data regarding the community’s health, (2) recent assessments developed by state and local health departments, and (3) input from community stakeholders who participated in the community meeting and/or interview process. In addition, data were gathered to evaluate the impact of various services and programs identified in New Castle County’s previous CHNA process. See Appendix E.

Data Sources Community health needs were identified by collecting and analyzing data from multiple sources. Statistics for numerous community health status, health care access, and related indicators were analyzed, including data provided by local, state, and federal government agencies, local community service organizations, and ChristianaCare. Comparisons to benchmarks were made where possible. Findings from recent assessments of the community’s health needs conducted by other organizations (e.g., local health departments) were reviewed as well. Input from persons representing the broad interests of the community was taken into account through key informant interviews (7 participants) and community meetings (56 participants). Stakeholders included: individuals with special knowledge of or expertise in public health; local public health departments; hospital staff and providers; representatives of social service organizations; and leaders, representatives, and members of medically underserved, low-income, and minority populations. ChristianaCare posts CHNA reports and Implementation Plans online at https://christianacare.org/about/whoweare/communitybenefit/community-healthneeds-assessment/.

501(r) Final Rule, 2014. “Secondary data” refers to data published by others, for example the U.S. Census and Delaware Health and Social Services. “Primary data” refers to data observed or collected from first-hand experience, for example by conducting interviews. 4 5

APPENDIX A – OBJECTIVES AND METHODOLOGY

Consultant Qualifications Verité Healthcare Consulting, LLC (Verité) was founded in May 2006 and is located in Arlington, Virginia. The firm serves clients throughout the United States as a resource that helps hospitals conduct Community Health Needs Assessments and develop Implementation Strategies to address significant health needs. Verité has conducted more than 100 needs assessments for hospitals, health systems, and community partnerships nationally since 2012. The firm also helps hospitals, hospital associations, and policy makers with community benefit reporting, program infrastructure, compliance, and community benefit-related policy and guidelines development. Verité is a recognized national thought leader in community benefit and Community Health Needs Assessments.

APPENDIX B – SECONDARY DATA ASSESSMENT

APPENDIX B – SECONDARY DATA ASSESSMENT This section presents an assessment of secondary data regarding health needs in the ChristianaCare. The community is defined as New Castle County, Delaware.

Demographics Exhibit 7: Change in Community Population by Age/Sex Cohort, 2020 to 2030

Age / Sex Cohort 0-19 Female, 20-44 Male, 20-44 45-64 65+ New Castle County

Total Population 2020 138,635 96,480 96,243 148,946 90,754 571,058

Projected Population 2030 130,621 96,980 98,606 141,370 118,413 585,990

Percent Change 2020-2030 -5.8% 0.5% 2.5% -5.1% 30.5% 2.6%

Source: Delaware Office of State Planning Coordination, The Delaware Population Consortium, 2021.

Description Exhibit 7 portrays the estimated population by age and sex cohort in 2020 and projected to 2030. Observations •

Between 2020 and 2030, the community’s population is expected to grow by approximately 14,932 people, or 2.6 percent.

•

The population 65 years and older is projected to grow much more rapidly (30.5 percent).

•

The growth of older populations is likely to lead to greater demand for health services, since older individuals typically need and use more services than younger persons.

•

The 0-19 age and 45-64 age cohorts are projected to decline more than 5 percent each (5.8 and 5.1 respectively).

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 8: Percent of Population – Aged 65+, 2016-2020

Source: U.S. Census, ACS 5-Year Estimates, 2020 and Caliper Maptitude, 2021.

Description Exhibit 8 portrays the percent of the population 65 years of age and older by ZIP Code. Observations •

The highest percentage of population 65 years and older were in the northern part of the county and in Community 2.

APPENDIX B – SECONDARY DATA ASSESSMENT

Exhibit 9: Percent of Population – Black, 2016-2020

Source: U.S. Census, ACS 5-Year Estimates, 2020 and Caliper Maptitude, 2021.

Description Exhibit 9 portrays the percent of the population – Black by ZIP Code. Observations •

In Community 1 ZIP Codes 19801 and 19802, over 75 percent of the population identified as Black. 30

APPENDIX B – SECONDARY DATA ASSESSMENT

•

Approximately 48 percent of the population in the combined ZIP Codes of Community 1 identified as Black, while about 17 percent of the combined ZIP Codes of Community 2 identified as Black.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 10: Percent of Population – Hispanic (or Latino), 2016-2020

Source: U.S. Census, ACS 5-Year Estimates, 2020 and Caliper Maptitude, 2021.

Description Exhibit 10 portrays the percent of the population – Hispanic (or Latino) by ZIP Code. Observations •

ZIP Codes 19804 and 19805, both in the city of Wilmington and Community 1, had the highest percentage of population identified as Hispanic (21.0 and 25.2 percent).

APPENDIX B – SECONDARY DATA ASSESSMENT •

Approximately 15 percent of the population in the combined ZIP Codes of Community 1 identified as Hispanic, while about 8 percent of the combined ZIP Codes of Community 2 identified as Hispanic.

APPENDIX B – SECONDARY DATA ASSESSMENT

Socioeconomic Indicators This section includes indicators for poverty, unemployment, health insurance status, crime, housing affordability, and “social vulnerability.” All have been associated with health status. Exhibit 11: Selected Socioeconomic Indicators, 2016-2020

Source: U.S. Census, ACS 5-Year Estimates, 2020.

Description Exhibit 11 portrays the percent of the population (aged 25 years and above) without a high school diploma, with a disability, and linguistically isolated in New Castle, Kent and Sussex Counties, Delaware, and the United States. Linguistic isolation is defined as residents who speak a language other than English and who speak English less than “very well.” Observations •

In 2016-2020, the percentage of residents aged 25 and older without a high school diploma in New Castle County and Delaware was below the national average.

•

New Castle County had a lower percentage of population with a disability than both Delaware and the United States.

•

New Castle County had a lower population of residents who were linguistically isolated compared to national averages.

•

Percentages of those linguistically isolated was similar throughout Delaware and lower than that of the U.S. average.

APPENDIX B – SECONDARY DATA ASSESSMENT

People in Poverty Exhibit 12: Percent of People in Poverty, 2016-2020

Source: U.S. Census, ACS 5-Year Estimates, 2020.

Description Exhibit 12 portrays poverty rates in New Castle County, Kent County, Sussex County, Delaware, and the United States. Observations •

In 2016-2020, the poverty rate in New Castle County was below all Delaware counties and United States averages.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 13: Poverty Rates by Race and Ethnicity, 2016-2020

Area New Castle County Kent County Sussex County Delaware United States

White 7.9% 10.2% 9.7% 18.4% 10.6%

Black 16.7% 18.9% 20.2% 17.6% 22.1%

Asian 10.8% 12.2% 16.0% 11.4% 10.6%

Hispanic All Races/ (or Latino) Ethnicities 16.3% 10.7% 17.6% 13.2% 24.6% 11.7% 18.4% 11.4% 18.3% 12.8%

Source: U.S. Census, ACS 5-Year Estimates, 2020.

Description Exhibit 13 portrays poverty rates by race and ethnicity. Light grey shading indicates rates above the U.S average for all races/ethnicities combined (12.8 percent) and dark grey shading indicates rates more than 50 percent above the U.S. average for all races/ethnicities combined. Observations •

In 2016-2020, New Castle County poverty rates were above the U.S. average for Black and Hispanic (or Latino) populations than for both White population and all races/ethnicities combined.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 14: Low Income Census Tracts, 2019

Source: U.S. Department of Agriculture, Economic Research Service, 2019 and Maptitude, 2021.

Description Exhibit 14 portrays the location of federally designated low-income census tracts. Observations •

In 2019, low-income census tracts were located primarily in Newark and Wilmington and Community 1.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 15: Select Socioeconomic Characteristics, Community 1 versus Community 2, 20152019

Indicator Total Population Living in Poverty Low Income(<200% of FPL) Percent Racial/Ethnic Minority Percent Hispanic Percent Black Uninsured Limited English Less than High School Diploma

Community 1 204,004 16.8% 35.2% 59.5% 14.4% 40.7% 6.7% 3.1% 12.5%

Community 2 347,490 8.3% 17.5% 33.2% 7.5% 16.2% 4.5% 2.0% 5.7%

New Castle County 551,494 11.2% 24.0% 42.0% 9.7% 25.0% 5.2% 2.4% 8.4%

Source: Health Resources and Services Administration. UDS Mapper, 2019.

Description Exhibit 15 illustrates the substantial disparity in socioeconomic indicators between Community 1, Community 2, and New Castle County as a whole. Observations •

Community 1 had more than double the population living in poverty compared to Community 2 (16.8 percent compared to 8.3 percent)

•

Community 1 had a significantly higher percentage of residents who identified as a racial/ethnic minority.

•

Community 1 residents were more likely to be uninsured, have limited English proficiency and were less likely to have a high school diploma than Community 2 residents.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 16: Select Socioeconomic Characteristics, Delaware, LGBT versus Straight, 2019

LGBT Demographic Data Interactive, January 2019, Los Angeles, CA: The Williams Institute, UCLA School of Law.

Description Exhibit 16 illustrates the significant disparity in socioeconomic indicators between the LGBT community in Delaware versus the straight community in Delaware. Observations •

LGBT individuals are more likely to be unemployed, uninsured, food insecure and have low-income than those who identify as straight/heterosexual.

APPENDIX B – SECONDARY DATA ASSESSMENT

Unemployment Exhibit 17: Unemployment Rates, 2017 to 2021

Source: U.S. Bureau of Labor Statistics

Description Exhibit 17 shows unemployment rates for 2017 through 2021 by county with Delaware and national rates for comparison. Observations •

Between 2016 and 2019, unemployment rates in New Castle County declined. However, the COVID-19 pandemic led to significant increases in unemployment in 2020.

•

In 2021, rates declined as the economy began to recover from the pandemic; however, unemployment rates remained above national rates in New Castle County.

APPENDIX B – SECONDARY DATA ASSESSMENT

Health Insurance Status Exhibit 18: Percent of Population without Health Insurance, 2016-2020

ZIP Code

City/Town

19701 Bear 19702 Newark 19703 Claymont 19706 Delaware City 19707 Hockessin 19709 Middletown 19711 Newark 19713 Newark 19716 Newark 19717 Newark 19720 New Castle 19730 Odessa 19731 Port Penn 19732 Rockland 19733 Saint Georges 19734 Townsend 19736 Yorklyn 19801 Wilmington 19802 Wilmington 19803 Wilmington 19804 Wilmington 19805 Wilmington 19806 Wilmington 19807 Wilmington 19808 Wilmington 19809 Wilmington 19810 Wilmington Community 1 Community 2 Community Total Delaware United States

Population 42,141 54,659 15,356 1,792 16,070 44,775 52,972 30,127 1,426 3,649 58,539 441 350 81 68 13,069 59 15,688 25,957 21,095 17,516 37,560 8,940 7,307 37,609 14,667 25,177 155,260 391,830 547,090 951,930 321,525,041

Percent Uninsured 6.3% 7.9% 5.3% 7.0% 2.1% 2.7% 4.6% 6.9% 1.6% 1.8% 6.2% 7.0% 12.9% 24.7% 0.0% 4.4% 0.0% 5.4% 5.3% 3.3% 4.7% 7.6% 3.6% 2.1% 4.5% 3.5% 2.3% 5.8% 5.2% 5.1% 5.8% 8.7%

Source: U.S. Census, ACS 5-Year Estimates, 2020.

Description Exhibit 18 presents the estimated percent of population without health insurance. Light grey shading indicated ZIP Codes that have a higher percentage uninsured than the

APPENDIX B – SECONDARY DATA ASSESSMENT Delaware state average and dark grey shading indicates ZIP Codes that are more than 50 percent above the state average. Observations

•

New Castle County had a lower percentage of the population without health insurance compared to national averages.

•

Delaware Medicaid expansion became effective January 1, 2014. According to an analysis published in October 2019 by the Kaiser Family Foundation, 62,500 adults became eligible for coverage under Delaware Medicaid expansion. 6

•

About a third of New Castle County ZIP Codes had higher percentages of population without health insurance compared to the Delaware state average.

•

Port Penn’s and Rockland’s rate of uninsured was more than 50 percent above the state average.

•

The average rate of uninsured population in Community 1 was higher than Community 2; however, it was the same as the state of Delaware.

http://files.kff.org/attachment/fact-sheet-medicaid-state-DE

APPENDIX B – SECONDARY DATA ASSESSMENT

Crime Rates Exhibit 19: Crime Rates by Type and Jurisdiction, Per 1,000, 2020

Indicator

New Castle County

Total Offenses Violent Offenses Serious Property Offenses Drug Offenses Other Property and Social Offenses Robbery Assault Burglary Larceny/Theft Motor Vehicle Theft Fraud Property Destruction/Vandalism Weapons Law Violations

66.0 15.8 22.4 7.2 20.6 1.2 13.9 2.9 17.0 2.3 5.9 9.9 2.6

Kent County 74.6 20.2 21.9 11.9 20.5 0.4 18.6 2.3 18.1 1.3 6.3 9.3 2.0

Sussex County

Delaware

67.4 18.4 15.9 13.7 19.3 0.3 17.3 2.2 12.8 0.6 7.0 7.9 1.5

67.9 17.3 20.7 9.7 20.2 0.8 15.6 2.6 16.2 1.7 6.2 9.3 2.2

Source: Delaware Criminal Justice Council and Delaware State Bureau of Identification, 2021.

Description Exhibit 19 provides crime statistics available from the Delaware Statistical Analysis Center within the Delaware Criminal Justice Council. Light grey shading indicates rates above the Delaware state average. Observations •

In 2020, New Castle County crime offenses were above Delaware averages for eight of the thirteen indicators listed.

APPENDIX B – SECONDARY DATA ASSESSMENT

Housing Affordability Exhibit 20: Percent of Rented Households Rent Burdened, 2016-2020

ZIP Code 19701 19702 19703 19706 19707 19709 19711 19713 19716 19717 19720 19730 19731 19732 19733 19734 19736 19801 19802 19803 19804 19805 19806 19807 19808 19809 19810

Town/Area

Bear Newark Claymont Delaware City Hockessin Middletown Newark Newark Newark Newark New Castle Odessa Port Penn Rockland Saint Georges Townsend Yorklyn Wilmington Wilmington Wilmington Wilmington Wilmington Wilmington Wilmington Wilmington Wilmington Wilmington Community 1 Community 2 New Castle County Delaware United States

Occupied Units Households Paying Rent Paying >30% 3,173 7,630 2,925 163 655 2,120 6,416 4,149 0 0 6,417 17 0 0 0 131 24 4,619 5,041 1,065 1,794 6,589 2,706 850 3,125 1,851 1,921 24,460 38,954 63,414 98,989 40,484,226

1,226 2,787 1,213 80 356 542 3,638 1,739 0 0 2,951 8 0 0 0 57 0 2,326 2,572 424 894 3,976 1,125 226 1,385 834 914 12,719 16,559 29,278 48,702 19,886,052

Source: U.S. Census, ACS 5-Year Estimates, 2020.

Rent Burden > 30% of Income 38.7% 36.5% 41.4% 49.1% 54.3% 25.5% 56.7% 41.9% 0.0% 0.0% 46.0% 47.1% 0.0% 0.0% 0.0% 43.5% 0.0% 50.4% 51.0% 39.8% 49.9% 60.4% 41.6% 26.6% 44.3% 45.1% 47.5% 51.5% 30.9% 46.2% 49.2% 49.1%

APPENDIX B – SECONDARY DATA ASSESSMENT

Exhibit 21: Map of Percent of Rented Households Rent Burdened, 2016-2020

Source: U.S. Census, ACS 5-Year Estimates, 2020, and Caliper Maptitude, 2021.

Description The U.S. Department of Housing and Urban Development (HUD) has defined “rent burdened” households as those spending more than 30 percent of income on housing. 7 Exhibits 20 and 21 portray the percent of rented households that meet this definition. Light https://www.federalreserve.gov/econres/notes/feds-notes/assessing-the-severity-of-rentburden-on-low-income-families-20171222.htm 7

APPENDIX B – SECONDARY DATA ASSESSMENT grey shading in Exhibit 19 indicates ZIP Codes that are above the U.S. average of 49.1 percent for rent burdened households. Observations As stated by the Federal Reserve, “households that have little income left after paying rent may not be able to afford other necessities, such as food, clothes, health care, and transportation.” 8

•

On average approximately 52 percent of households were rent burdened in Community 1 compared to an average of 31 percent in Community 2.

•

The highest percentages were in ZIP Codes 19711 and 19805 (56.7 percent and 60.4 percent respectively).

Ibid.

APPENDIX B – SECONDARY DATA ASSESSMENT

Dignity Health Community Need IndexTM Exhibit 22: Community Need IndexTM Score by ZIP Code

ZIP Code

Town/Area

19801 Wilmington 19802 Wilmington 19805 Wilmington 19703 Claymont 19713 Newark 19720 New Castle 19804 Wilmington 19806 Wilmington 19702 Newark 19706 Delaware City 19711 Newark 19701 Bear 19716 Newark 19807 Wilmington 19809 Wilmington 19808 Wilmington 19733 Saint Georges 19731 Port Penn 19736 Yorklyn 19734 Townsend 19810 Wilmington 19709 Middletown 19717 Newark 19730 Odessa 19707 Hockessin 19803 Wilmington 19732 Rockland Community 1 Community 2 New Castle County Source: Dignity Health, 2021.

CNI Score 4.6 4.4 4.4 3.8 3.6 3.6 3.4 3.2 3.0 3.0 3.0 2.8 2.8 2.8 2.8 2.6 2.4 2.2 2.2 2.0 2.0 1.8 1.8 1.8 1.4 1.4 1.2 4.4 2.5 2.8

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 23: Community Need Index™

Source: Dignity Health, 2021 and Caliper Maptitude, 2021.

Description Exhibits 22 and 23 present Community Need Index™ (CNI) scores. Higher scores (4.2 to 5.0) indicate the highest levels of community need. A score of 3.0 represents a U.S.-wide median score. Light grey shading in Exhibit 22 indicates CNI scores that are above U.S. median score of 3.0.

APPENDIX B – SECONDARY DATA ASSESSMENT Dignity Health developed the CNI to assess barriers to health care access. The index, available for every ZIP Code in the United States, consists of five social and economic indicators: • • • • •

The percentage of elders, children, and single parents living in poverty; The percentage of adults over the age of 25 with limited English proficiency, and the percentage of the population that is non-White; The percentage of the population without a high school diploma; The percentage of uninsured and unemployed residents; and The percentage of the population renting houses.

Dignity Health grouped scores into “Lowest Need” (1.0-1.7) to “Highest Need” (4.2-5.0) categories. Observations •

Three of the twenty-seven New Castle County ZIP Codes (19801, 19802, and 19805) were in the highest need category (4.2 and above). All three of these ZIP Codes are in Community 1.

•

The median CNI score for Community 1 was 4.4, well above the U.S. median of 3.0.

•

The median CNI for Community 2 was 2.5 and for New Castle County was 2.8, both below the U.S. median of 3.0.

APPENDIX B – SECONDARY DATA ASSESSMENT

Centers for Disease Control and Prevention Social Vulnerability Index (SVI) Exhibits 24 through 27 show the Centers for Disease Control and Prevention’s Social Vulnerability Index (SVI) scores for census tracts throughout the community. Red highlighted census tracts are in the bottom quartile nationally for different indicators on which the SVI is based. The overall SVI is based on 15 variables derived from U.S. census data. Variables are grouped into four themes, including: • • • •

Socioeconomic status; Household composition; Race, ethnicity, and language; and Housing and transportation.

Exhibits 24 through 27 highlight SVI scores for each of these themes.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 24: Socioeconomic Status Index – Bottom Quartile Census Tracts

Source: Centers for Disease Control and Prevention, 2018, and Caliper Maptitude, 2021.

Description Exhibit 24 identifies census tracts in the bottom quartile nationally for socioeconomic vulnerability. Observations

APPENDIX B – SECONDARY DATA ASSESSMENT •

Census tracts with the highest levels of socioeconomic vulnerability were Wilmington and Newark.

•

Most of these census tracts were located within Community 1 ZIP Codes.

•

About 20 percent of the community’s total population lived in census tracts with the highest socioeconomic vulnerability.

Exhibit 25: Household Composition and Disability Index – Bottom Quartile Census Tracts

Source: Centers for Disease Control and Prevention, 2018, and Caliper Maptitude, 2021.

APPENDIX B – SECONDARY DATA ASSESSMENT Description Exhibit 25 identifies census tracts in the bottom quartile nationally for household composition and disability vulnerability. Observations •

Census tracts with the highest household composition and disability index were in Wilmington and Newark.

•

Most of these census tracts were located within Community 1 ZIP Codes

•

About 12 percent of the community’s total population lived in the highlighted census tracts.

APPENDIX B – SECONDARY DATA ASSESSMENT

Exhibit 26: Minority Status and Language Index

Source: Centers for Disease Control and Prevention, 2018, and Caliper Maptitude, 2021.

Description Exhibit 26 portrays minority status and language vulnerability by census tract. Observations •

The highest percentage of population with minority status and language vulnerability were in Wilmington, Newark, and Bear. 54

APPENDIX B – SECONDARY DATA ASSESSMENT •

Many of these census tracts were located within Community 1 ZIP Codes.

•

About 29 percent of the community’s total population lived in tracts with the highest minority status and language vulnerability.

Exhibit 27: Housing Type and Transportation Index – Bottom Quartile Census Tracts

Source: Centers for Disease Control and Prevention, 2018, and Caliper Maptitude, 2021.

APPENDIX B – SECONDARY DATA ASSESSMENT Description Exhibit 27 identifies census tracts in the bottom quartile nationally for housing type and transportation vulnerability. Observations •

The highest percentage of population with housing type and transportation vulnerability were in New Castle, Newark, Claymont and Wilmington.

•

About 23 percent of the community’s total population lived in tracts with the highest housing type and transportation vulnerability.

APPENDIX B – SECONDARY DATA ASSESSMENT

Other Health Status and Access Indicators County Health Rankings Exhibit 28: County Health Rankings Data Compared to State and U.S. Averages, 2021 Indicator Category Length of Life Quality of Life

Health Behaviors Adult Smoking Diet and Exercise

Alcohol and Drug Use Sexual Activity

New Castle County, DE

Data

Delaware

United States

Health Outcomes Years of potential life lost before age 75 per 100,000 population Percentage of adults reporting fair or poor health Average number of physically unhealthy days reported in past 30 days Average number of mentally unhealthy days reported in past 30 days Percentage of live births with low birthweight (< 2,500 grams) Health Factors

7,918 16.6% 3.7 4.3 9.0%

7,938 16.3% 3.7 4.2 8.9%

6,900 17.0% 3.7 4.1 8.0%

Percentage of adults who are current smokers Percentage of the adult population (age 20 and older) with BMI >=30 Index of factors that contribute to a healthy food environment, from 0 (worst) to 10 (best) Percentage of adults age 20 and over reporting no leisure-time physical activity Percentage of population with adequate access to locations for physical activity Percentage of adults reporting binge or heavy drinking Percentage of driving deaths with alcohol involvement Number of newly diagnosed chlamydia cases per 100,000 population Number of births per 1,000 female population ages 15-19

18.4% 30.2% 8.3 24.7% 96.9% 19.2% 25.4% 643.1 15.8

17.4% 32.4% 7.8 27.3% 86.5% 19.8% 26.0% 627.7 19.0

17.0% 30.0% 7.8 23.0% 84.0% 19.0% 27.0% 539.9 21.0

Percentage of population under age 65 without health insurance Ratio of population to primary care physicians Ratio of population to dentists Ratio of population to mental health providers Rate of hospital stays for ambulatory-care sensitive conditions Percentage of Medicare enrollees that received an annual mammography screening Percentage of fee-for-service (FFS) Medicare enrollees that had an annual flu vaccination

5.9% 1121:1 1639:1 287:1 4,896 46.0% 56.0%

6.8% 1334:1 2041:1 354:1 4,871 48.0% 56.0%

10.0% 1,320:1 1,400:1 380:1 4,236 42.0% 48.0%

Clinical Care Access to Care

Quality of Care

Source: County Health Rankings, 2021.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 28: County Health Rankings Data Compared to State and U.S. Averages, 2021 (continued) Indicator Category

New Castle County, DE

Data

Social & Economic Factors Percentage of adults ages 25 and over with a high school diploma or equivalent Education Percentage of adults ages 25-44 with some post-secondary education Employment Percentage of population ages 16 and older unemployed but seeking work Percentage of people under age 18 in poverty Income Ratio of household income at the 80th percentile to income at the 20th percentile Percentage of children that live in a household headed by single parent Family and Social Support Number of membership associations per 10,000 population Number of reported violent crime offenses per 100,000 population Community Safety Number of deaths due to injury per 100,000 population Physical Environment Air Pollution Average daily density of fine particulate matter in micrograms per cubic meter (PM2.5) Percentage of households with at least 1 of 4 housing problems: overcrowding, high Severe Housing Problems housing costs, lack of kitchen facilities, or lack of plumbing facilities Driving Alone to Work Long Commute - Drive Alone

Percentage of the workforce that drives alone to work Among workers who commute in their car alone, the percentage that commute more than 30 minutes Source: County Health Rankings, 2021.

Delaware

United States

91.6% 63.9% 3.7% 13.4% 4.6 28.1% 10.7 551.3 82.0

90.0% 61.8% 3.8% 16.3% 4.4 27.9% 10.3 499.0 81.8

88.0% 66.0% 3.7% 17.0% 4.9 26.0% 9.3 386.0 72.0

9.4

7.3

7.2

13.9% 79.9%

14.3% 80.9%

18.0% 76.0%

34.5%

35.1%

37.0%

APPENDIX B – SECONDARY DATA ASSESSMENT Description Exhibit 28 presents County Health Rankings, a University of Wisconsin Population Health Institute initiative funded by the Robert Wood Johnson Foundation that incorporates a variety of health status indicators into a system that ranks each county/city within each state in terms of “health factors” and “health outcomes.” The health factors and outcomes are composite measures based on several variables grouped into the following categories: health behaviors, clinical care, 9 social and economic factors, and physical environment. 10 County Health Rankings is updated annually. County Health Rankings 2021 relies on data from 2010 to 2020. Most data are from 2015 to 2019. Exhibit 28 provides data that underlie the County Health Rankings and compares indicators to statewide and national averages.11 Light grey shading highlights indicators found to be worse than the national average; dark grey shading highlights indicators more than 50 percent worse. Note that higher values generally indicate that health outcomes, health behaviors, and other factors for a given county are unfavorable when compared to averages for the United States. However, for several indicators, lower values are more problematic, including: • • • • • •

Food environment index, Percent with access to exercise opportunities, Percent receiving mammography screening, Percent receiving flu vaccination, High school graduation rate, and Percent with some college.

Observations •

The following indicators compared unfavorably to U.S. averages: o o o o o

Years of potential life lost before age 75 Average number of mentally unhealthy days Live births with low birthweight Adults who are current smokers Adults with obesity (BMI>=30)

A composite measure of Access to Care, which examines the percent of the population without health insurance and ratio of population to primary care physicians, and Quality of Care, which examines the hospitalization rate for ambulatory care sensitive conditions, whether diabetic Medicare patients are receiving HbA1C screening, and percent of chronically ill Medicare enrollees in hospice care in the last 8 months of life. 10 A composite measure that examines Environmental Quality, which measures the number of air pollution-particulate matter days and air pollution-ozone days, and Built Environment, which measures access to healthy foods and recreational facilities and the percent of restaurants that are fast food. 11 County Health Rankings provides details about what each indicator measures, how it is defined, and data sources at http://www.countyhealthrankings.org/sites/default/files/resources/2013Measures_datasources _years.pdf 9

APPENDIX B – SECONDARY DATA ASSESSMENT o o o o o o o o o o o

Adults with no leisure time physical activity Adults reporting binge or heavy drinking Number of newly diagnosed chlamydia cases Ratio of population to dentists Rate of hospital stays for ambulatory-care sensitive conditions Adults with some college Children in single-parent households Violent crime offenses Deaths due to injury Average daily density of fine particulate matter Workforce that drives alone to work

Community Health Status Indicators Exhibit 29: Community Health Status Indicators, 2021 (Light Grey Shading Denotes Bottom Half of Peer Counties; Dark Grey Denotes Bottom Quartile)

APPENDIX B – SECONDARY DATA ASSESSMENT

Category

New Castle County

Indicator

Length of Life Years of Potential Life Lost Before 75 Per 100,000 % of Adults Reporting Fair or Poor Health Average Number of Physically Unhealthy Days Per Month Quality of Life Average Number of Mentally Unhealthy Days Per Month % of Live Births with Low Birthweight % of Adults who Smoke % Adults with Obesity Food Environment Index % Physically Inactive Health % With Access to Exercise Opportunities Behaviors % of Adults Reporting Binge or Heavy Drinking % Driving Deaths with Alcohol Involvement Newly Diagnosed Chlamydia Cases per 100,000 Births per 1,000 Females Aged 15-19 Years % of Population Under 65 Uninsured Primary Care Physicians Per 100,000 Dentists Per 100,000 Clinical Care Mental Health Providers Per 100,000 Preventable Hospitalizations Per 100,000 Medicare Enrollees % of Females 65-74 With Annual Mammogram % of FFS Medicare Beneficiaries with Annual Flu Vaccination % of Adults 25+ Who Completed High School % of Adults 25-44 with Some College % Unemployed Social & % Children in Poverty Economic Ratio of Income at 80th Percentile to 20th Percentile % Children in Single-Parent Households Factors Membership Associations per 10,000 Reported Violent Crime Offenses per 100,000 Deaths Due to Injury Per 100,000 Average Daily Density of Fine Particulate Matter (PM2.5) Physical % of Households with Severe Housing Problems Environment % Drive Alone to Work % Long Commute - Drives Alone

Description

7,917.7 16.6% 3.7 4.3 9.0% 18.4% 30.2% 8.3 24.7% 96.9% 19.2% 25.4% 643.1 15.8 5.9% 89.2 61.0 348.8 4,896 46.0% 56.0% 91.6% 63.9% 3.7% 13.4% 4.6 28.1% 10.7 551.3 82.0 9.4 13.9% 79.7% 34.5%

Peer Counties Average 6,720 16.4% 3.9 4.4 7.9% 17.9% 31.4% 8.2 22.6% 82.5% 20.1% 29.6% 451.7 16.4 9.1% 60.9 57.3 180.0 4,232 43.3% 50.9% 91.9% 69.9% 3.3% 12.0% 4.2 22.4% 8.5 255.2 72.8 7.9 14.3% 80.8% 39.6%

Quartile Ranking 4 2 2 2 4 3 2 2 3 1 2 2 4 2 1 1 2 1 3 1 1 3 4 4 3 4 4 1 4 3 4 3 2 2

Source: County Health Rankings and Verité Analysis, 2021.

County Health Rankings has assembled community health data for all 3,143 counties in the United States. Following a methodology developed by the Centers for Disease Control’s Community Health Status Indicators Project (CHSI), County Health Rankings also publishes lists of “peer counties,” so comparisons with peer counties in other states can be made. Each county in the U.S. is assigned 30 to 35 peer counties based on 19 variables including population size, population growth, population density, household income, unemployment, percent children, percent elderly, and poverty rates. CHSI formerly was available from the CDC. Because comparisons with peer counties (rather than only counties in the same state) are meaningful, Verité Healthcare Consulting rebuilt the CHSI comparisons for this and other CHNAs. Exhibit 29 compares each county to its respective peer counties and highlights community health issues found to rank in the bottom half and bottom quartile of the counties included

APPENDIX B – SECONDARY DATA ASSESSMENT in the analysis. Light grey shading indicates rankings in the bottom half of peer counties; dark grey shading indicates rankings in the bottom quartile of peer counties. Underlying statistics also are provided. See Appendix D for lists of peer counties. Note that higher values generally indicate that health outcomes, health behaviors, and other factors are worse in the county than in its peer counties. However, for several indicators, lower values are more problematic, including: • • • • • •

Observations •

New Castle County compared unfavorably to peer counties for 16 of the 34 benchmark indicators.

•

New Castle County ranked in the bottom quartile for the following indicators: o o o o o o o o o

Years of potential life lost before age 75 Live births with low birthweight Number of newly diagnosed chlamydia cases Adults with some college Unemployment Income inequality Children in single-parent households Violent crime offenses Average daily density of fine particulate matter

APPENDIX B – SECONDARY DATA ASSESSMENT

COVID-19 Incidence and Mortality Exhibit 30: COVID-19 Incidence and Mortality (As of April 25, 2022)

Area New Castle County Delaware United States

Cases

Deaths

148,107 260,799 79,498,661

1,412 2,905 975,518

Incidence Rate per 100,000 26,479.1 26,965.1 24,366.5

Mortality Rate per 100,000 252.4 300.4 299.0

Source: Johns Hopkins University, 2022.

Description Exhibit 30 presents data regarding COVID-19 incidence and mortality. Observations •

New Castle County experienced a COVID-19 incidence rate and mortality rate lower than both the state of Delaware and the United States.

•

However, there have been 26,479 cases and 252 deaths due to the pandemic since it began in March 2020.

APPENDIX B – SECONDARY DATA ASSESSMENT

Causes of Death Exhibit 31: Selected Causes of Death, Age-Adjusted Rates per 100,000 Population, 2020 New Castle County

Condition Major cardiovascular diseases Diseases of heart Malignant neoplasms All other diseases Other and unspecified infectious and parasitic diseases and their sequelae COVID-19 Ischemic heart diseases Accidents (unintentional injuries) Other heart diseases Nontransport accidents Cerebrovascular diseases Other forms of chronic ischemic heart disease Accidental poisoning and exposure to noxious substances All other forms of heart disease Malignant neoplasms of trachea, bronchus and lung Alzheimer disease All other forms of chronic ischemic heart disease Chronic lower respiratory diseases Other chronic lower respiratory diseases Heart failure Diabetes mellitus Atherosclerotic cardiovascular disease All other and unspecified malignant neoplasms Nephritis, nephrotic syndrome and nephrosis

225.0 152.9 149.9 113.5 75.0 71.3 71.1 70.2 65.1 57.8 57.4 56.7 45.3 38.4 35.4 34.6 33.8 27.9 27.9 25.6 24.0 22.9 19.6 15.0

Delaware

United States

225.2 159.6 151.1 102.2 76.3 73.4 65.2 70.9 60.8 58.6 52.5 65.2 46.4 38.1 34.6 35.1 42.6 32.7 30.1 21.8 23.8 22.5 18.2 12.4

223.0 168.2 144.1 96.7 87.8 85.0 91.8 57.6 56.5 44.3 38.8 64.4 26.9 35.1 31.9 32.4 46.0 36.4 33.4 20.7 24.8 18.4 18.4 12.7

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Underlying Cause of Death, 2020.

Description Exhibit 31 provides age-adjusted mortality rates for selected causes of death. Light grey shading indicates rates above U.S. averages, dark grey shading indicates rates more than 50 percent above U.S. averages. Observations •

In New Castle County, rates for 15 out of 24 causes of death were above U.S. averages.

•

Rates for accidental poisoning and exposure to noxious substances were more than 50 percent above the national average.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 32: Age-Adjusted Cancer Mortality Rates per 100,000 Population, 2015-2019

Type of Cancer

New Castle County

All cancer sites Bladder Brain and other nervous system Breast (female) Cervix Colon and rectum Corpus and uterus, NOS Esophagus Kidney and renal pelvis Leukemia Liver and bile duct Lung and bronchus Melanoma of the skin Non-Hodgkin lymphoma Oral cavity and pharnyx Ovary Pancreas Prostate Stomach

161.3 5.3 4.1 21.3 2.2 13.3 6.1 4.1 3.1 6.5 7.7 39.4 2.1 5.5 2.7 6.0 12.9 18.3 3.3

Delaware

United States

161.5 5.4 4.0 21.3 2.3 13.1 6.0 3.9 3.6 6.6 6.7 41.1 2.7 5.5 2.4 6.5 12.2 17.0 3.0

152.4 4.2 4.4 19.9 2.2 13.4 5.0 3.9 3.6 6.1 6.6 36.7 2.2 5.3 2.5 6.5 11.1 18.9 2.9

Source: Centers for Disease Control and Prevention, State Cancer Profiles.

Description Exhibit 32 provides age-adjusted mortality rates for selected forms of cancer in 2015-2019. Light grey shading indicates mortality rates that are higher than the U.S. average. Observations •

New Castle County had above average, overall cancer mortality rate than the U.S.

•

New Castle County had a higher mortality rate for 11 of 18 cancer types compared to U.S. averages.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 33: Death due to Poisoning (including drug overdose) per 100,000, 2016-2020

Report Area

Total Population

Five Year Total Deaths

New Castle County 559,280 Delaware 968,350 United States 326,747,554

1,212 1,976 389,651

Crude Death Rate 43.3 40.8 23.9

AgeAdjusted Death Rate 43.5 43.0 24.0

Source: Centers for Disease Control and Prevention, National Vital Statistics System, Accessed via CDC WONDER.

Description Exhibit 33 provides mortality rates due to poisoning, including drug overdose, for 20162020. Dark grey shaded indicates rates more than 50 percent above U.S. rates. Observations •

New Castle County’s death due to poisoning rate was over 75 percent higher than that of the U.S.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 34: Death due to Poisoning (including drug overdose) by Gender, per 100,000, 2016-2020

Source: Centers for Disease Control and Prevention, National Vital Statistics System, Accessed via CDC WONDER.

Description Exhibit 34 provides death due to poisoning, including drug overdose, by gender. Observations •

Deaths due to poisoning, including drug overdose, were more than double for males compared to females in both New Castle County and Delaware compared to the United States.

•

New Castle County male deaths were almost four times that of U.S.-wide female deaths for poisoning.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 35: Death due to Poisoning (including drug overdose) by Race/Ethnicity, per 100,000, 2016-2020

Source: Centers for Disease Control and Prevention, National Vital Statistics System, Accessed via CDC WONDER.

Description Exhibit 35 provides death due to poisoning, including drug overdose, by race and ethnicity. Observations •

Deaths due to poisoning, including drug overdose, were significantly higher for the Non-Hispanic White population compared to Non-Hispanic Black and Hispanic or Latino populations in both New Castle County and Delaware compared to the United States.

•

New Castle County deaths were almost double that of U.S.-wide deaths for the Non-Hispanic White population.

APPENDIX B – SECONDARY DATA ASSESSMENT

Communicable Diseases Exhibit 36: Communicable Disease Incidence Rates per 100,000 Population, 2018

Indicator Chlamydia Gonorrhea Lyme disease Hepatitis B, chronic Campylobacteriosis Salmonellosis HIV (new infections) Streptococcus Pneumoniae AIDS Legionellosis

New Castle Kent County County 642.8 783.8 177.0 220.0 54.2 48.3 22.0 18.8 13.3 22.7 10.5 30.0 11.0 N/A 7.3 N/A 6.0 N/A 5.0 N/A

Sussex County 446.5 132.2 57.0 11.3 44.0 44.3 N/A 12.6 N/A N/A

Delaware 622.4 174.3 53.8 18.8 22.3 22.1 9.5 9.2 5.2 4.7

Source: Delaware Health and Social Services (DHSS), Health Data and Statistics.

Description Exhibit 36 presents incidence rates for certain communicable diseases. Light grey shading indicates rates that are higher than the state of Delaware. Observations •

New Castle County compared unfavorably to state averages for incidence of chlamydia, gonorrhea, Lyme disease, Hepatitis B (chronic), HIV (new infections), AIDS, and legionellosis.

APPENDIX B – SECONDARY DATA ASSESSMENT

Maternal and Child Health Exhibit 37: Percentage Low Birthweight Births, 2013-2019

Area

New Castle County Delaware United States

Total Live Births

Low Birthweight Births

Number of Births 44,945 4,065 151,924 13,500 54,416,819 4,440,508

9.0% 8.9% 8.2%

Low Birthweight Births NonHispanic White

Low Birthweight Births NonHispanic Black

Low Birthweight Births Hispanic or Latino

Percentage of Births 6.9% 13.7% 7.2% 13.3% 6.8% 13.5%

Source: National Center for Health Statistics - Natality Files, 2021

Description Exhibit 37 provides portrays percentage of low-birth-weight births by race. Light grey shading indicates measures that are above U.S. averages. Observations •

New Castle County had a higher percentage of low-birth weight babies for all races/ethnicities compared to the U.S.

7.3% 7.1% 7.3%

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 38: Number of Births per 1,000 Female Population Age 15-19, 2013-2019

Area

New Castle County Delaware United States

Female Population Age 15-19

Teen Births, Teen Births Teen Births Rate per Teen Births NonNon1,000 Hispanic or Hispanic Hispanic Female Latino White Black Population

130,818 417,112 144,319,360

15.8 19.0 20.9

8.1 11.8 13.6

27.3 27.6 30.3

28.8 36.3 32.1

Source: Centers for Disease Control and Prevention, National Vital Statistics System, 2021

Description Exhibit 38 provides rates of babies born to teen mothers from 2013-2019 by race. Observations •

Rates for teen mothers giving birth were lower in New Castle County for all races/ethnicities compared to the U.S.

•

Rates for Non-Hispanic Black and Hispanic or Latino teen mothers giving birth are more than three times that of Non-Hispanic White teen mothers in New Castle County.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 39: Infant Mortality Rates per 1,000 Live Births by Race, 2015-2019

10.8 Non-Hispanic Black

12.5 13.1 4.6 4.2 4.3

Non-Hispanic White

5.7 All Races

7.2 7.8 0

United States

Delaware

New Castle County

Source: Delaware Vital Statistics Annual Report, Infant Mortality, 2019 and CDC.

Description Exhibit 39 compares infant mortality rates in New Castle County and Delaware for 20152019. Data for the U.S. are for 2018. Observations •

In New Castle County, infant mortality rates for all races/ethnicities combined were higher than Delaware and U.S. averages.

•

The infant mortality rate for Non-Hispanic Blacks also was higher in New Castle County than in Delaware and the U.S.

•

Non-Hispanic Black infant mortality rates have been more than double those for Non-Hispanic White populations.

APPENDIX B – SECONDARY DATA ASSESSMENT

Behavioral Risk Factor Surveillance System Exhibit 40: Behavioral Risk Factor Surveillance System, 2019 New Castle Kent County County

Indicator Behavioral Risk Factors Current Cigarette Smoker Total Tobacco Use Obese Overweight Sedentary Did not meet physical activity guidelines Did not consume at least five fruits and/or vegetables per day Binge drinking Chronic heavy drinking Chronic Health Conditions Disability Diabetes Prediabetes High Cholesterol Hypertension Angina or Coronary Heart Disease Coronary Heart Disease or Myocardial Infarction Stroke Skin Cancer Other Cancer Asthma COPD Arthritis Limited work ability due to arthritis Depressive disorder Vision impairment Preventive Medicine: Immunizations and Screenings Age > 65 flu shot in past year Age > 65 pneumonia vaccine Adults who are at high risk for HIV Adults who have been tested for HIV Health Care Coverage/Health Status No health insurance (age 18-64) Health status: poor to fair

Delaware

13.8% 21.4% 31.5% 35.3% 24.2% 35.2% 84.4% 19.8% 7.8%

18.5% 18.5% 42.0% 31.4% 30.2% 39.3% 87.3% 12.6% 5.8%

18.8% 24.9% 35.3% 35.1% 29.5% 37.7% 88.5% 14.8% 7.1%

15.9% 25.3% 34.4% 34.5% 26.6% 36.6% 86.0% 17.2% 7.3%

22.0% 11.8% 11.4% 33.4% 33.9% 4.0% 5.6% 3.2% 6.3% 7.0% 9.5% 9.5% 23.5% 28.6% 18.9% 4.8%

29.1% 13.2% 12.9% 35.0% 37.4% 3.9% 6.2% 3.7% 5.8% 6.5% 12.7% 12.7% 29.5% 31.2% 18.9% 5.1%

31.3% 14.7% 11.8% 40.3% 41.4% 5.9% 10.8% 5.9% 10.8% 12.0% 8.5% 8.5% 35.2% 34.3% 18.4% 5.1%

25.6% 12.8% 11.8% 35.4% 36.4% 4.4% 7.0% 4.0% 7.3% 8.2% 9.8% 9.8% 27.4% 30.9% 18.8% 4.9%

65.1% 75.2% 6.6% 46.0%

58.6% 68.6% 6.3% 49.0%

63.4% 78.7% 5.5% 42.0%

63.4% 75.3% 6.3% 45.5%

11.9% 17.3%

11.5% 20.2%

17.7% 20.9%

13.0% 18.7%

Source: Delaware Behavior Risk Factor Survey, 2019.

Sussex County

APPENDIX B – SECONDARY DATA ASSESSMENT Description The Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS) gathers data through a telephone survey regarding health risk behaviors, health care access, and preventive health measures. Data are collected for the entire United States. Analysis of BRFSS data can identify localized health issues, trends, and health disparities, and can enable county, state, or nation-wide comparisons. Exhibit 40 presents BRFSS data for all Delaware counties and the state of Delaware. Light grey shading indicates measures that are unfavorable compared to state averages. Observations •

New Castle County compared unfavorably to state averages for several indicators, including: o o o o o o

Overweight status Binge drinking Chronic heavy drinking Depressive disorder Age 65+ with pneumonia vaccine Adults who are at high risk for HIV

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 41: BRFSS Measures by New Castle County ZIP Code ZIP Code 19801 19802 19805 19720

BRFSS Measures (N=30) In Bottom Quartile

Below U.S. Average

20 13 6 1

22 19 18 14 13 11 9 9 8 6 4 4 3 3 3 3 3 3 3 3 2 2 2 2 2

19804 19706 19733 19717 19716 19711

4 8 8 4

19703 19713 19810 19730 19803 19734 19702 19807

1 1 2 2 2

19707 19701 19709

2 2

19806 19731

19809 19808

Source: Verité Analysis of PLACES, Centers for Disease Control and Prevention, 2022.

Description Exhibit 41 presents the number of BRFSS measures that fall below U.S. average and in the bottom quartile nationally by New Castle County ZIP Code. There is a total of 30 BRFSS measures in CDC PLACES data. Observations •

Community 1 ZIP Codes had a third or more BRFSS measures fall below U.S. averages.

•

Wilmington ZIP Code 19801 (Community 1) had 20 measures in the bottom quartile nationally and 22 measures below U.S. average.

•

Community 1 compared unfavorably for all measures compared to Community 2.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 42: New Castle County BRFSS Measures by ZIP Code Compared to United States

BRFSS Measure Mental health not good >=14 days Core preventive services for older women

19801

19802

19805

19720

19804

All teeth lost 65+ Taking high blood pressure medicine Lack of health insurance (18-64) Stroke Core preventive services for older men High blood pressure Dental visit Asthma Chronic kidney disease Cholesterol screening Obesity Cervical cancer screening Fair or poor self-rated health status Physical inactivity Current smoking Colorectal cancer screening Physical health not good >=14 days Diabetes Chronic obstructive pulmonary disease Sleep < 7 hours Binge drinking Depression Source: Verité Analysis of PLACES, Centers for Disease Control and Prevention, 2022.

Description Exhibit 42 presents the BRFSS measures for ZIP Codes that have benchmarked comparatively poorly. The exhibit shows the BRFSS measures by type. Light grey shading indicates measures that are below U.S. averages and dark grey shading shows measures in the bottom quartile. Observation •

All Community 1 ZIP Codes fell below U.S. averages for the following measures: all teeth lost 65+, lack of health insurance (18-64), core preventive services for older

APPENDIX B – SECONDARY DATA ASSESSMENT men, asthma, fair or poor self-rated health status, physical inactivity, and colorectal cancer screening. •

Wilmington ZIP Codes 19801 and 19802 compared particularly unfavorably to U.S. averages with 20 and 13 measures in the bottom quartile, respectively.

APPENDIX B – SECONDARY DATA ASSESSMENT

Delaware School Survey Exhibits 43 through 45 show select results of the Delaware School Survey. The Delaware School Survey is an annual survey of 5th, 8th, and 11th grade public school students in Delaware. The surveys are administered at the public schools in Delaware. Analysis of the Delaware School Survey data can identify localized health issues and trends among youth. Exhibit 43: New Castle County Students’ Self-Reported Binge Drinking (past two weeks), 2015-2021

Source: Center for Drug and Health Studies, University of Delaware, 2021. Note: Delaware Rate: 11%, 2018-2019.

Description Exhibit 43 presents self-reported binge drinking in the past two weeks for New Castle County youth. Observations •

Self-reported binge drinking had declined amongst both 8th and 11th graders from 2015-2021. There was no data reported for 5th graders for this measure.

•

New Castle County youth binge drinking rates compared favorably to the Delaware rate of 11%.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 44: New Castle County Students’ Self-Reported E-Cigarette and/or Vaping Device (past 30 days), 2015-2021

Source: Center for Drug and Health Studies, University of Delaware, 2021. Note: Delaware Rate: 12%, 2018-2019.

Description Exhibit 44 presents self-reported e-cigarette and/or vaping device use for New Castle County youth. Observations •

Self-reported e-cigarette and/or vaping device use had declined amongst both 8th and 11th graders from 2015-2021.

•

There was no reported e-cigarette and/or vaping device use amongst 5th graders.

•

New Castle County youth e-Cigarette and vaping device use compared favorably to the Delaware rate of 12%.

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 45: New Castle County Students’ Self-Reported Marijuana Use (past 30 days), 2015-2021

Source: Center for Drug and Health Studies, University of Delaware, 2021. Note: Delaware Rate: 23%, 2018-2019.

Description Exhibit 45 presents self-reported marijuana use for New Castle County youth. Observations •

Self-reported marijuana use had declined amongst both 8th and 11th graders from 2015-2021.

•

There was no reported e-cigarette and/or vaping device use amongst 5th graders.

•

New Castle County marijuana use amongst youth compared favorably to the Delaware rate of 23%.

APPENDIX B – SECONDARY DATA ASSESSMENT

Food Deserts Exhibit 46: Locations of Food Deserts, 2019

Description

Source: U.S. Department of Agriculture, Economic Research Service, 2019 and Maptitude, 2021. .

Exhibit 46 identifies where food deserts are present in the defined ChristianaCare community. The U.S. Department of Agriculture’s Economic Research Service defines urban food deserts as low-income areas more than one mile from a supermarket or large grocery 81

APPENDIX B – SECONDARY DATA ASSESSMENT store, and rural food deserts as more than 10 miles from a supermarket or large grocery store. Many government-led initiatives aim to increase the availability of nutritious and affordable foods to people living in these areas. Observations •

Census tracts designated as food deserts were in Newark, New Castle, and Wilmington and within Community 1.

•

Approximately 14 percent of New Castle County’s population lives in these census tracts.

APPENDIX B – SECONDARY DATA ASSESSMENT

Medically Underserved Areas and Populations Exhibit 47: Locations of Medically Underserved Areas and Populations, 2022

Source: Health Resources and Services Administration, 2022 and Caliper Maptitude, 2021.

Description Exhibit 47 identifies the location of Medically Underserved Areas (MUAs) and Medically Underserved Populations (MUPs). Medically Underserved Areas and Populations (MUA/Ps) are designated by HRSA based on an “Index of Medical Underservice.” The index includes the following variables: ratio of

APPENDIX B – SECONDARY DATA ASSESSMENT primary medical care physicians per 1,000 population, infant mortality rate, percentage of the population with incomes below the poverty level, and percentage of the population age 65 or over. 12 Areas with a score of 62 or less are considered “medically underserved.” Populations receiving MUP designation include groups within a geographic area with economic barriers or cultural and/or linguistic access barriers to receiving primary care. If a population group does not qualify for MUP status based on the IMU score, Public Law 99-280 allows MUP designation if “unusual local conditions which are a barrier to access to or the availability of personal health services exist and are documented, and if such a designation is recommended by the chief executive officer and local officials of the state where the requested population resides.”13 Observations •

There were several census tracts in New Castle County that have been designated by HRSA as Medically Underserved Areas. Medically Underserved Areas were present in Community 1 in areas proximate to Wilmington Hospital, and in the northern area of Community 2.

Heath Resources and Services Administration. See http://www.hrsa.gov/shortage/mua/index.html 13 Ibid. 12

APPENDIX B – SECONDARY DATA ASSESSMENT

Health Professional Shortage Areas Exhibit 48: Health Professional Shortage Areas (HPSAs), 2022 HPSA Source Name

Address

City

James T. Vaughn Correctional Center 1181 Paddock Rd Smyrna Baylor Women's Correctional Institution 660 Baylor Blvd New Castle Howard R. Young Correctional Institution 1301 E 12th St Wilmington Low Income Population Newark, Wilmington Westside Family Healthcare, Inc. Westside Family Healthcare - Administration Office 300 Water St STE 200 Wilmington Westside Family Healthcare - Ancillary Administration Office 13 Reads Way Ste 102 New Castle Westside Family Healthcare - Bear / New Castle 404 Foxhunt Dr Bear Westside Family Healthcare - Dover 1020 Forrest Ave STE 1 Dover Westside Family Healthcare - Mobile Health Unit- No.1 120 Holly Oak Ln Dover Westside Family Healthcare - Newark 27 Marrows Rd Newark Westside Family Healthcare - Northeast 908 E 16th St STE B Wilmington Westside Family Healthcare - Support Services, Dover 1058 S Governors Ave STE 102Dover Westside Family Healthcare - Wilmington 1802 W 4th St Wilmington Southbridge Medical Advisory Council Inc Henrietta Johnson Medical Center 601 New Castle Ave Wilmington Henrietta Johnson Medical Center @ Eastside 600 N Lombard St Wilmington Henrietta Johnson Medical Center at Claymont 2722 Philadelphia Pike Claymont Low Income Population Wilmington Low Income Population Newark, Stanton

HPSA Type Description Correctional Facility Correctional Facility Correctional Facility Low Income Population HPSA

Primary Mental Dental Care Health Health ● ● ● ● ● ● ● ● ● ● ●

Federally Qualified Health Center Federally Qualified Health Center Federally Qualified Health Center Federally Qualified Health Center Federally Qualified Health Center Federally Qualified Health Center Federally Qualified Health Center Federally Qualified Health Center Federally Qualified Health Center

● ● ● ● ● ● ● ● ●

Federally Qualified Health Center Federally Qualified Health Center Federally Qualified Health Center Low Income Population HPSA Low Income Population HPSA

● ● ●

● ● ● ● ●

● ● ●

Source: Health Resources and Services Administration, 2022.

Description Exhibit 48 identifies the locations of federally designated primary care, mental health and dental health, Health Professional Shortage Areas (HPSAs). A geographic area can be designated a HPSA if a shortage of primary medical care, dental care, or mental health care professionals is found to be present. In addition to areas and populations that can be designated as HPSAs, a health care facility can receive federal HPSA designation and an additional Medicare payment if it provides primary medical care services to an area or population group identified as having inadequate access to primary care, dental, or mental health services.

APPENDIX B – SECONDARY DATA ASSESSMENT

HPSAs can be: “(1) An urban or rural area (which need not conform to the geographic boundaries of a political subdivision, and which is a rational area for the delivery of health services); (2) a population group; or (3) a public or nonprofit private medical facility.”14 Observations

•

Both Westside Family Healthcare and Henrietta Johnson Medical Center were HPSA designated Federally Qualified Health Centers (FQHC) for primary care, mental health, and dental health professionals.

•

The low-income population of Newark and Wilmington have been designated as Primary Care and Dental Care HPSAs.

•

The low-income population of Newark and Stanton have been designated as Mental Health HPSA.

U.S. Health Resources and Services Administration, Bureau of Health Professionals. (n.d.). Health Professional Shortage Area Designation Criteria. Retrieved 2012, from http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/index.html

APPENDIX B – SECONDARY DATA ASSESSMENT

Findings of Other Assessments Delaware State Health Improvement Plan, 2019 Annual Report Following the first year of implementation within a five-year cycle, the 2019 Annual Report assesses policy improvements and the alignment of activities among nine key Delaware stakeholder groups with the 2018-2023 Delaware State Health Needs Assessment (DSHNA) and State Health Improvement Plan (SHIP). A SHIP is best practice for state health departments and is required for accreditation by the Public Health Accreditation Board (PHAB). The DSHNA identified and prioritized local and statewide strategies that address critical health needs. This data was gathered with four nationally recognized Mobilizing for Action through Planning and Partnerships assessments: forces of change, local public health assessment, community themes and strengths, and community health status. The DSHNA identified four areas of priority focus: chronic disease; maternal and child health; substance use disorders; and mental health. Fourteen recommendations (outlined below) were provided to address these four priority areas. SHIP Priority Areas and Recommendations: Chronic Disease 1. Reduce obesity by promoting healthy diet and exercise 2. Increase access to healthy foods 3. Improve the built environment 4. Promote access to remote patient monitoring for patients with chronic conditions 5. Increase access to community health workers and care coordination 6. Reduce lung disease (e.g., asthma, lung cancer, chronic obstructive pulmonary disease) 7. Increase the number of primary care physicians in underserved areas 8. Increase the number of Medicaid dental providers in underserved areas 9. Develop a focused effort to “make the healthy choice the easy choice” Maternal & Child Health 10. Embed education for pre- and inter-conception care in schools Substance Use Disorders 11. Reduce tobacco and tobacco-substitute use 12. Reduce substance use Mental Health 13. Improve access to behavioral and mental health services System-wide Recommendations 14. Adopt a Policy, Systems, and Environmental (PSE) change approach to promoting health in all policies, incorporating a social marketing approach, and addressing the social determinants of health The Delaware Health Improvement Plan for 2018-2023 can be accessed at www.delawareship.org.

APPENDIX C – COMMUNITY INPUT PARTICIPANTS

APPENDIX C – COMMUNITY INPUT PARTICIPANTS Exhibit 49: Community Meeting and Interview Participants Organization AIDS Delaware Bureau of Health Equity Central and Walnut YMCA - YMCA of Delaware Children and Families First Delaware Inc. ChristianaCare Health System Community Collaboration of Delaware Delaware Coalition Against Domestic Violence (DCADV) Delaware Community Reinvestment Action Council (DCRAC) Delaware Division of Substance Abuse and Mental Health Delaware Guidance Services Delaware Health and Social Services Delaware HIV Consortium Department of Children and Families Division Public Health Domestic Violence Coordinating Council Edgemoor Revitalization Cooperative, Inc. Endless Possibilities in the Community (EPIC)

Habitat for Humanity of New Castle County Healthy Communities Delaware Hilltop Lutheran Neighborhood Center HOPE Commission Housing Alliance Delaware Latin American Community Center Life Health Center Ministry Out Of Bounds, Inc Office of the Lieutenant Governor Parents as Teachers PFLAG Wilmington Northern, DE Inc. Rotary Club Of Wilmington DE Sunday Breakfast Mission Victorious Faith Christian Worship Center William Penn High School Wilmington Police Dept. Victim Services Unit Woodlawn Trustees

APPENDIX D – CHSI PEER COUNTIES

APPENDIX D – CHSI PEER COUNTIES County Health Rankings has assembled community health data for all 3,143 counties in the United States. Following a methodology developed by the Centers for Disease Control’s Community Health Status Indicators Project (CHSI), County Health Rankings also publishes lists of “peer counties,” so comparisons with peer counties in other states can be made. Each county in the U.S. is assigned 30 to 35 peer counties based on 19 variables including population size, population growth, population density, household income, unemployment, percent children, percent elderly, and poverty rates. Exhibit 50 lists peer counties for New Castle County, Delaware.

APPENDIX D – CHSI PEER COUNTIES Exhibit 50: CHSI Peer Counties

New Castle County, Delaware Pinal County, Arizona Arapahoe County, Colorado Gilpin County, Colorado Clay County, Florida St. Johns County, Florida Seminole County, Florida Floyd County, Indiana Leavenworth County, Kansas Campbell County, Kentucky Kenton County, Kentucky St. Tammany Parish, Louisiana DeSoto County, Mississippi Clay County, Missouri Platte County, Missouri Strafford County, New Hampshire Iredell County, North Carolina Butler County, Ohio Cleveland County, Oklahoma Washington County, Oregon Newport County, Rhode Island York County, South Carolina Rutherford County, Tennessee Sumner County, Tennessee Galveston County, Texas Hays County, Texas Henrico County, Virginia Prince George County, Virginia Chesapeake city, Virginia Williamsburg city, Virginia Clark County, Washington Jefferson County, West Virginia Pierce County, Wisconsin

APPENDIX E – IMPACT EVALUATION

APPENDIX E – IMPACT EVALUATION ChristianaCare abides by the ChristianaCare Way: We serve our neighbors as respectful, expert, caring partners in their health. We do this by creating innovative, effective, affordable systems of care that our neighbors value. ChristianaCare is guided by its commitment to partnering with our neighbors to better understand their needs and goals for health.

Impacts of COVID-19 In March 2020, the COVID-19 pandemic was declared and our focus, across the system, was an all-out response to support testing and expert-informed care to ensure all aspects of patient safety were addressed. ChristianaCare was a regional leader with our pandemic response, especially with the introduction of COVID-19 vaccinations. Between January 16 and June 11, 2021, ChristianaCare held 28 vaccination events at its Newark Campus and administrative location in Wilmington, Avenue North. A total of 22,362 first and second doses were provided to community members. ChristianaCare’s Office of Health Equity also organized eight first and second dose vaccination events in community locations throughout New Castle County between February and June 2021. At these events, 2,810 1st doses and 2,616 2nd doses were provided. Individuals who received a 1st dose were invited back to the same location to receive their second dose. These individuals received reminders to get their second dose as well. In December 2020, ChristianaCare was also able to begin providing monoclonal antibody treatments to individuals to ensure they do not face severe illness or hospitalization due to COVID-19. To date, 2,395 individuals have received this treatment since it was first offered at ChristianaCare. To ensure that transportation barriers would not prevent someone from receiving this life-saving treatment, ChristianaCare’s Center for Virtual Health and Community Health Department worked together to create a pipeline to provide transportation for those receiving these treatments. Before the vaccines and treatments were available, ChristianaCare also worked to ensure it served the community with COVID-19 testing. Between March 13th and June 3rd, 2020, ChristianaCare organized and carried out 16 mobile testing events throughout New Castle County and one testing event was also held in neighboring Cecil County, Maryland. At a time when testing was difficult to obtain, 3,526 individuals were able to be tested at these events. ChristianaCare ended its mobile testing initiative once the state and county were able to provide routine testing within our communities. ChristianaCare also collaborated with the Latin American Community Center (LACC) and Kingswood Community Center (KCC) to offer COVID-19 testing centrally located in Wilmington in historically underserved minority communities. Testing began in April 2020 at both LACC and KCC and it continued at LACC until April 2021, at which time the LACC resumed its own programming in that space. During the period from July 2020 to April 2021, ChristianaCare saw 497 patients at the LACC testing site. COVID-19 testing continues to be offered at the Kingswood Community Center, but within a newly developed primary care practice that began operating in April 2021.

APPENDIX E – IMPACT EVALUATION

ChristianaCare is proud of its quick response to the pandemic to keep our patients safe and bring COVID-19 testing, vaccination, and treatment to the community. Within the new landscape of the pandemic, it became apparent how much we relied upon being community-based to provide education, screenings, and other resources to our communities when these avenues for providing community benefit were no longer an option. Simply put: the specter of COVID-19 on almost all aspects of life are impossible to ignore; and many areas of work which were community-based were the first to shut down. Nevertheless, the community benefit we continued to undertake to address our prioritized areas of need continued to be significant.

CHNA Activities In the most recent CHNA, finalized June 2019, ChristianaCare identified the community’s most significant needs as: • • • • •

Social Determinants of Health including poverty, food insecurity, housing, affordability of care, education, and employment/job security Mental Health and Substance Use Disorder Violence and Public Safety Maternal and Child Health especially Infant Mortality Access to Dental and Primary Care

All but access to dental and primary care were also identified as significant health needs in the 2016 CHNA. In the 2016 CHNA, ChristianaCare also identified transportation, housing, and employment as significant needs, but determined that it was not able to address these needs at that time given a lack of expertise and infrastructure. Addressing social determinants of health is essential to improving the health of our community and we have advanced our organizational capacity to support a social care framework to integrate internal and external resources as we work to address these issues.

Social Determinants of Health In fiscal year 2019, ChristianaCare’s Office of Health Equity designed the Community Investment Fund in partnership with ChristianaCare’s Finance Department. In fiscal year 2020, ChristianaCare gave nearly $2,000,000 in community investment funding to 32 community organizations across the state. Due to the disruption and financial uncertainty caused by the pandemic, the Office of Health Equity was unable to provide Community Investment funding in fiscal year 2021, but in fiscal year 2022, 13 organizations addressing substance use disorder and housing were selected by ChristianaCare to receive just over $1,000,000 in Community Investment funding. ChristianaCare has supported the Purpose Built Communities’ REACH Riverside Community Development Initiative. In March 2019, ChristianaCare gave a gift of $1,000,000 to the initiative in support of community health and youth development

APPENDIX E – IMPACT EVALUATION programs in Riverside, one of Wilmington’s oldest and most underserved communities. ChristianaCare leadership serves on the REACH Riverside Board and the Health, Wellness, and Safety Committee and as mentioned previously, ChristianaCare now has a Virtual Health Primary Care Practice located at Kingswood Community Center which is located within the Riverside community. Bringing easily accessible healthcare into the community was one of the goals of the initiative that we were eager to help the community meet. The Office of Health Equity launched Unite Delaware in November 2019. Unite Delaware is a coordinated care network of health and social service providers connected through a shared technology platform, Unite Us, which enables all organizations on the platform to send and receive referrals to address individuals’ social and health needs. There are nearly 200 participating organizations from throughout the state of Delaware on the platform that can address a variety of social and health needs. In fiscal year 2021, ChristianaCare partnered with Delaware 211 to bring them onboard the Unite Us platform to address any need that may not be met by the current participating partner. The Delaware 211 partnership ensures that no Delawarean who seeks help through Unite Delaware will leave empty handed. ChristianaCare also began working with Unite Us to integrate the platform into the Electronic Health Record to ensure easier access to address patients’ needs in clinical settings. Another comprehensive way in which ChristianaCare addresses social determinants of health is the Delaware Medical Legal Partnership (MLP) created in partnership with Delaware’s Community Legal Aid Society, Inc. (“CLASI”). The MLP provides free, civil legal services to low-income patients, adults, and children who are facing legal matters or needs that may negatively impact their health or legal matters or needs which may have been created or aggravated by a person’s health issues. Some of the matters addressed through this program are safe housing, prevention of subsidized and public housing evictions, assistance obtaining or preserving income maintenance and government benefits, access to social services, appropriate educational services, health insurance, and access to health care. In anticipation that the pandemic would exacerbate existing legal needs in the areas of housing, unemployment, domestic violence, and other areas for already vulnerable populations, ChristianaCare expanded its contract with CLASI. This was prescient as we quickly realized this increased demand and served more than double the number of individuals in the MLP program in fiscal year 2021, 274, than were served in the prior fiscal year. ChristianaCare also addressed social determinants of health through its commitment to a Community Health Workers (CHW) program. As recently as 2017, ChristianaCare did not employ any CHWs, but like many states, Delaware is transitioning from volume to value which presents an exciting opportunity to develop a standardized, scalable, sustainable CHW program. ChristianaCare partnered with University of Pennsylvania’s Center for Community Health Workers’ IMPaCT team to develop an effective, optimized CHW program. As of this writing, ChristianaCare has employed nearly 40 CHWs. CHWs are embedded within:

•

The Wilmington Hospital Emergency Department (ED) to provide support to patients who are high ED utilizers

APPENDIX E – IMPACT EVALUATION

• • • •

6 Primary Care Practices 9 School Based Health Centers Women’s Health Delaware Food Farmacy

These CHWs work with patients to address their social determinants of health and craft and meet personal goals, health related or not, so that the patient can successfully improve their health. Food Insecurity ChristianaCare’s Community Health Department launched the Delaware Food Farmacy (DFF) in in collaboration with Primary Care, Nutrition Services, Behavioral Health, and iREACH (ChristianaCare Institute for Research on Equity and Community Health). ChristianaCare partnered with Lutheran Community Services to develop and launch the DFF, a program that addresses healthcare inequities by providing holistic care with radical convenience. DFF is designed to help Medicaid at-risk patients with uncontrolled diabetes, hypertension and/or heart failure self-manage their chronic condition through a nutritionbased comprehensive care model - treating the “whole person.” ChristianaCare is also continuing its long-standing partnership with Urban Acres to support Produce Delivery. Through this partnership, from July 2020 through June 2021,190 at-risk, food insecure, patients were provided with fresh, local produce on a weekly basis for a minimum of 6 months. Housing ChristianaCare made significant investments (nearly $600,000) in housing and housing improvement initiatives in fiscal year 2020. • Funding provided to The Friendship House, a community-based organization which houses and provides community for homeless individuals as they assist in transitioning to permanent housing, allowed for additional housing for women who have recently left a substance use treatment disorder facility, along with case management and administrative support. • Funding provided to Attack Addiction, a statewide non-profit organization committed to addressing and preventing substance use disorder, to build a continuum of housing for women in New Castle County. There will be three houses with the capability of serving 26 women at one time. These houses will provide women with a safe and affordable place to live while initiating and continuing with substance use disorder treatment. • Funding provided to Housing Alliance Delaware, a statewide non-profit organization that addresses affordable housing needs and homelessness, to undertake a program that will serve chronically homeless individuals at risk of poor health outcomes by offering financial assistance to reduce economic barriers to exiting homelessness, engineer a more efficient and comprehensive process to ensure hospitalized homeless individuals are connected to the health and housing services 94

APPENDIX E – IMPACT EVALUATION they need, and finally, conduct a qualitative assessment to allow those experiencing chronic homelessness share their barriers to receiving behavioral, medical, and social needs. Importantly, we have also offered our partnership along with funding. We are collaborating with these community organizations to ensure individuals are not only housed but having their health needs met as well. In fiscal year 2021, ChristianaCare provided $50,000 in funding to Housing Alliance Delaware, a statewide non-profit organization that addresses affordable housing needs and homelessness, to continue its program that will serve chronically homeless individuals at risk of poor health outcomes by offering financial assistance to reduce economic barriers to exiting homelessness and engineering a more efficient and comprehensive process to ensure hospitalized homeless individuals are connected to the health and housing services they need. A qualitative assessment to allow those experiencing chronic homelessness to share their barriers to receiving behavioral, medical, and social needs is also conducted through this program. This is the second year of funding this program. In December 2020, New Castle County government purchased a hotel along I-95 and rapidly transformed it into an emergency homeless shelter, The Hope Center. ChristianaCare served as a partner to the County during this process and is now on-site providing medical care to the residents. The uncertainty of the pandemic did not allow ChristianaCare to provide as much community funding for housing in fiscal year 2021, but as affordable housing becomes increasingly difficult to obtain nationally and locally, we expect to respond to our community need in this area. Education ChristianaCare’s Workforce Development aims to expose high school scholars to careers in health care. Typically, scholars mistakenly think that the health system is primarily made up of professionals wearing white coats and/or scrubs. The programming provided by Work Force Development sets out to confirm that those wearing white coats and scrubs are not the only professionals in healthcare. The Work Force Development programming explores careers in health care, aims to build successful partnerships and reduce achievement gaps. Participants in this programming are high school students, specifically the systemically overlooked members of our community, to ensure we develop a pipeline for a workforce of caregivers that reflect the communities we serve. Transportation In the 2016 CHNA, ChristianaCare decided not to address transportation as a community need as we did not have the ability to do so. In 2020, we began to address transportation needs by partnering with Roundtrip Health to provide, to those patients with transportation barriers, convenient and free transportation to get them to and from medical services. During fiscal year 2021, the use of Roundtrip was so successful for the patients and caregivers that we decided to expand it to other areas. In May 2022, other departments, and programs such as Discharge, Heart Failure Bridge Clinic, Outpatient Behavioral Health,

APPENDIX E – IMPACT EVALUATION Metabolic Health, and Cancer Care Management, among others, will also have access to Roundtrip to provide patients with transportation barriers rides to their medical appointments. Between July 1, 2020, and June 30, 2021, 1,493 rides were given to 206 unique patients. We also recognize that to improve patient health there is a need to identify and address individual patients’ SDOH. Addressing patients’ social needs in addition to providing clinical care has become a major public health initiative and is a key component of our work at ChristianaCare to create an integrated clinical and social care framework. Since the 2019 CHNA, ChristianaCare has developed its systemwide standardized SDOH screening tool that is being universally implemented throughout ChristianaCare. As use of the screening tool is expanding, ChristianaCare internal access to Unite Delaware is also increasing through integration in the electronic health record. These are two vitally connected initiatives because we feel strongly that if a patient discloses a need, we must be prepared to help them address it. Unite Delaware allows us to do exactly that through social service referrals to a platform of community-based organizations.

Mental Health and Substance Use Disorder ChristianaCare strives to provide personalized and effective treatment for mental health illnesses and substance use disorders. Access to behavioral health services has been a long-standing concern of our communities, and the pandemic certainly exacerbated the issues of access. Through programming introduced in the last three years, ChristianaCare hopes to make behavioral health services more accessible. ChristianaCare’s Center for Hope and Healing, which began operating in fiscal year 2020, offers support to people in our communities who are struggling with mental, medical, and social health problems. The goal of the Center is to give patients access to providers who can help stabilize their health and their lives. Specialists work together to quickly stabilize patients’ health and then put long-term support in place with other providers and programs. The Center offers flexible, responsive care in a respectful, caring, and supportive setting. In fiscal year 2021, the Center for Hope and Healing opened a second location in Wilmington. This new location incorporates a primary care practice for this patient population. ChristianaCare’s Community Substance Overdose Support (Community SOS), which was created in partnership with New Castle County in 2019, employs peer engagement specialists who are in recovery to engage with individuals in their homes or communities after they have been brought to the hospital following a suspected overdose. The primary goal is to help the individual enter treatment. Community SOS also offers harm reduction education to those who are not yet ready to enter treatment and provides naloxone and training on its use to those with substance use disorder and their friends and family. In fiscal year 2021, Community SOS gave out 325 naloxone kits to individuals. In November 2021, ChristianaCare launched a partnership with New Castle County, to embed six caregivers within the New Castle County Police Department’s Behavioral Health Unit. Four of these caregivers engage in the community with individuals who suffered a non-fatal overdose and provide them with a treatment plan and ongoing case management. The other two caregivers accompany county police when responding to 911

APPENDIX E – IMPACT EVALUATION calls when mental health is thought to be an issue. The caregivers will ensure the individual’s mental health needs are addressed as well as provide them with connection to care.

Violence and Public Safety ChristianaCare recognizes that violence is a public health issue and determined that as a health system, it was necessary to address violence head on by implementing a Hospital Based Violence Intervention Program (HVIP), Empowering Victims of Lived Violence (EVOLV). EVOLV launched on February 15, 2021. EVOLV works with patients who have suffered a gunshot wound, stab wound, or violent blunt assault, are residents of New Castle County, and aged 13 years or older. EVOLV’s initial focus included patients admitted in the Trauma Department for a complex injury. The EVOLV social worker approached patients at the hospital to introduce the program goals and explain the support the program provides. The Social Worker enrolls hospitalized patients and provides a warm hand-off to the EVOLV community health worker (CHW) to start the rapport building process and prepare for the community engagement prior to discharge. The CHW actively follows patients and supports them by providing them with access to care, addressing any social determinants, and identifying and achieving patient centered goals and outcomes. The length of engagement is three months. Importantly, in FY21, ChristianaCare collaborated with the State of Delaware’s Office of the Governor around the issue of violence and as part of this collaborative, EVOLV began engaging with community organizations that focus on violence, including Social Contract, Community Intervention Team (CIT), and Group Violence Intervention (GVI) which each have their own unique approach to addressing the gun violence issue in Delaware. CIT and GVI are both Wilmington based organizations with a mix of community and governmental support. ChristianaCare continued to provide education to youth throughout Delaware about violence prevention with the Choice Road Program which urges students to consider the choices they make and a new program which introduces students to the concept of gun violence as a public health issue. In addition to violence prevention, ChristianaCare also educates adolescents and adults about safe choices to prevent injuries. The Trauma team adapted to hold many of these sessions virtually and continued to be a presence in schools and senior centers despite the pandemic.

Maternal and Child Health especially Infant Mortality ChristianaCare is working to improve the infant mortality rate through programs aimed at pregnant women like the embedded CHWs in Women’s Health mentioned previously, but also by addressing social determinants of health. While it will not be immediately apparent, our expectation is that improving communities will improve maternal and child health and decrease infant mortality. 97

APPENDIX E – IMPACT EVALUATION

Since 2012, the State of Delaware has awarded ChristianaCare a grant to support the Health Ambassadors Program since 2012. The program is designed to improve maternal and child morbidity and mortality through the promotion of health before, during, and after pregnancy. In fiscal year 2021, the Health Ambassadors assisted and were able to successfully meet the needs of 3,212 individuals. Since 2018, ChristianaCare’s Community Health Department in the Office of Health Equity has also provided Boot Camp for New Dads (BCND) and Boot Camp for New Moms (BCNM). BCND provides community-based workshops to help new and soon to be dads become confident in their ability to care for their infants, support their partner, and successfully become capable dads. These workshops are for dads of all ages, cultures, and economic levels. The workshops are co-facilitated by local dads who were recruited and trained by ChristianaCare. BCNM seeks to provide information about what happens after pregnancy, labor, and delivery. BCNM is focused on helping new moms handle the changes in her life and the relationship with her partner once her baby has been born. In partnership with the Delaware Division of Public Health, ChristianaCare’s Healthy Beginnings Program brings together preconception care which identifies and addresses potential risks to future pregnancies, pregnancy planning which guides the woman through the first steps that lay the groundwork for a healthy pregnancy, and prenatal care that ensures the good health of mother and baby from conception to birth. This holistic approach is undertaken by a team that includes doctors, nurse practitioners, social workers, case workers, resource mothers, and dieticians, working with the mother to assist her in having a healthy pregnancy and infant. The ChristianaCare Healthy Beginnings Program is also utilizing Roundtrip transportation services to ensure patients can attend their medical appointments.

Access to Dental and Primary Care ChristianaCare successfully expanded dental services at Wilmington Hospital with the completion of a two-year renovation project in fiscal year 2020 that increased the clinical capacity of our dentistry and oral-maxillofacial surgery practices. This increase enables more than 5,000 additional visits per year at one of the few access points in the community for dental care. ChristianaCare is expanding primary care services to support improved access to the preventive care and chronic disease management that helps patients to be healthy and avoid costly unnecessary emergency room visits and hospital admissions. ChristianaCare will continue to seek opportunities to place providers and staff in community settings to meet patient needs at convenient access points. This is necessary because there are barriers to accessing care caused by transportation and work schedules. We aim to meet the needs of our neighbors in the community where they live, work, and play as demonstrated by our previously described newly established practice at Kingswood Community Center and the new Center for Hope and Healing practice. In fiscal year 2021, ChristianaCare also launched a primary care practice embedded in the Helen F. Graham Cancer Center and Research Institute. ChristianaCare is one of the first cancer programs in the nation to offer patients undergoing cancer treatments the opportunity to see a primary care provider on-site. In fiscal year 2021, ChristianaCare also acquired a 98

APPENDIX E – IMPACT EVALUATION practice, Su Centro de Salud with Primary Care at Kirkwood, which serves patients with Spanish speaking and culturally competent providers and staff to ensure the health needs of Hispanic community can be met.

Planning for 2023, and Beyond Over the past several years, even amidst the COVID-19 pandemic, ChristianaCare has worked to address our community’s needs through significant investment and carefully considered programming. We have worked hard to ensure that our programs address our neighbors’ needs in a way that is convenient for them, and if not, then we have adapted to pivot quickly to what will serve our neighbors. With this new CHNA, we are eager to continue and create new community partnerships and programs to address the needs in ways that our communities find helpful and value.

2022 New Castle County Community Health Needs Assessment

Articles inside

APPENDIX E – IMPACT EVALUATION

APPENDIX C – COMMUNITY INPUT PARTICIPANTS

Food Deserts

Health Professional Shortage Areas

APPENDIX D – CHSI PEER COUNTIES

Medically Underserved Areas and Populations

Delaware School Survey

Behavioral Risk Factor Surveillance System

Maternal and Child Health

Causes of Death

COVID-19 Incidence and Mortality

Communicable Diseases

Community Health Status Indicators

Centers for Disease Control and Prevention Social Vulnerability Index (SVI

Crime Rates

Health Insurance Status

Unemployment

Community and Internal Hospital Meetings

Socioeconomic Indicators

Other Local Health Status and Access Indicators

Consultant Qualifications

People in Poverty

Data Sources

Violent Crime

Findings of Other CHNAs