2019 Community Health Needs Assessment

Community Health Needs Assessment ChristianaCare June 26, 2019

TABLE OF CONTENTS

TABLE OF CONTENTS TABLE OF CONTENTS .............................................................................................................. 1 EXECUTIVE SUMMARY ............................................................................................................ 4 ASSESSMENT SUMMARY ........................................................................................................ 7 Introduction .............................................................................................................................. 7 Community Assessed .............................................................................................................. 7 Significant Community Health Needs .................................................................................. 8 Access to Affordable Medical and Dental Care ............................................................... 9 Chronic Disease..................................................................................................................... 9 Substance Use Disorder ....................................................................................................... 9 Health Disparities ............................................................................................................... 10 Infant Mortality ................................................................................................................... 10 Mental Health...................................................................................................................... 10 Smoking and Tobacco Usage ............................................................................................ 11 Obesity and Diabetes ......................................................................................................... 11 Services for Seniors ............................................................................................................. 11 Social Determinants of Health .......................................................................................... 12 DATA AND ANALYSIS ........................................................................................................... 13 Definition of Community Assessed ..................................................................................... 13 Secondary Data Summary..................................................................................................... 16 Community Health Indicators .......................................................................................... 17 Relevant Findings of Other CHNAs ................................................................................ 19 Primary Data Summary......................................................................................................... 20 Selected Actions Taken Since Last Assessment ................................................................. 26 Prevalence of poverty and other factors including food insecurity, housing, affordability of care, and employment/job security ...................................................... 26 Produce Rx Program .......................................................................................................... 26 Delaware Medical Legal Partnership .............................................................................. 27 Health Guides ..................................................................................................................... 27 Community Health Workers ............................................................................................ 28 School-Based Health Centers (SBHC).............................................................................. 28 Mental Health and Substance Use Disorder ................................................................... 29 Behavioral Health Integration with Primary Care......................................................... 30 Project Engage ..................................................................................................................... 30 Project Recovery.................................................................................................................. 31 Community Substance Overdose Support (SOS) Program .......................................... 31 Violence and Public Safety ................................................................................................ 32 1

TABLE OF CONTENTS Stop the Bleed ...................................................................................................................... 32 Play Streets Wilmington .................................................................................................... 33 You Only Live Once (YOLO) ............................................................................................ 33 Choice Road ......................................................................................................................... 33 ThinkFirst for Teens ........................................................................................................... 34 Distracted Driver Simulators ............................................................................................ 34 A Matter of Balance ............................................................................................................ 34 Delaware Coalition for Injury Prevention and Safe Kids Delaware/New Castle County .................................................................................................................................. 34 Maternal and Child Health ............................................................................................... 35 Long Acting Reversible Contraceptive (LARC) Program ............................................ 35 Alliance for Adolescents Pregnancy Prevention ............................................................ 35 Healthy Beginnings Program............................................................................................ 36 Health Ambassadors Program ......................................................................................... 36 Boot Camp for New Dads (BCND) and Boot Camp for New Moms (BCNM) ......... 37 Delaware Healthy Mother and Infant Consortium ....................................................... 37 United States Breastfeeding Committee .......................................................................... 38 Mother/Baby Class and Breastfeeding Support Group................................................. 38 Prioritized Significant Health Needs ................................................................................... 38 Process and Criteria Used to Prioritize Health Needs .................................................. 39 OTHER FACILITIES AND RESOURCES IN THE COMMUNITY .................................... 41 Federally Qualified Health Centers ................................................................................. 41 Hospitals .............................................................................................................................. 41 Other Community Resources............................................................................................ 42 APPENDIX A – OBJECTIVES AND METHODOLOGY ...................................................... 43 Regulatory Requirements ..................................................................................................... 43 Methodology ........................................................................................................................... 43 Collaborating Organizations ............................................................................................. 45 Data Sources ........................................................................................................................ 45 Information Gaps ................................................................................................................ 45 Consultant Qualifications .................................................................................................. 46 APPENDIX B – SECONDARY DATA ASSESSMENT ......................................................... 47 Demographics ......................................................................................................................... 47 Economic indicators ............................................................................................................... 55 People in Poverty ................................................................................................................ 55 Unemployment ................................................................................................................... 59 Insurance Status .................................................................................................................. 60 Crime .................................................................................................................................... 62 Housing Affordability ........................................................................................................ 63 Dignity Health Community Need Index ........................................................................ 65 2

TABLE OF CONTENTS Other Community Health Indicators .................................................................................. 68 County Health Rankings ................................................................................................... 69 Community Health Status Indicators .............................................................................. 72 America’s Health Rankings ............................................................................................... 74 Delaware Department of Health ...................................................................................... 77 National Cancer Institute................................................................................................... 84 Behavioral Risk Factor Surveillance System ................................................................... 85 UDS Mapper ........................................................................................................................ 87 Youth Risk Behavior Surveillance System ...................................................................... 88 Food Deserts ........................................................................................................................ 91 Medically Underserved Areas and Populations ............................................................ 92 Health Professional Shortage Areas................................................................................. 94 Ambulatory Care Sensitive Conditions ........................................................................... 97 Findings of Other Assessments ............................................................................................ 97 Delaware State Health Improvement Plan, 2017 ........................................................... 97 APPENDIX C – COMMUNITY INPUT PARTICIPANTS ................................................... 99

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EXECUTIVE SUMMARY

EXECUTIVE SUMMARY Christiana Care Health System (Christiana Care) undertook the 2019 Community Health Needs Assessment (CHNA) to identify significant community health needs and to inform the development of an Implementation Strategy to address current needs. Christiana Care includes two hospital facilities, Christiana Hospital in Newark, 19718, and Wilmington Hospital in Wilmington, 19801. Because the two hospitals defined their communities to be the same (New Castle County, Delaware), they are sharing this joint CHNA report.

Christiana Care’s mission is to serve its neighbors as respectful, expert, caring partners in their health by creating innovative, effective, affordable systems of care that our neighbors value. Christiana Care is deeply committed to improving the health of the communities we serve and advancing health equity so that everyone in our community has the opportunity to achieve optimal health. We embraced the CHNA as an opportunity to listen to and learn from our communities and to better serve them by addressing their needs and understanding the obstacles they face in the way of good health.

Because of Christiana Care’s commitment to truly understand the challenges faced by the communities it serves, this CHNA assessed community health needs in two geographic areas in New Castle County: “Community 1” (zip codes 19801, 19802, 19804, 19805, and 19720) and “Community 2” (all other zip codes). This distinction was made to ensure that the significant variation in socioeconomic conditions across New Castle County would be recognized, and that the most urgent needs would not be hidden by county-wide statistics. For example, the poverty rate in both New Castle County and Delaware were below the national average throughout 2012-2016, but the poverty rate in Community 1 during this time was above average.

To complete this CHNA, Christiana Care gathered secondary and primary data. 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 the State of Delaware; and (3) input from the participants in the community meetings and interview.

To collect primary data, Christiana Care held a series of community meetings: four meetings of 98 community stakeholders; six meetings of 53 local teenagers; and two 4

EXECUTIVE SUMMARY internal meetings of 13 Christiana Care staff members. The community stakeholders represented local health departments, non-profit organizations, local businesses, health care providers, local policymakers, parks and recreation departments, and school systems; the staff members were those who worked directly with patients; and the teenagers represented a number of areas across New Castle County, including Newark, New Castle, Wilmington and Claymont. Christiana Care was purposeful in the inclusion of a broad array of community voices at these meetings to ensure a diversity of viewpoints.

These meetings all began with a presentation of preliminary secondary community health data. Participants then were asked (a) to identify community health issues that may not have been well measured by secondary data and (b) through a voting process, to identify which needs they believed were most significant in New Castle County.

In addition to the above meetings, an interview was conducted with an Associate Deputy Director within the Delaware Department of Health and Social Services. During that interview, secondary data findings and significant needs also were discussed.

Christiana Care leaders examined the secondary data and primary data gathered from meetings and interviews to determine which health needs should be prioritized. When making this determination, leaders considered the prior 2016 CHNA, the severity and urgency of the need as shown by the data as well as demonstrated by community input, and whether Christiana Care has the ability to address the issue. The primary and secondary data collected clearly demonstrates that the health of New Castle County residents continues to be influenced by factors that cannot be addressed simply through the provision of health care.

The secondary data and community input continued to prioritize the same significant areas of need identified as top priorities in the 2016 CHNA: prevalence of poverty (i.e.: social determinants of health), mental health and substance use disorder, maternal and children’s health, and violence and public safety. Christiana Care determined that the most efficient and effective course of action would be to continue to address these issues as prioritized areas of need. Christiana Care also prioritized the additional need of access to dental and primary care.

The following comprise Christiana Care’s 2019 prioritized areas of need: 1. Social Determinants of Health including poverty, food insecurity, housing, affordability of care, education, and employment/job security 2. Mental Health and Substance Use Disorder 5

EXECUTIVE SUMMARY 3. Violence and Public Safety.

4. Maternal and Child Health especially Infant Mortality 5. Access to Dental and Primary Care.

The way in which Christiana Care will address these needs will be outlined in the forthcoming 2019 Community Health Implementation Plan (CHIP). Christiana Care was grateful for the opportunity to learn from its neighbors during this needs assessment process, and expects to continue to deepen its engagement and communication with its communities and neighbors about how best to serve them and advance the health of our community.

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ASSESSMENT SUMMARY

ASSESSMENT SUMMARY Introduction This Community Health Needs Assessment (CHNA) was conducted by Christiana Care Health System to identify significant community health needs and to inform development of an Implementation Strategy to address current needs. Christiana Care includes two hospital facilities, Christiana Hospital and Wilmington Hospital. 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 hospital facility in Newark, Delaware (zip code 19718).

Christiana Hospital is a teaching hospital that provides Delaware’s only Level I trauma center. Christiana Hospital also is the only high-risk delivering hospital in Delaware, offering Level III neonatal intensive care. More than 7,200 babies are born at Christiana Hospital each year. More than 1,400 physicians are active members of Christiana Care’s medical-dental staff. Many medical staff members have located at least part of their practices in two Medical Arts Pavilions on the hospital campus.

Wilmington Hospital is a 321-bed hospital facility located in Wilmington, Delaware (zip code 19801). A Wilmington landmark since 1890, Wilmington Hospital serves as Christiana Care’s corporate headquarters and provides access to high quality hospital services in the heart of Wilmington.

Additional information on Christiana Care and its two hospital facilities can be found at: christianacare.org/about.

Community Assessed For purposes of this report, the Christiana Care community is defined as New Castle County, Delaware. During the year ended June 30, 2018, New Castle County accounted for 77 percent of discharges total for Christiana Hospital and 88 percent of discharges for Wilmington Hospital (79 percent of Christiana Care discharges). The county’s estimated total population in 2018 was 555,778.

Substantial variation in socioeconomic conditions is present across New Castle County.

For example, the poverty rate in zip code 19801 (where Wilmington Hospital is located) 7

ASSESSMENT SUMMARY is approximately 37 percent and the rate in zip code 19701 is under 5 percent.

Accordingly, this CHNA assessed community health needs in two geographic areas: “Community 1” (zip codes 19801, 19802, 19804, 19805, and 19720) and “Community 2” (all other zip codes). Community 1 accounted for 27 percent of Christiana Care discharges in 2018 and Community 2 accounted for 52 percent.

The following map portrays the community served by Christiana Care.

Significant Community Health Needs Based on an assessment of secondary data (a broad range of community health indicators and an assessment published by the Delaware Department of Health and Social Services, Division of Public Health) and of primary data (received through community meetings and an interview with a state public health official), the following were identified as significant health needs in the community served by Christiana Care.

The significant needs are presented in alphabetical order.

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ASSESSMENT SUMMARY

Access to Affordable Medical and Dental Care According to individuals who provided input during community meetings, access to basic health care services is challenging for some residents of New Castle County, often due to financial and insurance issues, transportation, operating hours of providers, the supply of providers, and other issues. Some are relying on emergency departments for basic primary care needs due to the above access barriers and a lack of health literacy.

Access to dental care is challenging for low-income individuals and those without dental insurance benefits (including Medicaid recipients). Community members are presenting at emergency departments with health issues and comorbidities relating to poor dental health.

Both County Health Rankings and America’s Health Rankings indicate that the community served by Christiana Care has an undersupply of dentists.

Several census tracts in New Castle County have been designated by the U.S. Health Resources and Services Administration (“HRSA”) as Medically Underserved Areas, primary care Health Professional Shortage Areas (“HPSA”), and dental care HPSAs.

Chronic Disease The Delaware Department of Health and Social Services, Division of Public Health, Delaware State Health Needs Assessment (“2017 State Needs Assessment”) includes Chronic Disease (including heart disease, diabetes, and asthma) as one of four “priority areas of focus.”

America’s Health Rankings ranks Delaware 40th (out of 50 states) for the incidence of high blood pressure. A ranking of 1 indicates best in the nation, while a ranking of 50 indicates worst in the nation.

Data from the Delaware Department of Health and Social Services indicate that both New Castle County and Delaware as a whole have above average cancer incidence rates (overall and for virtually all cancer types).

Substance Use Disorder The 2017 State Needs Assessment also includes Substance Use Disorders (including the opioid epidemic and accidental overdoses) as a second priority area of focus.

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ASSESSMENT SUMMARY

America’s Health Rankings ranks Delaware 42nd (out of 50 states) for mortality associated with drugs. Mortality from drug overdoses has been increasing rapidly both in New Castle County and across Delaware.

Health Disparities Disparities in health outcomes were identified as significant by participants in the community meetings, particularly for infant mortality.

America’s Health Rankings ranks Delaware 41st (out of 50 states) for income inequality.

A number of community heath indicators are worse in lower income zip codes (and in areas where the “percent racial/ethnic minority” are highest), including: low birth rates; rates of diabetes, high blood pressure, and obesity; and prevalence of adults with no dental visits in the past year, who have delayed or not sought care due to cost, and with no usual source of care such as a regular doctor or clinic.

Infant Mortality The 2017 State Needs Assessment also includes maternal and child health (including teen pregnancy, premature births, and low birth weight infants) as a third priority area of focus.

Community members mentioned infant mortality as a problem in New Castle County and as evidence of recurring health disparities.

America’s Health Rankings ranks Delaware 48th (out of 50 states) for infant mortality.

At 8.4 per 1,000 live births, New Castle County’s infant mortality rate is much higher than the national average (5.9 per 1,000 live births).

Low birth weight births (as a percent of total) in New Castle County (8.8 percent) is above the average for counties designated by the Centers for Disease Control as “peers” (7.8 percent).

Mental Health

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ASSESSMENT SUMMARY The 2017 State Needs Assessment includes mental health (including diagnosis, suicide, and impacts of trauma) as a fourth priority area of focus.

Community members also identified mental health as a significant issue. They indicated that many New Castle County residents present at emergency rooms or primary care physician offices with previously undiagnosed and difficult to treat mental health problems. Problems with stigma and obtaining access to affordable mental health treatment are present.

Smoking and Tobacco Usage The 2017 State Needs Assessment includes tobacco and e-cigarette use as a “sub-focus” element of substance use disorders. More high school students in New Castle County use electronic vapor products than other students in the U.S.

Obesity and Diabetes The 2017 State Needs Assessment describes reducing obesity as important to reducing problems associated with chronic disease.

America’s Health Rankings ranks Delaware 41st (out of 50 states) for physical inactivity.

In New Castle County, the percentages of adults who are obese and who are physically inactive both are above U.S. averages. More high school students in New Castle County are overweight and physically inactive than students in the U.S. Several census tracts in New Castle County have been designated by the U.S. Department of Agriculture as food deserts.

Services for Seniors New Castle County’s population is expected to grow 3.4 percent from 2018 to 2023. The population 65 years of age and older is anticipated to grow at a much higher rate of 19.2 percent.

In community meetings, several stakeholders stressed the importance of meeting the needs of a growing elderly population. Many seniors lack strong family or community supports, making their needs even more significant.

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ASSESSMENT SUMMARY

Social Determinants of Health Community members discussed the significance of social determinants of health.

Poverty, low wages and a need for workforce training, a lack of affordable housing and homelessness, and inequitable access to education were described as major drivers of poor health status and health disparities. Violence is problematic (particularly in lower income areas), leading to traumatic experiences and mental health issues for many.

While the overall poverty rates for New Castle County is 11 percent, (below the national average of 15.1 percent), the poverty rates were over 20 percent in four zip codes that are home to over 80,000 persons. These areas have a higher prevalence of households that are “rent burdened.”

New Castle County’s “percent of children living in poverty” is 15.4 percent, which is above the average for a group of counties designated by the Centers for Disease Control as “peer counties.” The percent of children living in poverty in Community 1 is 28.9 percent while the percent of children living in poverty in Commnity 2 is 9 percent.

Violent crime rates also have been well above rates for peer counties.

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DATA AND ANALYSIS

DATA AND ANALYSIS Definition of Community Assessed This section identifies the community that was assessed by Christiana Care. The community was defined by considering the geographic origins of Christiana Care’s discharges in fiscal year 2018.

For purposes of this report, the Christiana Care community is defined as New Castle County, Delaware. During the year ended June 30, 2018, New Castle County accounted for 77 percent of discharges for Christiana Hospital and 88 percent of discharges for Wilmington Hospital (79 percent of Christiana Care discharges).

Substantial variation in socioeconomic conditions is present across New Castle County.

For example, the poverty rate in zip code 19801 (where Wilmington Hospital is located) is approximately 37 percent and the rate in zip code 19701 is under 5 percent.

Accordingly, this CHNA assessed community health needs in two geographic areas: “Community 1” (zip codes 19801, 19802, 19804, 19805, and 19720) and “Community 2” (all other zip codes). Community 1 accounted for 27 percent of Christiana Care discharges in 2018 and Community 2 accounted for 52 percent. On that basis, the Christiana Care community is defined as 27 zip codes that comprise New Castle County, Delaware, accounting for 79 percent of total inpatients to both hospitals combined in 2018 (Exhibit 1).

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DATA AND ANALYSIS Exhibit 1: Christiana Care Inpatient Discharges by Zip Code, 2018

19720

New Castle

4,925

832

5,757

Percent of Total CCHS Discharges 10.0%

19702

Newark

3,761

403

4,164

7.2%

19808

Wilmington

3,131

416

3,547

6.2%

19701

Bear

3,055

339

3,394

5.9%

ZIP Code

City/Town

Christiana Hospital

Wilmington Hospital

CCHS Discharges

19713

Newark

2,996

358

3,354

5.8%

19805

Wilmington

2,310

1,017

3,327

5.8%

19711

Newark

2,810

412

3,222

5.6%

19709

Middletown

2,585

295

2,880

5.0%

19802

Wilmington

1,250

1,418

2,668

4.6%

19801

Wilmington

951

1,018

1,969

3.4%

19804

Wilmington

1,534

319

1,853

3.2%

19810

Wilmington

828

888

1,716

3.0%

19803

Wilmington

755

815

1,570

2.7%

19809

Wilmington

580

584

1,164

2.0%

19707

Hockessin

950

179

1,129

2.0%

19703

Claymont

588

530

1,118

1.9%

19806

Wilmington

371

555

926

1.6%

19734

Townsend

770

89

859

1.5%

19807

Wilmington

287

229

516

0.9%

19706

Delaware City

208

23

231

0.4%

19730

Odessa

58

5

63

0.1%

19733

Saint Georges

24

3

27

0.0%

19731

Port Penn

24

1

25

0.0%

19736

Yorklyn

13

3

16

0.0%

19732

Rockland

3

5

8

0.0%

19716

Newark

2

2

0.0%

19717

Newark

-

-

-

-

0.0%

New Castle County

34,769

10,736

45,505

79.0%

Community 1

10,970

4,604

15,574

27.0%

Community 2

23,799

6,132

29,931

52.0%

Other Areas

10,635

1,470

12,105

21.0%

All Discharges

45,404

12,206

57,610

100.0%

Source: Analysis of Christiana Care Utilization Data, 2018.

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DATA AND ANALYSIS The total population of the community in 2018 was approximately 556,000 persons, with Community 1 comprised of approximately 162,000 persons, and Community 2 comprised of 394,000 persons (Exhibit 2).

Exhibit 2: Community Population, 2018 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

County

City/Town

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

Total Population 2018 42,321 56,414 15,340 1,894 17,171 42,609 55,358 30,509 891 1,753 59,548 457 109 129 406 13,316 71 16,977 26,772 20,905 18,264 39,977 9,723 7,797 38,047 14,198 24,822 161,538 394,240 555,778

Percent of Population 7.6% 10.2% 2.8% 0.3% 3.1% 7.7% 10.0% 5.5% 0.2% 0.3% 10.7% 0.1% 0.0% 0.0% 0.1% 2.4% 0.0% 3.1% 4.8% 3.8% 3.3% 7.2% 1.7% 1.4% 6.8% 2.6% 4.5% 29.1% 70.9% 100.0%

Source: The Claritas Company, 2018.

Christiana Hospital is located in Newark, DE (zip code 19718, which lies within zip code 19716). Wilmington Hospital is located in Wilmington, DE (zip code 19801).

The map in Exhibit 3 portrays the zip codes that comprise the Christiana Care community and the outlines of Community 1 and Community 2 within New Castle County.

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DATA AND ANALYSIS

Exhibit 3: Christiana Care Community

Source: Microsoft MapPoint and Cleveland Clinic, 2018.

Secondary Data Summary Exhibit 4 summarizes community health indicators found to be particularly unfavorable.

An indicator is considered unfavorable if it was found to vary materially from a benchmark statistic (e.g., an average value for the State of Delaware or for the United States). For example, the recent infant mortality rate in New Castle County was 8.4 per 1,000 live births; the average for the United States was 5.0 per 1,000. The last column of the Exhibit 4 identifies exhibits where more information regarding the data sources can be found.

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DATA AND ANALYSIS Exhibit 4: Significant Indicators Indicator 65+ Population change, 2018-2023 Poverty rate, Black, 2012-2016 Poverty rate, Hispanic, 2012-2016 Percent low income (0-200% of FPL) Percent less than high school diploma Community Need Index Score Percent children in poverty Percent of households rent burdened Violent Crime per 100,000 Infant mortality rate Infant mortality rate (Black) Percent live births with low birthweight Low birth weight births Percent adults obese Percent adults physically inactive Adults obese Percent high school students overweight Rank among U.S. states - high blood pressure Age-adjusted cancer incidence rate per 100,000 Chlamydia rate per 100,000 Population per dentist Drug injury death rate Drug overdose mortality rate Percent driving deaths w/alcohol involvement Percent high school students ever used marijuana

Area

Value

Community ZIP codes New Castle County New Castle County Community 1 Community 1 Community 1 New Castle County Community 1 New Castle County New Castle County New Castle County New Castle County Community 1 New Castle County New Castle County Community 1 New Castle County Delaware New Castle County New Castle County New Castle County Delaware New Castle (2017) New Castle County New Castle County

19.2% 17.3% 24.3% 40.9% 15.7% 3.9 15.0% 56.0% 550 8.4 13.2 8.8% 9.4% 29.2% 24.5% 28.9% 33.9% 41 484 496 1,673 20.0 36.8 32.0% 47.3%

Value 3.4% 8.8% 8.8% 18.6% 6.7% 2.4 13.3% 44.4% 251 5.9 11.2 7.8% 7.8% 28.0% 23.0% 24.6% 31.5% 31 441 410 1,480 15.0 18.6 29.0% 35.6%

Benchmark Area New Castle County New Castle County, White New Castle County, White Community 2 Community 2 Community 2 Peer Counties Community 2 Peer Counties United States United States Peer Counties Community 2 United States United States Community 2 United States Delaware - overall rank United States Peer Counties United States United States New Castle (2013) United States United States

Exhibit

8 15 15 17 17 22 25 21 25 31 31 25 36 24 24 36 37 26 34 25 24 27 33 24 37

Source: Verité Analysis.

Community Health Indicators Key observations from the assessment of secondary data include the following: •

New Castle County is home to 555,778 persons (2018). The county’s population is expected to grow 3.4 percent from 2018 to 2023; every zip code in New Castle County is projected to increase in population. The population 65 years of age and older is anticipated to grow at a much higher rate of 19.2 percent (Exhibits 7 and 8).

•

The poverty rates in both New Castle County and Delaware were below the national average throughout 2012-2016. However, at 20 percent, the poverty rate in Community 1 was well above average and was much higher than the rate in Community 2 (7.9 percent. Exhibits 14 and 17).

•

Violent crime rates in New Castle County have been well above rates for a group of counties designated by the Centers for Disease Control as “peer counties” (Exhibit 25).

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DATA AND ANALYSIS •

About 56 percent of households in Community 1 are “rent burdened” because they spend over thirty percent of household income on rent. The highest percentages are in zip codes 19805 and 19802 (62 percent and 60 percent respectively) (Exhibit 21).

•

Two Community 1 zip codes (19801 and 19802) have been scored by the Dignity Health Community Needs IndexTM (“CNI”) in the “highest need” category. Both of these zip codes are in Wilmington. The weighted average CNI score for Community 1 was well above the national median (Exhibit 22).

•

In County Health Rankings and/or Community Health Status Indicators, indicators for the following issues benchmark particularly unfavorably (Exhibits 24 and 25): o o o o o o o o

•

In America’s Health Rankings Delaware ranked 31st for “overall health” – in the bottom one-half of U.S. states. Because New Castle County represents approximately 60 percent of Delaware’s population, these rankings are particularly meaningful. The state also ranked in the bottom ten states for the following indicators (Exhibit 26): o o o o o o o o o o

•

Percent of children in poverty Violent crimes per 100,000 Percent of live births with low birthweight Percent of adults obese Percent of adult physically inactive Rates of chlamydia per 100,000 Population per dentist Percent of driving deaths with alcohol involvement.

Infant mortality Supply of dentists Chlamydia incidence Underemployment rate Drug deaths Air pollution Percent of youth feeling disconnected Income inequality Percent physically inactive High blood pressure incidence.

Mortality from drug overdoses has been increasing rapidly (Exhibits 27 and 33).

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DATA AND ANALYSIS •

Both New Castle County and Delaware as a whole have above average cancer incidence rates, both overall and for virtually all cancer types (Exhibit 24).

•

Low birth rates; rates of diabetes, high blood pressure, obesity; and the prevalence of adults with no dental visits in the past year, adults who have delayed or not sought care due to cost, and adults with no usual source of care all are higher in Community 1 than in Community 2 (Exhibit 36).

•

More high school students in New Castle County are overweight and physically inactive, use electronic vapor products, use marijuana, and are sexually active than students in the U.S. (Exhibit 37).

•

Several census tracts in New Castle County have been designated by the U.S. Department of Agriculture as food deserts, particularly within Community 1 (Exhibit 38).

•

Several census tracts in New Castle County have been designated by HRSA as Medically Underserved Areas, primary care Health Professional Shortage Areas (“HPSA”), and dental care HPSAs (Exhibits 39 and 40).

Relevant Findings of Other CHNAs The Delaware Public Health Institute (DPHI) conducted the Delaware State Health Needs Assessment (DSHNA) from April to November 2016 to “identify local and statewide trends for the identification and prioritization of strategies that address critical health needs.” 1 The DSHNA identified four priority areas of focus, and provided additional sub-focus areas within each, as follows: 1. Chronic Disease o Heart disease o Diabetes o Asthma.

2. Maternal and Child Health o Teen pregnancy o Premature births o Low birth weight infants.

Delaware Department of Health and Social Services, Division of Public Health, Delaware State Health Needs Assessment, 2017.

1

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DATA AND ANALYSIS 3. Substance Use Disorders o Opioid epidemic o Accidental overdose o Tobacco and e-cigarette use.

4. Mental Health o Diagnosis, particularly among youth o Suicide and suicide ideations o Impact of trauma.

Primary Data Summary From January 22 through 24, 2019, six meetings comprised of external community stakeholders (four meetings) and also of internal Christiana Care staff (two meetings) were held to obtain input on community health needs in New Castle County.

Staff from Christiana Care’s Office of Health Equity’s Community Health section identified a wide sample of individuals and organizations to invite to four strategically planned community meetings. After a first round of individuals was contacted, the Christiana Care team reassessed the list and invited additional individuals and organizations to assure broad representation. Invitees were encouraged to send an alternate if they were not able to attend Ninety-eight (98) persons participated in the four community meetings. These individuals represented organizations such as local health departments, non-profit organizations, local businesses, health care providers, local policymakers, parks and recreation departments, and school systems.

The meetings were held at the following locations: • • • •

January 22 – Bellevue Community Center - 500 Duncan Rd., Wilmington, DE 19809 January 23 – Route 9 Library - 3022 New Castle Ave., New Castle, DE 19720 January 23 – Kirkwood Library - 6000 Kirkwood Highway, Wilmington DE 19808 January 24 – William G Turner Building - 500 Wilmington Ave., Wilmington DE 19801.

Thirteen (13) Christiana Care employees participated in the internal staff meetings and included individuals from emergency departments, case management, social services, 20

DATA AND ANALYSIS and other similar departments. The internal meetings were held at the following locations: • •

January 22 – Christiana Hospital January 23 – Wilmington Hospital.

Six meetings comprised of teenaged residents were also held to obtain input on community health needs from the perspective of teens and students. Staff from the Community Health section of Christiana Care’s Office of Health Equity leveraged relationships with local teens participating in a number of community-based programs, including: • • • • •

A year-round health-focused camp A local, peer-led, youth group A number of local high school gender-sexuality alliances A number of sites providing an evidence-based reproductive health education program Two local community centers.

These teens represented a number of areas across New Castle County, including Newark, New Castle, Wilmington, and Claymont.

Staff took a conversation-based approach to gathering feedback.

In total, 53 local teens participated in these sessions and were asked to identify what they viewed as the most important community needs, both among their peers and across all of New Castle County.

Through these meetings, Christiana Care sought to understand community perspectives on the most significant health needs in New Castle County. The specific organizations represented at the community meetings are listed in Appendix C. The meetings began with a presentation of preliminary secondary community health data. Participants then were asked (a) to identify community health issues that may not have been well measured by secondary data and (b) through a voting process, to identify which needs they believed were most significant in New Castle County.

In addition to the above meetings, an interview was conducted with an Associate Deputy Director within the Delaware Department of Health and Social Services.

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DATA AND ANALYSIS During that interview, secondary data findings and significant needs also were discussed.

Through this process, the following nine health needs were most often identified by those participating in the community meetings, internal meetings, and the interview.

The needs that were mentioned most frequently are listed first: •

Social determinants of health, including poverty (and income inequality), affordable housing, educational achievement levels, and crime, and associated health disparities

•

Mental health

•

Maternal and child health, particularly infant mortality

•

Substance use disorder and overdoses

•

Access to dentists and primary care physicians

•

Obesity and contributing factors, particularly physical inactivity and access to healthy foods

•

Needs of the growing senior population

•

Health literacy and education

•

Community violence.

A summary of community input regarding these and other issues is provided below.

•

Social determinants of health were discussed with great frequency and considered to be a major driver of poor health status and health disparities. o Poverty is a significant issue for a number of community members, affecting their ability to access health care services, access healthy foods, complete high school and access other educational and training opportunities, and maintain healthy lifestyles. o Low wages and a need for more employment and workforce training opportunities contribute to economic instability.

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DATA AND ANALYSIS o Individuals living just above the poverty line (and therefore not eligible for assistance programs) are at risk if emergency situations arise and have difficulty securing affordable services. o Housing issues and homelessness are increasing needs, made worse by the recent closure of a homeless shelter. Safe and affordable housing is often difficult for community residents to secure, especially for those with mental health and substance use disorder issues. o Significant inequities in educational opportunities and resources are present. Bussing students to schools far away from home is common, especially in the City of Wilmington as there are practically no schools in the downtown area.

•

Mental health is a significant issue, with many residents presenting at emergency rooms or primary care physician offices with mental health concerns. These mental health conditions often have been undiagnosed and are difficult to treat, especially in an emergency setting. o While reducing, stigma associated with mental health issues remains a deterrent for many residents to seek treatment. o Access to mental health treatment due to cost and a lack of providers is a problem, particularly for lower and middle-income residents. Wait times are long and access for patients recently discharged from the hospitals is problematic. o Mental health and substance use disorder are interconnected.

•

Substance use disorder, including the opioid epidemic, is a well-recognized issue in the community across all demographics. Substance use disorder also exacerbates mental health problems, homelessness, financial difficulties, and other issues in New Castle County.

•

Access to dental care is challenging for low-income individuals and those without dental insurance benefits (including Medicaid recipients). Few dental providers accept these patients. Many community members are presenting at emergency departments with health issues and comorbidities relating to poor dental health.

•

Access to basic health care services is challenging for some, often due to financial and insurance issues, transportation, operating hours of providers, the supply of 23

DATA AND ANALYSIS providers, and other issues. Some are relying on emergency departments for basic primary care needs due to the above access barriers and a lack of health literacy.

•

Transportation presents access barriers due to a lack of public and affordable options. Options that do exist often take a long time for short trips. Residents who are low-income, elderly, disabled, and obese have particular problems.

•

A lack of health literacy and education contribute substantially to poor health.

Many residents lack knowledge of preventive health, healthy eating, insurance benefits and eligibility, and similar information. Community members stressed the importance of having community health education provided to communities directly, rather than, for example, requiring people to travel to hospital-based resources.

•

Several stakeholders stressed the importance of meeting the needs of a growing elderly population. Many seniors lack strong family or community supports, making their needs even more significant.

•

Violence is prevalent (particularly in Community 1), leading to traumatic experiences and mental health issues for many. o There is a need for more “trauma-informed care” to be available.

Traumatic experiences have profound and (if untreated) recurring effects on mental and physical health. o Gun violence and other violent crimes are common in parts of the county. o Many residents are fearful to go outside and walk around their neighborhoods due to safety concerns, contributing to sedentary lifestyles and isolation. o Other forms of violence, such as sexual assault and family or domestic violence, were mentioned as significant problems.

•

Meeting participants emphasized the need to enhance cultural competency in the delivery of health care services. Language barriers make communications and understanding health terminology challenging and complicate patient adherence with treatment plans.

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DATA AND ANALYSIS o There also is a lack of trust towards the health system by many, particularly minority groups due to past wrongs, structural racism, and perceived bias. o Meeting participants also stressed the need to improve competency in interacting with disabled residents and patients. It was reported that many non-verbal and other disabled residents face difficulties in their interactions with providers.

•

Some meeting participants indicated that an adequate supply of social and health services is available, but more collaboration is needed. Some form of service or navigator to connect residents to services was described as an important need.

•

Communicable disease, particularly HIV and chlamydia, were mentioned as issues. Some observed that the incidence of HIV and other diseases is increasing due to substance use disorder and needle sharing.

•

Alcohol use disorder was described as present and problematic but overshadowed by use of opioids and other drugs.

•

Disparities in health outcomes were discussed, particularly for infant mortality.

Black residents disproportionately experience poor outcomes.

The following six community health needs were identified most often by the teens who provided input as significant: •

Substance use disorder and overdoses

•

Alcohol use disorder

•

Sexually transmitted diseases, particularly chlamydia

•

Cancer incidence

•

Maternal and child health, particularly infant mortality

•

Social determinants of health, including poverty (and income inequality), affordable housing, educational achievement levels, and crime, and associated health disparities.

The participating teens also discussed a variety of other issues facing the community.

These included issues facing the LGBTQ+ community, mental health, and unhealthy relationships between teens and their parents.

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DATA AND ANALYSIS

Selected Actions Taken Since Last Assessment Prevalence of poverty and other factors including food insecurity, housing, affordability of care, and employment/job security In its 2016 Community Health Needs Assessment, Christiana Care determined that poverty, specifically housing, employment/job security, food insecurity, and affordability of care were significant issues in the communities we serve. Addressing poverty and the associated social determinants of health is not the traditional work of hospitals, and Christiana Care recognized in its 2017-2019 Community Health Implementation Plan that it lacked the expertise and infrastructure to address these problems with only its own programs. As a result, Christiana Care has committed to partnering with community organizations to address social determinants of health, and has even made great strides in developing programming to address food insecurity along with creating and strengthening its programs that assist community members in accessing community resources for social service needs. Listed below are a few examples of the work Christiana Care has undertaken in this area.

Produce Rx Program In the summer of 2017, Christiana Care partnered with Westside Family Healthcare and Urban Acres Produce, a community-owned farm stand, to establish the Fresh Produce Prescription Pilot Program. This Pilot Program provided weekly farmers markets at two Westside Family Healthcare locations in Wilmington during the summer, and sought to address food insecurity among a cohort of Westside Family Healthcare patients who were pre-diabetic or prenatal women living within the 19801, 19802 and 19805 zip codes. This initiative ended in October 2017, and Christiana Care expanded upon this effort in continued partnership with Urban Acres Produce the following spring and summer.

With Christiana Care support, Urban Acres Produce was able to operate farm stands in six locations throughout the city of Wilmington including a stand at the Wilmington Hospital and continuing the two stands at Westside Family Healthcare locations that were established in the prior pilot. The stands, located in areas where fresh produce was not easily accessible, were in operation from May 1st to September 30th, 2018.

Anyone was welcome to purchase affordable produce from the stands, but pregnant and post-partum women who lived in high risk zip codes and were enrolled in Healthy 26

DATA AND ANALYSIS Beginnings, a Christiana Care program which began as an effort to reduce infant mortality, were eligible to receive “prescriptions” or vouchers for use at any of the produce stands. 173 patients were enrolled in this program. At each produce stand, a Christiana Care Community Health Worker or Health Guide provided helpful information about accessing healthcare and different Christiana Care programs, and a dietician was also present with samples of healthy foods and recipes to share because making produce accessible can only be impactful if individuals know how to prepare it in appetizing ways.

Christiana Care has been interviewing participants and analyzing evaluation responses to determine how the program can be improved when it begins again in the spring of 2019 to ensure those provided a prescription take full advantage of its offerings and that a positive impact on health occurs. Christiana Care looks forward to continuing this initiative with Urban Acres Produce because this partnership also supports community economic development. Urban Acres Produce is a Wilmington-based farm stand which not only seeks to provide its community with access to affordable fresh produce, but also high-level jobs and the establishment of a local-focused distribution network.

Delaware Medical Legal Partnership Since 2015 Christiana Care has partnered with Delaware’s Community Legal Aid Society, Inc. (CLASI) to provide 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. CLASI attorneys are located on-site at the Wilmington Hospital and are integrated into health care teams.

Health Guides Health Guides provide uninsured patients with linkages to quality, affordable healthcare. Christiana Care's Health Guides assist patients with the financial assistance process and help patients navigate the healthcare system through personal interaction, health risk assessment, and identification of barriers to care. Health Guides also host education sessions to educate the community on how to use their insurance. During the 2018 reporting year, Health Guides assisted 2,160 individuals.

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DATA AND ANALYSIS

Community Health Workers A Community Health Worker (CHW) is a member of the health care team who works directly with individuals and families to assist them in addressing their non-clinical health and social service needs in a culturally competent way to achieve better health outcomes and health equity in the communities they serve. In June 2017, Health Management Associates in partnership with the Delaware Department of Health and Social Services and the Delaware Center for Health Innovation issued a report, “Development and Deployment of Community Health Workers in Delaware: Establishing a Certification Program and Reimbursement Mechanism” which addressed the ways in which CHWs can be established and utilized in Delaware to improve population health.

Christiana Care answered the call and established a standardized curriculum, training, and certification program for Community Health Workers (CHW) in alignment with the report recommendations.

In January 2018, Christiana Care’s first CHW training was launched with a six-week program that 16 participants successfully completed. Christiana Care is only in the beginnings of its CHW efforts. Embedding CHWs in school-based health centers for students and their families to access as well as in Christiana Care’s Women and Children’s Service Line to directly address infant mortality are just some of the strategies Christiana Care is pursuing as it determines how best to utilize and develop its CHW program. Although there is no reimbursement model for CHWs, Christiana Care will continue to support and integrate CHWs into its operations as they have been shown to have a positive impact on addressing patients’ social determinants of health.

In further support of the CHW model, Christiana Care also partnered with the Delaware Coalition Against Domestic Violence (DCADV) to support its Domestic Violence CHW program. DCADV employs CHWs who are specially trained in recognizing and responding to domestic violence. These CHWs will receive referrals from Christiana Care and Westside Family Healthcare, and the CHW will be able to meet with the victim of domestic violence in a safe location and offer trauma-informed support as well as community resources.

School-Based Health Centers (SBHC) In the 2018 fiscal year, Christiana Care operated sixteen SBHCs in New Castle County in partnership with six school districts and the Delaware Division of Public Health, Department of Health and Social Services. In fiscal year 2018, the sixteenth SBHC was 28

DATA AND ANALYSIS opened at St. George’s Technical High School. SBHCs provide comprehensive medical and mental health care, treatment, and health education to promote a healthy lifestyle.

SBHCs are located in schools to ensure ease of access for students so they can avoid the barriers of transportation, inconvenient appointment times, or worries about cost and confidentiality. During the 2018 reporting year, there were 26,717 total visits and 4,204 risk assessments completed at Christiana Care’s SBHCs. Christiana Care also committed to opening its first elementary SBHC at Emalea P. Warner Elementary School in Wilmington in the fall of 2018 due to the overwhelming need of the students, and in response to requests from the Red Clay Consolidated School District. Warner Elementary is located less than a mile from the Wilmington Hospital in 19802 which is a state identified at-risk zip code and where the CDC noted a high incident and risk of gun violence. 83 percent of Warner students come from low income families, 97 percent of Warner students are minorities, one third of Warner students have identified special needs, and one fourth of Warner students have been diagnosed with asthma. Christiana Care eagerly responded to the call to help address the needs of these students, and expects to create a strong presence in the school to comprehensively address the needs of students and their families.

Mental Health and Substance Use Disorder Christiana Care addressed this area of need through initiatives intended to improve access to mental health services, including more early interventions to address mental health issues, and provide substance use disorder treatment and education in the communities of New Castle County. As Delaware, and the nation, continues to be in the midst of an opioid epidemic, Christiana Care also has worked collaboratively with community partners and other health systems to address this significant community issue. In early 2018, Christiana Care helped found the Opioid Working Group of the eBrightHealth LLC comprised of Delaware health systems and Federally Qualified Health Centers, with the purpose of sharing best practices on treating opioid use disorder so that geography does not determine whether a person will get the best treatment possible. Christiana Care also developed the Community Substance Overdose Support Community (SOS) program in collaboration with the New Castle County Executive Office. Christiana Care will continue working with health system partners on how best to effectively treat patients with opioid use disorder as the Governor of Delaware signed into law legislation enacting a statewide overdose care system.

Christiana Care is eager for this opportunity to coordinate and share best practices with other health systems to ensure excellent service for its communities. Other programs

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DATA AND ANALYSIS and initiatives addressing mental health and substance use disorder include the following:

Behavioral Health Integration with Primary Care Christiana Care continues to integrate behavioral health with primary care which will serve to improve access for behavioral health services for those individuals who present with behavioral health problems as part of their unique medical concerns. The integration has been successful in increasing the number of individuals served. In the 2018 reporting year, 7,390 patients were seen across 12 primary care practices compared to 1,626 patients seen in the final year of the traditional model. Integration will allow for whole person care and improved outcomes.

Project Engage Project Engage is an innovative early intervention and referral to substance use disorder treatment program designed to help hospital patients who may be struggling with alcohol or drug use. Project Engage collaborates with hospital staff to identify and connect patients with community-based substance use disorder treatment programs and other resources.

Project Engage integrates peers in recovery, who are called Engagement Specialists, into the clinical setting in the hospital to meet with patients at their bedside about their alcohol and/or drug use. The Engagement Specialists learn about the patient’s goals and coordinate treatment options that support the patient’s needs. The Engagement Specialists use motivational interviewing to empower each patient in the decisionmaking process, assisting them to take that critical first step to seek help for their substance use. Project Engage Social Workers are experts in community resources, in obtaining access to facilities in the area and in assisting the team to overcome barriers so patients can receive care and transition into treatment.

In addition to working with the patient and the hospital clinical team, Project Engage also works with treatment providers and insurers to develop a discharge plan to achieve the best possible outcome for each patient. After leaving the hospital and engaging in treatment, patients may have the opportunity to continue to work with an Engagement Specialist to help them stay engaged in their treatment. Christiana Care also educates other health systems in Delaware, and throughout the nation, about Project Engage with the intention of assisting these other health systems in replicating the program.

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DATA AND ANALYSIS In the 2018 reporting year, Project Engage staff conducted 2,524 patient engagements.

Of those patient engagements, 39 percent (909) patients were referred to substance use disorder treatment, and of those referred to treatment, 57 percent (560 patients) received treatment after discharge.

Project Recovery In the 2017-2019 Community Health Implementation Plan, Christiana Care described its Outpatient Substance Abuse Program as a pilot program to treat patients being seen in Christiana Care providers’ outpatient practices. This program has since graduated from its pilot phase and is now the outpatient program, Project Recovery, providing evidence-based treatment for substance use and co-occurring disorders to patients of Christiana Care Health System and members of the community. The program also provides referral and consultation support to Behavioral Health Consultants who are embedded in Christiana Care Primary Care offices. Project Recovery provides treatment and services through the use of medication assisted treatment as well as psychiatric treatment. Patients are also provided with substance use disorder individual and group therapy with specially trained addiction therapists.

Community Substance Overdose Support (SOS) Program In early 2018, Christiana Care participated in a roundtable discussion with state and county officials on the potential partnership between Christiana Care and New Castle County in creating a program, modeled on West Virginia’s Quick Response Team, to address the needs of individuals who overdose out in the community and connect them to follow-up care and resources. Discussions continued, and on March 14th, 2018, a press conference at Christiana Hospital announced Christiana Care’s partnership with New Castle County and the creation of the Community Substance Overdose Support (SOS) Program. The Community SOS Program will consist of a response team of engagement specialists who will visit patients in their homes following an overdose. The engagement specialists will use motivational interviewing to empower the patients to accept help for their substance use disorder. Regardless of whether the patient is ready to seek treatment, the engagement specialists will also provide education to them and their family members on the use of Naloxone and existing resources in the community.

This program provides an opportunity to reach those patients who do not have the opportunity to connect with Project Engage because they were not admitted to the hospital. This program developed in response to our partners in the New Castle County reaching out to Christiana Care to discuss the need for some type of intervention with 31

DATA AND ANALYSIS those individuals who overdose repeatedly. Community SOS launched as a pilot in early 2019.

Violence and Public Safety The issue of violence and public safety continues to be a unifying area of concern throughout the state of Delaware, and particularly within the City of Wilmington which has experienced an epidemic of gun violence. While the level of gun violence did decrease in Wilmington in 2018, as the only Level 1 Trauma Center within the state, Christiana Care is keenly aware of the devastation gun violence continues to have within communities, and sought out partnerships with community organizations to support violence prevention programming. An example of such a community partnership is the one Christiana Care has with the Wilmington organization, Corner 2 Corner. Corner 2 Corner enlists volunteers who monitor school bus stops in the Red Clay Consolidated School District (including bus stops for Warner Elementary where Christiana Care opened its first elementary school-based health center) to ensure children arrive to and from their school bus stops safely. Besides anti-violence efforts, Christiana Care is also focused on programming that educates adolescents and adults about safe choices to prevent injuries. Programs and initiatives include the following:

Stop the Bleed Stop the Bleed is a national awareness campaign that empowers bystanders with the knowledge and tools they need to recognize and stop life-threatening bleeding.

Through Stop the Bleed, everyone – those in the medical profession and those without any medical training, are able to learn hemorrhage control which is powerful knowledge because the number one cause of preventable death after traumatic injury is uncontrolled bleeding (hemorrhage). Since Stop the Bleed was formed, trauma centers across the nation have been tasked with training their own staff to become instructors in Stop the Bleed who can train their colleagues and take the training into communities.

Christiana Care’s Trauma Program has embraced this campaign. The Stop the Bleed training is available in the Learning Center, and Christiana Care trauma physicians and nurses, emergency department physicians, and VEST center staff all receive instructor training.

Christiana Care is also bringing this training out into the community. During the 20172018 school year, school nurses from Brandywine and Red Clay Consolidated School Districts and all of the family nurse practitioners in the school-based health centers received the Stop the Bleed training. The teachers at the Conrad Schools of Science were also trained, and Christiana Care’s Trauma Program partnered with the school’s HOSA 32

DATA AND ANALYSIS – Future Health Professionals program, to provide the students with additional knowledge and skills. Along with the trainings, Christiana Care donated wall-mounted kits that include supplies such as tourniquets, quickclot, and compression dressing to all 49 schools in the Brandywine and Red Clay Consolidated school districts.

Play Streets Wilmington Christiana Care partnered with the Wilmington Office of the Mayor and the Parks and Recreation Department to offer the Play Streets Wilmington program each week in different Wilmington neighborhoods throughout the summer. Play Streets shuts down a street to traffic for two hours allowing it to become an outdoor play space where kids and families can play games and sports, dance, have a healthy snack and spend time with their neighbors in a way that encourages positive engagement and social cohesion.

Christiana Care’s support of this initiative is strategic and rooted in Christiana Care’s commitment to improving the infant mortality rate, but the initiative also creates safe spaces in Wilmington neighborhoods for community members to enjoy. Christiana Care intends to keep partnering with the City of Wilmington to support Play Streets and expects to better understand the impact of the program as demonstrated by evaluation from the University of Delaware.

You Only Live Once (YOLO) YOLO is a violence prevention program that educates adolescents about the consequences of violence on the victim and the family. Adolescents visit the hospital to watch a re-enactment of trauma resuscitation in the hospital simulation lab, and they participate in a group discussion with the Christiana Care violence prevention coordinator about choices. This program allows adolescents to see the real consequences of violence, and it provides the students affected by violence the opportunity to talk about it with each other and a health care professional. In the 2018 reporting period, 232 students participated in YOLO, and it is Christiana Care’s hope that these students will be more apt to make choices that allow them to avoid situations in which they may become the perpetrators or victims of violence.

Choice Road This program is designed for adolescents in 6th to 12th grades. The presentation includes a 15-minute film where a 16 year-old boy joins a gang, is shot, and becomes a quadriplegic. Following the film, the violence intervention and prevention coordinator leads a discussion with a former trauma patient from Christiana Care and/or a local rap 33

DATA AND ANALYSIS artist known in Delaware for his community activism and positive messages. The intent of this program is to engage the youth in a frank and engaging discussion of “choices� and consequences. During the 2018 reporting period, 2,722 students from schools throughout New Castle County participated in this program.

ThinkFirst for Teens ThinkFirst is a national program presented by the Christiana Care Prevention Coordinator in urban and suburban schools and at organizations for adolescents such as the Girl Scouts and the YMCA. The program teaches adolescents about injuries and how they happen, how to prevent them, and the consequences of injuries, with an emphasis on brain and spinal cord injuries. Trauma survivors present along with the coordinator and share their stories and how the injury has forever changed their life.

During the 2018 reporting period, 5,769 students in schools in all three Delaware counties participated in the program.

Distracted Driver Simulators The Christiana Care Prevention Coordinator presents this program that addresses traumatic injury resulting from car crashes. Students use a virtual cell phone or their own cell phone to text the computer while they drive the simulator. During the 2018 reporting period, 631 high school students from throughout New Castle County and Dover participated in this program.

A Matter of Balance Christiana Care partners with the Delaware Department of Health and Social Services to provide this 8 week falls prevention class for people over the age of 60. Christiana Care hosts the program in its Ammon Education Center, and provides advertising, as well as general coordination of the program. Participant surveys have shown that 97 percent of participants increase their physical activity after completion of program.

Delaware Coalition for Injury Prevention and Safe Kids Delaware/New Castle County During this reporting period, members of Christiana Care’s trauma team spent 45 hours participating in these coalition meetings. Their time was spent sharing best practices and evidence-based programs and strategies to prevent injury and collaborating on injury prevention efforts throughout the year.

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DATA AND ANALYSIS

Maternal and Child Health Unintended pregnancies, premature births, and infant mortality were identified as areas of need in Christiana Care’s 2016 Community Health Needs Assessment, and Delaware’s infant mortality rate and racial disparities in these areas continue to be troubling, particularly the disparities within infant mortality rates.

To address these concerns, Christiana Care sought to increase preconception health and pre-natal care for pregnant women, and reduce the unintended pregnancy and premature birth rates. Christiana Care is working to improve the infant mortality rate through programs aimed at pregnant women, but also by seeking to address social determinants of health, particularly in Wilmington, because providing care for the pregnant mother during pregnancy alone is simply not enough to solve Delaware’s stubbornly high infant mortality rate. Underlying all of Christiana Care initiatives within Wilmington is the expectation that addressing the social determinants of health will have an impact on the infant mortality rate. Some of Christiana Care’s programs and initiatives in this area include the following:

Long Acting Reversible Contraceptive (LARC) Program Christiana Care partners with community organizations and the state to support access and coverage of LARC services. Doctors, nurse practitioners, and nurse midwives receive training in long acting reversible contraceptive options through the state initiative Delaware Contraceptive Access Now (CAN). If a patient states that she wants to receive birth control, Primary Care and OB-GYN clinicians can offer LARC options as in-office procedures or with immediate referral. The rapid response is important because the program is intended to serve women efficiently and effectively. An additional appointment may require time off work or obtaining childcare which may present too great an obstacle for some women to overcome. The goals of this program are to reduce unintended pregnancies, and to help women escape poverty. While it cannot be immediately known if avoiding unintended pregnancies helped a woman out of poverty, the number of women using some form of birth control in Delaware has increased. This program is a demonstration of one of the many ways in which Christiana Care partners with the state of Delaware to address community needs.

Alliance for Adolescents Pregnancy Prevention Christiana Care’s Center for Community Health’s Alliance for Adolescent Pregnancy Prevention works to reduce the number of teens who are sexually active, become 35

DATA AND ANALYSIS pregnant, and become teen parents through educational programming offered to teens and their parents. Its programming includes: Be Proud! Be Responsible! An STI/HIV prevention education programs for adolescents aged 13 to 18; Making Proud Choices, a safer sex approach to STI/HIV and teen pregnancy for 11-13 year olds; and Wise Guys, a program designed to prevent teen pregnancy by reaching out to adolescent males. This program acknowledges young males as “whole� individuals with a variety of needs and desires. Participatory lessons and activities focus on assisting them to ask themselves the questions: Who am I? Where am I going? How do I get there? During the 2018 reporting period, 742 students in middle schools, high schools, and community centers across the state participated in one of these programs.

Healthy Beginnings Program In partnership with the Delaware Division of Public Health, Christiana Care’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. In this reporting period, there were 849 pregnant women and 724 preconception women enrolled.

Health Ambassadors Program Christiana Care has been awarded grant funding from the state to support its 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. A team of Health Ambassadors conduct outreach within high-risk Wilmington zip codes to connect pregnant women to health care, social services, and education. The Health Ambassadors coordinate with Christiana Care partners such as Henrietta Johnson Medical Center, St. Francis Hospital, and Westside Family Healthcare. This program reaches women out in their communities and strives to ensure that they are connected to community and health care resources. Since 2013, the Health Ambassadors have also hosted a Community Baby Shower in Wilmington. This event features education on safe sleep and developmental milestones along with information about nutrition, safety, and breastfeeding. Christiana Care hopes to expand upon these successful events by offering additional Community Baby Showers at its Christiana Hospital as well as a Spanish language Community Baby Shower in the 36

DATA AND ANALYSIS future. Health Ambassadors tabled at community events or gave presentations 304 times during the 2018 reporting period providing community members near daily opportunities to receive information. Christiana Care looks forward to expanding upon the success of this program.

Boot Camp for New Dads (BCND) and Boot Camp for New Moms (BCNM) In the 2018 reporting period, Christiana Care partnered with the national organization Boot Camp for New Dads (BCND) to provide 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 Christiana Care. Along with the workshops, reunion meetings and ongoing support will also be available for participating dads and a BCND for Spanish speaking dads will be developed.

Given the early satisfaction with BCND, Christiana Care decided to also offer Boot Camp for New Moms (BCNM). This program 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.

Christiana Care offers BCND and BCNM to empower new parents to have healthy and positive relationships with both their new child and partner. A stronger relationship among parents, and more engaged dads, will have a positive impact on all members of the family.

Delaware Healthy Mother and Infant Consortium Dr. David Paul, Chair of Pediatrics at Christiana Care, also chairs the Delaware Healthy Mother and Infant Consortium of health care professionals throughout the state. The consortium’s mission is to provide statewide leadership and coordination of efforts to prevent infant mortality and to improve the health of women of childbearing age and infants throughout the state of Delaware. Each year, the Consortium also hosts an annual summit, attended by over 200 people, which brings together community leaders, healthcare providers, and state officials to learn about statewide health goals intended to reduce the infant mortality rate.

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DATA AND ANALYSIS

United States Breastfeeding Committee Christiana Care Nurse Manager Mona Liza Hamlin, MSN, RN, IBCLC serves on the United States Breastfeeding Committee Board of Directors. The mission of this committee is to drive collaborative efforts for policy and practices that create a landscape of breastfeeding support across the United States. Christiana Care is proud to have representation in this organization designed to improve the health of mothers and babies across the country.

Mother/Baby Class and Breastfeeding Support Group The weekly Mother/Baby Class is designed to help new mothers bond with their babies and ask questions and get answers about their infants. This class is open to all new mothers and is a source of support during new motherhood. The Breastfeeding Support Group is also held weekly and lactation consults meet with new mothers to answer their questions about breastfeeding and support the continuance of breastfeeding.

Prioritized Significant Health Needs The primary and secondary data collected in this 2019 Community Health Needs Assessment clearly demonstrates that the health of New Castle County residents continues to be influenced by factors that cannot be addressed simply through the provision of health care. For example, if an individual has diabetes, and is under the care of a doctor and is able to access affordable prescriptions, that individual’s diabetes will not be managed if they do not have a working refrigerator to keep insulin or they live in a neighborhood without access to healthy or affordable food. Nevertheless, Christiana Care recognizes that it has the ability to partner with community organizations to address social determinants of health as well as continue to develop and strengthen clinical programs to address population health.

After reviewing the data collected from primary and secondary sources, the following priorities have been identified as significant health needs in our communities: 1. Social Determinants of Health including poverty, food insecurity, housing, affordability of care, education, and employment/job security 2. Mental Health and Substance Use Disorder 38

DATA AND ANALYSIS 3. Violence and Public Safety 4. Maternal and Child Health especially Infant Mortality 5. Access to Dental and Primary Care.

Process and Criteria Used to Prioritize Health Needs Through the course of compiling the 2019 Community Health Needs Assessment, Christiana Care’s main priority was learning from the communities it serves. This assessment was not seen as simply a requirement, but embraced as an opportunity to listen to community members, and learn firsthand about the challenges they are facing.

To learn from its neighbors, Christiana Care held four community meetings comprised of ninety-eight stakeholders and community leaders who represented a diversity of communities and community issues; two meetings comprised of thirteen Christiana Care staff from the emergency departments, social services, and case management who interact daily with patients; and six meetings comprised of fifty-three teenaged residents who participate in community-based programs such as Camp FRESH. At each meeting, the preliminary secondary community health data was presented and participants were asked to identify community health issues that may have been missing from the secondary data, and then submit their votes on the needs they felt were the most significant in New Castle County. In addition to these meetings, an interview was also conducted with an Associate Deputy Director of the Delaware Department of Health and Social Services. As in the other meetings, secondary data findings were shared and significant needs were discussed.

Christiana Care leaders then examined the secondary data and primary data gathered from meetings and interviews to determine which health needs should be prioritized.

When making this determination, leaders considered the prior Community Health Needs Assessment, the severity and urgency of the need as shown by the data as well as demonstrated by community input, and whether Christiana Care has the ability to address the issue.

Because the secondary data and community input continued to place the 2016 areas of need: prevalence of poverty (i.e. social determinants of health), mental health and substance use disorder, maternal and children’s health, and violence and public safety, as top priorities, it was determined that the most efficient and effective course of action would be to continue to address these issues as prioritized areas of need. Along with the positive and potentially greater impact that enhancing existing programs would have in communities, Christiana Care also wants to demonstrate its commitment to 39

DATA AND ANALYSIS communities by continuing to address the areas that community members have again identified as areas of need. Christiana Care also prioritized the additional need of access to dental and primary care because it is an issue that the community, the data, and Christiana Care all agree is one that needs to be addressed given the significant impact on the health and wellness of individuals in the community we serve.

40

OTHER FACILITIES AND RESOURCES

OTHER FACILITIES AND RESOURCES IN THE COMMUNITY This section identifies other facilities and resources available in the community served

by Christiana Care 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 care, 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 ten FQHC sites operating in New Castle County (Exhibit 5).

Exhibit 5: Federally Qualified Health Centers, 2018 Address

Health Center Name

City

ZIP Code

Claymont Community Health Center

3301 Green St

Claymont

19703

Henrietta Johnson Medical Center

601 New Castle Ave

Wilmington

19801

Henrietta Johnson Medical Center - Eastside

600 N Lombard St

Wilmington

19801

Henrietta Johnson Medical Center Family Practice

1100 S Broom St

Wilmington

19805

Westside Family Healthcare - Administration Office

300 Water St Ste 200

Wilmington

19801

Westside Family Healthcare - Ancillary Administration Office

2 Penns Way Ste 412

New Castle

19720

Westside Family Healthcare - Bear / New Castle

404 Fox Hunt Dr

Bear

19701

Westside Family Healthcare - Newark

27 Marrows Rd

Newark

19713

Westside Family Healthcare - Northeast

908 E 16th St Ste B

Wilmington

19802

1802 W 4th St

Wilmington

19805

Westside Family Healthcare - Wilmington

Source: HRSA, 2018.

Hospitals Exhibit 6 presents information on hospital facilities that operate in New Castle County.

41

OTHER FACILITIES AND RESOURCES Exhibit 6: Hospitals, 2018 A I duPont Hospital for Children

1600 Rockland Rd PO Box 269

19803

Number of Beds 260

Christiana Care Health Services - Christiana Hospital

4755 Ogletown-Stanton Rd PO Box 6001 Newark

19718

906

Christiana Care Health Services - Wilmington Hospital

501 W. 14th St.

Wilmington

19801

321

Delaware Psychiatric Center

1901 North duPont Hwy

New Castle

19720

200

HealthSouth Rehabilitation Hospital of Middletown

250 East Hampden Rd

Middletown

19709

37

MeadowWood Behavioral Health System

575 South duPont Hwy

New Castle

19720

100

Rockford Center

100 Rockford Dr

Newark

19713

138

Select Specialty Hospital of Wilmington

701 N Clayton St Fifth Floor

Wilmington

19805

35

St Francis Healthcare

701 N Clayton St

Wilmington

19805

395

Hospital Name

Address

City

ZIP Code

Wilmington

Source: Delaware Health and Social Services (DHSS), 2018.

Other Community Resources A wide range of agencies, coalitions, and organizations that provide health and social services is available in the region served by Christiana Care. United Way 2-1-1 Delaware maintains a large, online database to help refer individuals in need to health and human services in Delaware. This service is provided from a partnership between Delaware Health and Social Services (DHSS), United Way Delaware, and Christiana Care. United Way 2-1-1 Delaware contains information on organizations and resources in the following categories: • • • • • • • • • • • • •

Clothing Crisis services (including rape, domestic violence, suicide intervention, abuse and neglect intervention, and others) Emergency / transitional shelters Food assistance Government information Housing assistance Legal help Medical care Mental health Substance use disorder Tax help Transportation Utility assistance.

Additional information about these resources is available at: 211service.com.

42

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. 2 In conducting a CHNA, each tax-exempt hospital facility must: • • •

• •

Define the community it serves; Assess the health needs of that community; Solicit and consider 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 (including how community input was obtained), 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: • • • •

2

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?

Internal Revenue Code, Section 501(r).

43

APPENDIX A – OBJECTIVES AND METHODOLOGY 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.

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 targeted disease).” 3 Data from multiple sources were gathered and assessed, including secondary data 4 published by others and primary data obtained through community input. See Appendix B. Input from the community was received through community meetings and an interview. Participants at these meetings represented the broad interests of the community and included individuals with special knowledge of or expertise in public health; the interview was conducted with a representative from the Delaware Department of Health and Social Services. 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 the State of Delaware, and (3) input from the participants in the community meetings and interview.

In addition, data were gathered to evaluate the impact of various services and programs identified in the previous CHNA process. See Appendix D.

501(r) Final Rule, 2014.

“Secondary data” refers to data published by others, for example the U.S. Census and the Delaware Department of Health and Social Services. “Primary data” refers to data observed or collected from firsthand experience, for example by conducting focus groups.

3 4

44

APPENDIX A – OBJECTIVES AND METHODOLOGY

Collaborating Organizations For this assessment, the two hospital facilities of Christiana Care Health System – Christiana Hospital and Wilmington Hospital – developed and produced this CHNA together. Because these two facilities defined their community to be the same, they are sharing this joint CHNA report.

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 Christiana Care. Comparisons to benchmarks were made where possible. Findings from recent assessments of the community’s health needs conducted by other organizations (e.g., state health departments) were reviewed as well.

Input from 98 persons representing the broad interests of the community was considered through community meetings. Participants included: individuals with special knowledge of or expertise in public health; local public health departments; agencies with current data or information about the health and social needs of the community; representatives of social service organizations; and leaders, representatives, and members of medically underserved, low-income, and minority populations.

Additionally, an interview was held with a representative from the Delaware Department of Health and Social Services, and input from 53 teenagers was obtained through several meetings.

Information Gaps This CHNA relies on multiple data sources and community input gathered between July 2018 and February 2019. Several data limitations should be recognized when interpreting results. For example, some data (e.g., County Health Rankings, Community Health Status Indicators, and others) exist only at a county-wide level of detail. Those data sources do not allow assessing health needs at a more granular level of detail, such as by zip code or census tract.

Secondary data upon which this assessment relies measure community health in prior years and may not fully reflect current conditions. The impacts of recent public policy 45

APPENDIX A – OBJECTIVES AND METHODOLOGY developments, changes in the economy, and other community developments are not yet reflected in those data sets.

The findings of this CHNA may differ from those of others that assessed this community. Differences in data sources, geographic areas assessed (e.g., hospital service areas versus counties or cities), interview questions, and prioritization processes can contribute to differences in findings.

Consultant Qualifications This CHNA was conducted by Verité Healthcare Consulting, LLC (Verité). 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 60 needs assessments for hospitals, health systems, and community partnerships nationally since 2010.

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.

46

APPENDIX B – SECONDARY DATA ASSESSMENT

APPENDIX B – SECONDARY DATA ASSESSMENT This section presents an assessment of secondary data regarding health needs in New Castle County. Secondary data are presented at various levels of detail – some on a county-wide basis (with data for the two other Delaware counties, the entire state, and the U.S. for comparison purposes), by zip code, and by census tract. For purposes of this CHNA, Christiana Care’s two hospital facilities defined their shared community to be New Castle County. Where possible, certain data were arrayed separately for “Community 1” (comprised of five lower-income zip codes – 19801, 19802, 19804, 19805, and 19720) and for “Community 2” (all remaining New Castle County zip codes).

Demographics Exhibit 7: Percent Change in Community Population by Zip Code, 2018-2023

47

APPENDIX B – SECONDARY DATA ASSESSMENT

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

County

City/Town

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

Total Population 2018 42,321 56,414 15,340 1,894 17,171 42,609 55,358 30,509 891 1,753 59,548 457 109 129 406 13,316 71 16,977 26,772 20,905 18,264 39,977 9,723 7,797 38,047 14,198 24,822 161,538 394,240 555,778

Projected Population 2023 44,648 59,472 15,954 2,005 17,461 46,391 56,750 31,087 910 1,797 60,798 500 116 131 447 14,394 74 17,695 27,484 21,094 18,605 40,437 9,832 8,034 38,888 14,386 25,081 165,019 409,452 574,471

Percent Change 2018-2023 5.5% 5.4% 4.0% 5.9% 1.7% 8.9% 2.5% 1.9% 2.1% 2.5% 2.1% 9.4% 6.4% 1.6% 10.1% 8.1% 4.2% 4.2% 2.7% 0.9% 1.9% 1.2% 1.1% 3.0% 2.2% 1.3% 1.0% 2.2% 3.9% 3.4%

Source: The Claritas Company, 2018.

Description Exhibit 7 portrays the estimated population by zip code in 2018 and projected to 2023.

Observations •

Between 2018 and 2023, every zip code in New Castle County is projected to increase in population. In total, the population is expected to grow by 3.4 percent.

•

Community 1 is expected to grow 2.2 percent and Community 2 at 3.9 percent.

48

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 8: Percent Change in Population by Age/Sex Cohort, 2018-2023 Age/Sex Cohort 0 - 17 Female 18 - 44 Male 18 - 44 45 - 64 65+ Community Total

Total Population 2018 121,049 102,162 99,512 148,241 84,814 555,778

Projected Population 2023 122,613 102,996 101,568 146,177 101,117 574,471

Percent Change 2018-2023 1.3% 0.8% 2.1% -1.4% 19.2% 3.4%

Source: The Claritas Company, 2018.

Description Exhibit 8 shows New Castle County’s population for certain age and sex cohorts in 2018, with projections to 2023.

Observations •

The population aged 65 years and older is projected to increase by 19.2 percent; all other age groups by 0.51 percent.

•

The growth of older populations is likely to lead to growing need for health services, since on an overall per-capita basis, older individuals typically need and use more services than younger persons.

49

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 9: Percent of Population Aged 65+ by Zip Code, 2012-2016

Source: U.S. Census, ACS 5-Year Estimates, 2017, and Microsoft MapPoint. *Note: Zip code 19732 excluded due to small sample size creating large outlier

Description Exhibit 9 portrays the percent of the population 65 years of age and older by zip code.

Observations •

Zip codes with the highest proportions of the population 65 years of age and older are located in the northern part of Community 2.

50

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 10: Percent of Population - Black, 2012-2016

Source: U.S. Census, ACS 5-Year Estimates, 2017, and Microsoft MapPoint.

Description Exhibit 10 portrays locations in the community where the percentages of the population that are Black have been highest.

Observations •

In 2012-2016 and in two Community 1 zip codes (19801 and 19802), over 70 percent of residents were Black.

51

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 11: Percent of Population - Asian, 2012-2016

Source: U.S. Census, ACS 5-Year Estimates, 2017, and Microsoft MapPoint.

Description Exhibit 11 portrays locations in the community where the percentage of the population that is Asian have been highest.

Observations •

In one zip code (19707), over 10 percent of residents were Asian (12.2 percent).

52

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 12: Percent of Population – Hispanic (or Latino), 2012-2016

Source: U.S. Census, ACS 5-Year Estimates, 2017, and Microsoft MapPoint.

Description Exhibit 12 portrays locations in the community where the percentages of the population that are Hispanic (or Latino) have been highest.

Observations •

The percentage of residents that are Hispanic (or Latino) was over 25 percent in one Community 1 zip code, 19805 (26.7 percent).

53

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 13: Other Socioeconomic Indicators, 2012-2016

Source: U.S. Census, ACS 5-Year Estimates, 2017.

Description Exhibit 13 portrays the percent of the population (aged 25 years and above) without a high school diploma, with a disability, and linguistically isolated, by county.

Observations •

The percentage of residents aged 25 years and older without a high school diploma in New Castle County and Delaware has been below the national average.

•

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

•

Compared to Delaware (but not to the United States), New Castle County had a higher proportion of the population that is linguistically isolated. Linguistic isolation is defined as residents who speak a language other than English and speak English less than “very well.”

54

APPENDIX B – SECONDARY DATA ASSESSMENT

Economic indicators The following economic indicators with implications for health were assessed: (1) people in poverty, (2) unemployment rate, (3) insurance status, (4) crime, and (5) the Dignity Health Community Needs IndexTM.

People in Poverty Exhibit 14: Percent of People in Poverty, 2012-2016

Source: U.S. Census, ACS 5-Year Estimates, 2017.

Description Exhibit 14 portrays poverty rates by Delaware county and for the U.S. Observations •

The poverty rate in both New Castle County and Delaware were below the national average throughout 2012-2016.

•

However, as shown in Exhibit 17, the 2012-2016 poverty rate in Community 1 was well above average (approximately 20 percent).

55

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 15: Poverty Rates by Race and Ethnicity, 2012-2016

Source: U.S. Census, ACS 5-Year Estimates, 2017.

Description Exhibit 15 portrays poverty rates by race and ethnicity.

Observations •

In New Castle County, Delaware, and the U.S., poverty rates have been higher for Black and for Hispanic (or Latino) residents than for Whites.

56

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 16: Low Income Census Tracts, 2017

Source: US Department of Agriculture Economic Research Service, ESRI, 2017.

Description Exhibit 16 portrays the location of federally-designated low income census tracts.

Observations •

Low income census tracts are prevalent in Community 1 and to the west of Christiana Hospital.

57

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 17: Selected Socioeconomic Characteristics, Community 1 versus Community 2, 2017 Community 1

Indicator Total Population Living In Poverty Low Income (0-200 percent of FPL) Percent Racial/Ethnic Minority Percent Hispanic Percent Black Uninsured Limited English Less than High School Diploma

161,811 19.6% 40.9% 63.1% 15.0% 45.0% 5.7% 3.0% 15.7%

Community 2 385,132 7.9% 18.6% 31.4% 7.1% 15.6% 4.3% 2.3% 6.7%

New Castle County 546,943 11.4% 25.3% 34.9% 9.4% 24.3% 4.6% 2.5% 9.3%

Source: Uniform Data Services (UDS) Mapper, 2018.

Description Exhibit 17 provides certain socioeconomic indicators for Community 1, Community 2, and New Castle County as a whole.

Observations •

Community 1 has a much higher “percent racial/ethnic minority” than Community 2.

•

The percent of residents in poverty and considered low income in Community 1 is about double the percent for Community 2.

•

Residents of Community 1 are more likely to be uninsured and to have limited English proficiency. High school graduation rates also have been much lower in Community 1 than in Community 2.

58

APPENDIX B – SECONDARY DATA ASSESSMENT

Unemployment Exhibit 18: Unemployment Rates, 2013-2017

Source: Bureau of Labor Statistics, 2018.

Description Exhibit 18 shows unemployment rates for 2013 through 2017 by county, with Delaware and national rates for comparison.

Observations •

Between 2013 and 2016, unemployment rates at the local, state, and national levels declined significantly. A slight increase in Delaware and Delaware counties occurred between 2016 and 2017.

•

Rates in New Castle County and Delaware overall were slightly above U.S. averages in 2017.

59

APPENDIX B – SECONDARY DATA ASSESSMENT

Insurance Status Exhibit 19: Percent of the Population without Health Insurance, 2012-2016

19701

New Castle

Bear

40,532

Percent Uninsured 6.8%

19702

New Castle

Newark

53,821

9.2%

15,157

6.0%

1,938

13.2%

ZIP Code

County

City/Town

Population

19703

New Castle

Claymont

19706

New Castle

Delaware City

19707

New Castle

Hockessin

15,548

3.9%

19709

New Castle

Middletown

38,355

4.7%

19711

New Castle

Newark

51,051

5.7%

19713

New Castle

Newark

30,584

7.2%

19716

New Castle

Newark

1,040

1.3%

19717

New Castle

Newark

4,417

1.9%

60,885

8.9%

1,251

3.2%

19720

New Castle

New Castle

19730

New Castle

Odessa

19731

New Castle

Port Penn

359

9.5%

19732

New Castle

Rockland

73

0.0%

19733

New Castle

Saint Georges

19734

New Castle

Townsend

19736

New Castle

Yorklyn

234

15.0%

11,892

5.8%

61

0.0%

19801

New Castle

Wilmington

14,012

7.0%

19802

New Castle

Wilmington

25,920

5.8%

19803

New Castle

Wilmington

21,414

3.9%

19804

New Castle

Wilmington

17,651

7.6%

19805

New Castle

Wilmington

40,475

11.6%

19806

New Castle

Wilmington

9,263

3.4%

19807

New Castle

Wilmington

6,906

2.8%

19808

New Castle

Wilmington

38,193

7.2%

19809

New Castle

Wilmington

15,130

6.7%

19810

New Castle

Wilmington

25,151

4.2%

Community 1

158,943

8.8%

Community 2

382,370

6.1%

Community Total

541,313

6.9%

Delaware

920,268

7.5%

313,576,137

11.7%

United States

Source: U.S. Census, ACS 5-Year Estimates, 2017.

Description

60

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 19 presents the estimated percent of population in community zip codes without health insurance (uninsured, 2012-2016). Light grey shading indicates rates that were higher (worse) than the Delaware average; dark grey shading indicates rates that were more than 50 percent higher than the Delaware average.

Observations

5

•

The rate of those uninsured in Community 1 (8.8 percent) was higher than the rate in Community 2 and Delaware.

•

After the ACA’s passage, a June 2012 Supreme Court ruling provided states with discretion regarding whether to expand Medicaid eligibility. Delaware was one of the states that expanded Medicaid resulting in a significant reduction in the number of uninsured individuals. Across the United States, uninsured rates have fallen most in states that decided to expand Medicaid. 5

See: http://hrms.urban.org/briefs/Increase-in-Medicaid-under-the-ACA-reduces-uninsurance.html

61

APPENDIX B – SECONDARY DATA ASSESSMENT

Crime Exhibit 20: Crime Rates by Type and Jurisdiction (Per 1,000), 2016 Indicator Total Offenses

New Castle Kent County County 83.6 98.3

Delaware 21.3

19.7

Serious Property Offenses

30.1

29.5

25.4

28.9

8.9

15.2

15.0

11.4

24.9

27.1

26.6

25.7

Robbery

2.1

1.1

0.7

1.6

Assault

16.6

23.8

19.4

18.6

Burglary

7.2

4.3

7.2

5.3

17.3

23.8

17.3

21.7

0.7

1.1

0.7

1.6

Other Property and Social Offenses

Larceny/Theft Motor Vehicle Theft

6.6

8.8

9.0

7.6

13.1

12.5

12.0

12.7

2.7

2.7

1.7

2.5

Fraud Property Destruction/Vandalism

21.4

87.4

Violent Offenses Drug Offenses

26.6

Sussex County 88.3

Weapons Law Violations

Source: Delaware Criminal Justice Council and Delaware State Bureau of Identification, 2017.

Description Exhibit 20 provides per-capita crime statistics. Light grey shading indicates rates that were higher (worse) than the Delaware average.

Observations •

2016 crime rates in New Castle County were higher than the Delaware averages for serious property offenses, robbery, burglary, property destruction/vandalism, and weapons law violations.

62

APPENDIX B – SECONDARY DATA ASSESSMENT

Housing Affordability Exhibit 21: Percent of Households Rent Burdened, 2013-2017

Source: U.S. Census, ACS 5-Year Estimates, 2018, and Microsoft MapPoint.

Description The U.S. Department of Housing and Urban Development (“HUD”) has defined households that are “rent burdened” as those spending more than 30 percent of income on housing. 6 On that basis and based on data from the U.S. Census, Exhibit 21 portrays the percentage of households in each zip code that are rent burdened.

Observations

https://www.federalreserve.gov/econres/notes/feds-notes/assessing-the-severity-of-rent-burden-on-lowincome-families-20171222.htm 6

63

APPENDIX B – SECONDARY DATA ASSESSMENT 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.” 7 • About 56 percent of households in Community 1 are rent burdened. Forty-four (44) percent in Community 2.

•

7

The highest percentages are in zip codes 19805 and 19802 (62 percent and 60 percent respectively).

Ibid.

64

APPENDIX B – SECONDARY DATA ASSESSMENT

Dignity Health Community Need Index Exhibit 22: Community Need IndexTM Score by Zip Code, 2018 ZIP Code

County

City/Town

CNI Score

19801

New Castle

Wilmington

4.8

19802

New Castle

Wilmington

4.4

19805

New Castle

Wilmington

4.0

19703

New Castle

Claymont

3.8

19720

New Castle

New Castle

3.6

19716

New Castle

Newark

3.2

19804

New Castle

Wilmington

3.2

19806

New Castle

Wilmington

3.2

19702

New Castle

Newark

3.0

19706

New Castle

Delaware City

3.0

19713

New Castle

Newark

3.0

19711

New Castle

Newark

2.8

19809

New Castle

Wilmington

2.6

19701

New Castle

Bear

2.4

19808

New Castle

Wilmington

2.4

19731

New Castle

Port Penn

2.0

19807

New Castle

Wilmington

2.0

19717

New Castle

Newark

1.8

19730

New Castle

Odessa

1.8

19733

New Castle

Saint Georges

1.8

19734

New Castle

Townsend

1.8

19736

New Castle

Yorklyn

1.8

19810

New Castle

Wilmington

1.8

19707

New Castle

Hockessin

1.6

19709

New Castle

Middletown

1.6

19803

New Castle

Wilmington

1.6

19732

New Castle

Rockland

1.4

Community 1

3.9

Community 2

2.4

New Castle County

2.9

Source: Dignity Health, 2018.

65

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 23: Community Need Index, 2018

Source: Microsoft MapPoint and Dignity Health, 2018.

Description Exhibits 22 and 23 present the Community Need Index™ (CNI) score for each zip code in the Christiana Care community. Higher scores (e.g., 4.2 to 5.0) indicate the highest levels of community need. The index is calibrated such that 3.0 represents a U.S.-wide median score.

Dignity Health, a California-based hospital system, developed and published the CNI as a way to assess barriers to health care access. The index, available for every zip code in the United States, is derived from 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; 66

APPENDIX B – SECONDARY DATA ASSESSMENT • • •

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.

CNI scores are grouped into “Lowest Need” (1.0-1.7) to “Highest Need” (4.2-5.0) categories Observations •

Two of the 27 zip codes in the Christiana Care community, Wilmington zip codes 19801 and 19802, scored in the “highest need” category. Both of these zip codes are in Community 1.

•

At 2.9, the weighted average CNI score for New Castle County is below the U.S. median of 3.0. However, the weighted average CNI score for Community 1 was 3.9 (in the second highest “need” range).

67

APPENDIX B – SECONDARY DATA ASSESSMENT

Other Community Health Indicators This section assesses other community health indicators for New Castle County. Data sources include: • • • • • • • • •

County Health Rankings Community Health Status Indicators (published by County Health Rankings) America’s Health Rankings Delaware Department of Health National Cancer Institute Health Resources and Services Administration U.S. Department of Agriculture Centers for Disease Control Christiana Care Health System (discharge data).

Throughout this section, data and cells are highlighted if indicators are unfavorable – because they exceed benchmarks (typically, Delaware and national averages). Where confidence interval data are available, cells are highlighted only if variances are unfavorable and statistically significant.

68

APPENDIX B – SECONDARY DATA ASSESSMENT

County Health Rankings Exhibit 24: County Health Rankings Data Compared to Delaware and U.S. Averages, 2018 Indicator Category Length of Life

Quality of Life

Health Behaviors Adult Smoking Adult Obesity Food Environment Index Physical Inactivity Access to Exercise Opportunities Excessive Drinking Alcohol‐Impaired Driving Deaths STDs Teen Births Clinical Care Uninsured Primary Care Physicians Dentists Mental Health Providers Preventable Hospital Stays Diabetes Screening Mammography Screening

Data Health Outcomes Years of potential life lost before age 75 per 100,000 population Percent 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 Percent of live births with low birthweight (<2500 grams) Health Factors Percent of adults that report smoking >= 100 cigarettes and currently smoking Percent of adults that report a BMI >= 30 Index of factors that contribute to a healthy food environment, 0 (worst) to 10 (best) Percent of adults aged 20 and over reporting no leisure-time physical activity Percent of population with adequate access to locations for physical activity Binge plus heavy drinking Percent of driving deaths with alcohol involvement Chlamydia rate per 100,000 population Teen birth rate per 1,000 female population, ages 15-19 Percent 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 Hospitalization rate for ambulatory-care sensitive conditions per 1,000 Medicare enrollees Percent of diabetic Medicare enrollees that receive HbA1c monitoring Percent of female Medicare enrollees, ages 67-69, that receive mammography screening Source: County Health Rankings, 2018.

69

New Castle County 6,883 14.6%

Kent County 8,122 16.9%

Sussex County 7,336 16.4%

Delaware 7,183 15.8%

United States 6,700 16.0% 3.7

3.3

3.5

3.3

3.4

3.8 8.8%

3.7 8.9%

3.6 7.8%

3.7 8.6%

3.8 8.0%

16.8%

18.2%

17.6%

17.7%

17.0%

29.2%

33.6%

31.6%

30.6%

28.0%

8.2

8.0

8.5

8.5

24.5%

30.3%

27.0%

26.1%

23.0%

96.4%

62.0%

78.9%

86.3%

83.0%

19.4%

16.4%

15.3%

18.4%

18.0%

32.0%

35.9%

42.6%

36.3%

29.0%

496 20.7

541 24.9

443 35.7

492 24.1

479 27.0

6.1% 1,226:1 1,673:1 357:1

6.9% 2,197:1 2,462:1 624:1

9.4% 1,529:1 4,005:1 612:1

6.9% 1,403:1 2,074:1 433:1

7.7

11.0% 1,320:1 1,480:1 470:1

45.3

59.8

42.6

47.2

49.0

85.1%

87.5%

87.9%

86.6%

85.0%

67.8%

69.8%

74.1%

70.4%

63.0%

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 24: County Health Rankings Data Compared to Delaware and U.S. Averages, 2018 (continued) Indicator Category

Social & Economic Factors High School Graduation Some College Unemployment Children in Poverty Income Inequality Children in Single‐Parent Households Social Associations Violent Crime Injury Deaths Physical Environment Air Pollution Severe Housing Problems Driving Alone to Work Long Commute – Drive Alone

New Castle County

Data

Kent County

Sussex County

Delaware

United States

Health Factors Percent of ninth-grade cohort that graduates in four years Percent of adults aged 25-44 years with some post-secondary education Percent of population age 16+ unemployed but seeking work Percent of children under age 18 in poverty Ratio of household income at the 80th percentile to income at the 20th percentile Percent of children that live in a household headed by single parent Number of associations per 10,000 population Number of reported violent crime offenses per 100,000 population Injury mortality per 100,000 The average daily measure of fine particulate matter in micrograms per cubic meter (PM2.5) in a county Percentage of households with at least 1 of 4 housing problems: overcrowding, high housing costs, or lack of kitchen or plumbing facilities Percent of the workforce that drives alone to work Among workers who commute in their car alone, the percent that commute more than 30 minutes Source: County Health Rankings, 2018.

70

85.3%

85.5%

86.1%

85.5%

83.0%

66.5%

58.5%

50.8%

62.2%

65.0%

4.3% 15.0%

4.7% 20.8%

4.4% 22.7%

4.4% 17.7%

4.9% 20.0%

4.5

4.1

4.1

4.3

5.0

37.7%

38.3%

38.5%

38.0%

34.0%

10.3 550 65.2

8.5 473 72.4

10.7 446 72.5

10.0 509 68.1

9.3 380 65.0

10.4

9.0

8.8

9.0

8.7

15.5%

15.9%

15.8%

15.6%

19.0%

80.2%

82.9%

83.3%

81.3%

76.0%

33.5%

35.0%

35.2%

34.1%

35.0%

APPENDIX B – SECONDARY DATA ASSESSMENT Description Because there are only three counties in Delaware, New Castle County’s ranking in comparison to other Delaware counties is not meaningful. However, the data underlying such rankings are useful and allow comparing various indicators for the county to national averages.

Exhibit 24 provides data that underlie the County Health Rankings. 8 The exhibit also includes Delaware and national averages. Light grey shading highlights indicators found to be worse than the national average; dark grey shading highlights indicators more than 50 percent worse than the national average.

Observations •

The following indicators for New Castle County (presented alphabetically) compared unfavorably to U.S. averages: o o o o o o o o o o o o o

Average daily particulate matter (PM2.5) Binge plus heavy drinking Chlamydia rate Injury mortality rate Percent of adults obese Percent of adults physically inactive Percent of births low birthweight Percent of children living in single-parent households Percent of driving deaths with alcohol involvement Percent of workforce driving alone to work Ratio of population to dentists Violent crime rate Years of potential life lost.

8

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

71

APPENDIX B â&#x20AC;&#x201C; SECONDARY DATA ASSESSMENT

Community Health Status Indicators Exhibit 25: Community Health Status Indicators, 2018 New Castle Kent County County

Indicator Years of Potential Life Lost Rate % Fair/Poor Health Physically Unhealthy Days Mentally Unhealthy Days % Low Birth Weight % Smokers % Obese Food Environment Index % Physically Inactive % With Access to Exercise Opportunities % Excessive Drinking % Driving Deaths Alcohol-Impaired Chlamydia Rate Teen Birth Rate % Uninsured Primary Care Physicians Rate Dentist Rate Mental Health Professionals Rate Preventable Hosp. Rate % Receiving HbA1c Screening % Mammography Screening High School Graduation Rate % Some College % Unemployed % Children in Poverty Income Ratio % Single-Parent Households Social Association Rate Violent Crime Rate Injury Death Rate Average Daily PM2.5 % Severe Housing Problems % Drive Alone to Work % Long Commute - Drives Alone

Source: County Health Rankings, 2018.

72

Sussex County

APPENDIX B – SECONDARY DATA ASSESSMENT

Description County Health Rankings has organized 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 25 compares Delaware counties to their respective peer counties and highlights community health issues found to rank in the bottom half and bottom quartile of the counties included 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.

Observations •

The CHSI data indicate that New Castle County ranked in the bottom quartile to peers for the following indicators: o o o o o

•

Chlamydia rate Percent births low birthweight Percent of children in poverty Percent of children in single-parent households Violent crime rate.

Additionally, New Castle County ranked in the bottom half of peers for the following indicators: o o o o o o o o o

Average daily PM2.5 air pollution High school graduation rate Income ratio Injury death rate Percent of adults physically inactive Percent of driving deaths alcohol-impaired Percent excessive drinking Percent of households experiencing severe housing problems Percent receiving HbA1c diabetes screening.

73

APPENDIX B – SECONDARY DATA ASSESSMENT o o o o

Percent smokers Percent with some college education Percent unemployed Years of potential life lost rate.

America’s Health Rankings Exhibit 26: America’s Health Rankings – 2018 Measure Name

Rank

Measure Name

Rank

Measure Name

Rank

Infant Mortality

48 Premature Death

32 Mental Health Providers

20

Dentists

47 Stroke

32 Voter Registration

20

Chlamydia

43 Heart Disease

31 Six+ Teeth Extractions

19

Underemployment Rate

43 Overall

31 Water Fluoridation

19

Drug Deaths

42 Behaviors

30 Primary Care Physicians

18

Air Pollution

41 Children in Poverty

30 Public Health Funding

18

Disconnected Youth

41 All Determinants

29 Injury Deaths

17

Income Inequality - Gini Index

41 Poor Mental Health Days

29 Vegetables

17

Physical Inactivity

41 Cardiovascular Deaths

28 Dedicated Health Care Provider

16

High Blood Pressure

40 Concentrated Disadvantage

28 HPV Immunization Females

15

Insufficient Sleep

39 Obesity

28 Excessive Drinking

13

Low Birthweight

39 Frequent Physical Distress

27 Colorectal Cancer Screening

12

All Outcomes

38 Adverse Childhood Experiences

26 Fruits

12

High Health Status

38 Dental Visit, Annual

26 Meningococcal Immunizations

12

Neighborhood Amenities

38 Tdap Immunizations

26 Immunizations - Adolescents

11

Unemployment Rate, Annual

38 High School Graduation

25 Uninsured

11

Violent Crime

38 Poor Physical Health Days

25 Binge Drinking

9

Cancer Deaths

36 Smoking

24 Suicide

9

Diabetes

36 Chronic Drinking

23 HPV Immunization Males

6

Salmonella

36 Preventable Hospitalizations

23 Immunizations - Children

6

Clinical Care

35 Severe Housing Problems

23 Policy

6

Frequent Mental Distress

35 Heart Attack

22 Seat Belt Use

6

High Cholesterol

35 Median Household Income

22 Cholesterol Check

5

Community & Environment

33 Occupational Fatalities

21 Pertussis

5

Infectious Disease

33 Disparity in Health Status

20

Source: America’s Health Rankings, 2018.

Description Exhibit 26 presents America’s Health Rankings for Delaware in 2018. The exhibit identifies community health issues for which Delaware ranks best (and worst) among all U.S. states. The ranking of 48 for infant mortality, for example, indicates that Delaware ranks at the bottom U.S. states for infant mortality rates.

America’s Health Rankings is particularly meaningful for New Castle County because the county is home to about 60 percent of Delaware’s total population.

74

APPENDIX B – SECONDARY DATA ASSESSMENT

Observations •

In terms of overall health, Delaware ranked 31st – in the bottom one-half of U.S. states.

•

Delaware ranked in the bottom ten states for the following indicators: o o o o o o o o o o

Infant mortality Supply of dentists Chlamydia incidence Underemployment rate Drug deaths Air pollution Percent of youth feeling disconnected Income inequality Percent physical inactive High blood pressure incidence.

Exhibit 27: Deaths due to drug injury of any intent (unintentional, suicide, homicide or undetermined), age-adjusted per 100,000 population

Source: America’s Health Rankings, 2018.

Description Exhibit 27 presents deaths due to drug injury for Delaware and the United States, yearly, between 2010 and 2017.

75

APPENDIX B – SECONDARY DATA ASSESSMENT

Observations •

The rates of drug injury death in Delaware have consistently been above national rates from 2011 through 2017.

•

The rate of drug injury death in Delaware has increased annually for every year between 2010 and 2017.

76

APPENDIX B â&#x20AC;&#x201C; SECONDARY DATA ASSESSMENT

Delaware Department of Health Exhibit 28: Selected Causes of Death, Age-Adjusted Rates per 100,000 Population, 2012-2016 New Castle Kent County County 165.6 197.2

Indicator Malignant neoplasms Diseases of the heart

Sussex County 160.1

Delaware 168.3

150.4

192.7

151.9

156.7

Accidents (unintentional injuries)

42.1

51.1

51.0

45.0

Chronic lower respiratory diseases

38.5

50.5

39.2

40.3

Cerebrovascular diseases

41.0

41.9

27.1

36.2

Dementia

42.3

39.5

24.7

35.6

Diabetes mellitus

18.5

22.5

17.0

18.9

Alzheimer's disease

20.3

22.6

14.7

18.6

Nephritis, nephrotic syndrome, and nephrosis

15.4

19.3

10.8

14.5

Intentional self-harm (suicide)

12.0

14.0

12.9

12.6

Influenza and pneumonia

13.8

14.3

8.7

12.2

Septicemia

10.4

11.9

11.5

17.0

Other diseases of respiratory system

9.0

11.4

7.9

8.9

Chronic liver disease and cirrhosis

6.8

8.6

11.3

8.2

Assault (homicide)

8.6

5.6

3.1

6.9

Parkinson's disease Certain conditions originating in the perinatal period

7.1

6.2

5.8

6.5

7.4

4.9

3.8

6.1

Pneumonitis due to solids and liquids Essential hypertension and hypertensive renal disease

5.3

5.6

3.6

4.8

4.1

6.5

4.2

4.6

Human immunodeficiency virus (HIV)

3.5

3.0

2.1

3.0

Aortic aneurysm and dissection Congenital malformations, deformations, and chromosomal abnormalities

2.7

4.0

2.4

2.8

2.4

3.0

3.2

2.7

Source: Delaware Vital Statistics Report, 2018.

Description Exhibit 28 provides age-adjusted mortality rates for selected causes of death (average age-adjusted rates per 100,000, 2012-2016). Light grey shading denotes indicators worse than the Delaware average; dark grey shading denotes any indicators more than 50 percent worse than the Delaware average.

Observations 77

APPENDIX B – SECONDARY DATA ASSESSMENT •

The following mortality rates compared particularly unfavorably to Delaware averages in New Castle County: o o o o o o o o o o o

Cerebrovascular disease Dementia Alzheimer’s disease Nephritis, nephrotic syndrome, and nephrosis Influenza and pneumonia Other diseases of respiratory system Assault (homicide) Parkinson’s disease Certain conditions originating in the perinatal period Pneumonitis due to solids and liquids Human immunodeficiency virus (HIV).

78

APPENDIX B â&#x20AC;&#x201C; SECONDARY DATA ASSESSMENT

Exhibit 29: Communicable Disease Incidence Rates per 100,000 Population, 2016 Indicator Chlamydia Gonorrhea Lyme Disease

New Castle Kent County County 571.4 670.3

Sussex County 458.6

Delaware 563.6

151.5

216.0

218.2

178.8

53.0

52.6

54.1

53.2

Hepatitis B, chronic

23.9

20.0

14.1

21.0

Campylobacteriosis

12.2

16.6

34.5

18.2

Salmonellosis

12.7

11.4

36.8

18.1

HIV (New Infections)

14.2

12.6

7.7

12.4

Shigellosis

10.1

8.6

5.5

8.7

Streptococcus Pneumoniae

6.1

8.6

10.0

7.5

AIDS

7.2

5.7

5.0

6.4

Syphilis (Primary & Secondary)

6.6

3.4

6.8

6.1

Legionellosis

2.9

1.7

3.2

2.7

Cryptosporidiosis

2.7

1.1

2.7

2.4

Ehrlichiosis/Anaplasmosis

1.1

0.6

5.9

2.1

Giardiasis Haemophilus influenzae, invasive

1.3

1.7

4.5

2.1

1.3

4.0

2.3

2.0

Source: Delaware Department of Health and Human Services (DHSS), 2017.

Description Exhibit 29 presents incidence rates for various communicable diseases. Light grey shading denotes indicators worse than the Delaware average; dark grey shading denotes indicators more than 50 percent worse than the Delaware average.

Observations â&#x20AC;˘

New Castle County compares unfavorably to state averages for incidence of chlamydia, Hepatitis B, HIV, shigellosis, AIDS, syphilis, legionellosis, and cryptosporidiosis.

79

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 30: Maternal and Child Health Indicators, 2012-2016 Indicator Teen Birth Rate (Age 15-19) Teen Birth Rate (Age 15-17) Births to Single Mothers

New Castle Kent County County 19.3 23.7

Sussex County 32.6

22.6

United States* 24.5

Delaware

9.1

9.8

13.7

10.1

12.5

44.6%

45.7%

54.9%

46.6%

40.5%

Low Birthweight Births (<2,500 grams)

8.9%

9.1%

7.5%

8.6%

Low Birthweight Births (White)

6.9%

7.6%

6.4%

6.9%

N/A

Low Birthweight Births (Black)

13.1%

12.3%

11.6%

12.7%

N/A

7.5%

8.2%

6.0%

7.1%

Low Birthweight Births (Hispanic) Very Low Birthweight Births (<1,500 grams)

2.0%

1.7%

1.3%

1.8%

Tobacco Use During Pregnancy

7.6%

10.2%

11.9%

9.0%

8.0%

7.1% 1.4% N/A

Source: Delaware Department of Health and Human Services (DHSS), 2017. *Note: U.S. data for years 2011-2015

Description Exhibit 30 presents various maternal and infant health indicators. Light grey shading denotes indicators worse than the Delaware average; dark grey shading denotes any indicators more than 50 percent worse than the Delaware average.

Observations •

New Castle County compares unfavorably to both Delaware and U.S. averages for low birthweight births, low birthweight births among Hispanic residents, and very low birthweight births.

•

New Castle County also compares unfavorably to the national average for births to single mothers and to the Delaware average for low birthweight births to Black residents.

80

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 31: Infant and Neonatal Mortality Rates by County, 2012-2016 Indicator Infant mortality rate (all races)

New Castle Kent County County 8.4 6.5

Sussex County 6.1

7.5

United States* 5.9

Delaware

Infant mortality rate (White)

5.6

4.6

4.4

5.1

5.0

Infant mortality rate (Black)

13.2

10.1

12.6

12.5

11.2

Neonatal mortality rate (all races)

6.5

4.6

3.8

5.5

4.0

Neonatal mortality rate (White)

3.9

3.5

2.9

3.6

3.4

Neonatal mortality rate (Black)

10.8

6.4

9.3

7.4

N/A

Source: Delaware Department of Health and Human Services (DHSS), 2017. *Note: U.S. data for years 2011-2015

Description Exhibit 31 presents infant mortality rates by race and ethnicity. Light grey shading denotes indicators worse than the Delaware average; dark grey shading denotes any indicators more than 50 percent worse than the Delaware average.

Observations •

Infant and neonatal mortality rates in New Castle County have been well above national averages both overall and for Black and White residents separately.

•

Rates for Black residents are more than double the rates of White residents in New Castle County, Delaware, and the U.S.

81

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 32: Infant Mortality Rates by Race, New Castle County, 2012-2016

Source: Delaware Department of Health and Human Services (DHSS), 2017.

Description Exhibit 32 presents infant mortality rates in New Castle County by race for year ranges from 2008 through 2016.

Observations •

Infant mortality rates for Black infants in Delaware were consistently more than double the rates for White infants. Rates for Black infants were also above rates for infants of all races.

•

Infant mortality rates have declined for all racial and ethnic groups between 2008 and 2016.

82

APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 33: Drug Overdose Mortality Rate, age-adjusted per 100,000 Population

Source: Delaware Opioid Metric Intelligence Project, 2018.

Description Exhibit 33 presents drug overdose mortality rates by county and for Delaware, annually between 2013 and 2017.

Observations •

Drug overdose mortality rates have increased every year in Delaware, and in general have increased every year in New Castle County.

•

In 2017, the rate of drug overdose mortality in New Castle County was higher than the Delaware rate.

83

APPENDIX B â&#x20AC;&#x201C; SECONDARY DATA ASSESSMENT

National Cancer Institute Exhibit 34: Age-Adjusted Cancer Incidence Rates per 100,000 Population, 2011-2015 Indicator All cancers Breast Prostate Lung and bronchus Colon and rectum Uterus Melanoma of the skin Bladder Non-Hodgkin lymphoma Childhood (<20 years) Kidney and renal pelvis Childhood (<15 years) Thyroid Leukemia Pancreas Oral cavity and pharynx Ovary Liver and bile duct Cervix Stomach Brain and ONS Esophagus

New Castle Kent County County 484.4 523.9 135.5 131.2 136.2 159.9 66.2 80.0 36.2 36.7 30.3 34.2 27.0 25.4 24.4 25.8 19.9 21.4 18.7 16.1 16.7 18.8 15.3 15.9 16.5 17.3 13.3 14.6 14.9 13.0 13.1 12.4 9.6 12.6 8.2 9.7 7.7 10.7 7.4 5.5 6.2 6.3 5.2 4.0

Sussex County 490.7 129.7 122.5 75.6 41.3 28.3 38.9 23.8 21.3 16.4 16.9 17.4 12.0 15.8 14.3 12.1 14.7 8.2 7.5 6.0 6.2 5.6

Delaware 493.5 133.8 136.1 71.2 37.2 30.5 30.0 24.5 20.7 17.8 17.1 15.9 15.7 14.2 14.4 12.7 11.4 8.4 8.2 6.7 6.2 5.1

United States 441.2 124.7 109.0 60.2 39.2 26.2 21.3 20.3 18.9 17.9 16.4 16.3 14.5 13.6 12.6 11.6 11.3 8.1 7.5 6.6 6.5 4.6

Source: National Cancer Institute, 2018.

Description Exhibit 34 provides age-adjusted incidence rates for selected forms of cancer for 20122016. Light grey shading denotes indicators worse than the U.S. average; dark grey shading denotes any indicators more than 50 percent worse than the national average.

Observations â&#x20AC;˘

Both New Castle County and Delaware as a whole have above average cancer incidence rates, both overall and for virtually all cancer types.

84

APPENDIX B – SECONDARY DATA ASSESSMENT

Behavioral Risk Factor Surveillance System Exhibit 35: Behavioral Risk Factor Surveillance System, 2017 (Shading Denotes Statistic is Worse than Delaware Rate, including Confidence Interval) New Castle Kent County County 15.9% 18.2%

Indicator Current Cigarette Smoker Total Tobacco Use

21.1%

24.4%

Sussex County 18.9% 23.4%

Delaware 17.0% 22.3%

Obese

29.3%

38.5%

32.6%

31.8%

Overweight

37.6%

31.0%

38.8%

36.7%

Sedentary

29.0%

32.9%

34.3%

31.0%

Did Not Meet Physical Activity Guidelines

42.3%

45.1%

46.3%

43.8%

Did Not Consume at Least 5 fruits and/or Vegetables a Day

83.8%

85.0%

85.7%

84.5%

Binge Drinking

15.6%

15.3%

12.4%

14.8%

Chronic Heavy Drinking

6.0%

7.0%

6.2%

6.2%

No Seatbelt Use

1.7%

2.0%

1.5%

1.7%

29.5%

32.3%

31.2%

30.4%

Disability Diabetes

10.1%

13.1%

12.6%

11.3%

High Cholesterol

33.0%

36.5%

36.9%

34.6%

Hypertension

33.7%

35.2%

37.6%

34.9%

3.5%

3.9%

5.9%

4.2%

Angina or Coronary Heart Disease Coronary Heart Disease or Myocardial Infarction

5.1%

7.4%

8.9%

6.4%

Stroke

2.6%

5.1%

4.1%

3.4%

Skin Cancer

6.3%

4.7%

9.9%

6.9%

Other Cancer

7.0%

8.6%

8.8%

7.7%

11.2%

11.5%

8.6%

10.6%

Asthma COPD Arthritis

7.7%

8.2%

8.9%

8.1%

23.6%

25.9%

28.9%

25.3%

Limited Work Ability Due to Arthritis

38.8%

37.4%

34.3%

37.3%

Depressive Disorder

20.1%

19.8%

18.9%

19.7%

6.1%

6.6%

5.5%

6.1%

Age ≥ 65 Flu Shot in Past Year

66.0%

64.4%

64.5%

65.2%

Age ≥ 65 Pneumonia Vaccine

75.2%

77.9%

81.2%

77.7%

Vision Impairment

Adults Who Have Been Tested for HIV

46.8%

51.7%

41.7%

46.5%

No Health Insurance (Age 18-64)

10.6%

11.8%

18.7%

12.5%

Health Status: Poor to Fair

17.8%

19.7%

20.2%

18.8%

Source: Delaware Department of Health and Human Services (DHSS), 2017.

85

APPENDIX B – SECONDARY DATA ASSESSMENT Description The Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS) gathers data through a telephone survey regarding health risk behaviors, healthcare 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 35 depicts BRFSS data for each county in Delaware compared to the state average. Shading denotes that the statistic is worse than the Delaware Rate, including a confidence interval.

Observations •

New Castle County compared favorably or on par with all Delaware-wide statistics.

86

APPENDIX B â&#x20AC;&#x201C; SECONDARY DATA ASSESSMENT

UDS Mapper Exhibit 36: UDS Indicators by Community, 2017 Indicator

Community 1

Low Birth Weight Rate Adults Ever Told had Diabetes Adults Ever Told had High Blood Pressure Adults Obese Adults with No Dental Visits Past Year Adults Who Have Delayed/ Not Sought Care Due to Cost Adults with No Usual Source of Care

9.4% 8.3% 28.7% 28.9% 27.1% 14.5% 12.1%

Community 2 7.8% 7.4% 28.5% 24.6% 23.1% 11.3% 10.3%

New Castle County 8.1% 7.5% 27.8% 25.2% 23.7% 11.9% 10.5%

Source: Uniform Data Services (UDS) Mapper, 2018.

Description The UDS Mapper made available by HRSA provides data selected community health indicators at a zip code level of detail. Exhibit 36 presents available indicators for New Castle County and also for Communities 1 and 2.

Observations â&#x20AC;˘

For all the UDS Mapper indicators presented, Community 1 compared unfavorably to Community 2.

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APPENDIX B â&#x20AC;&#x201C; SECONDARY DATA ASSESSMENT

Youth Risk Behavior Surveillance System Exhibit 37: Youth Risk Behavior Surveillance System, High School, 2017 (Shading Denotes Statistic is Worse than National Rate) Indicator Category

New Castle County 5.3%

Indicator Rarely or never wore a seat belt Texted or emailed while driving a vehicle Carried a weapon on school property Threatened or injured with a weapon on school property

In a physical fight Injuries and In a physical fight on school property Violence Electronically bullied Bullied on school property Did not go to school because felt unsafe Physically forced to have sexual intercourse Experienced sexual violence

39.2%

13.4%

13.5%

15.7%

3.5%

3.1%

3.8%

6.0%

6.0%

20.6%

20.0%

23.6%

9.3%

8.4%

8.5%

10.0%

10.1%

14.9%

13.3%

14.1%

19.0%

4.9%

5.1%

6.7%

6.4%

6.3%

7.4%

7.7%

9.7%

N/A

N/A

Experienced physical dating violence

6.7%

9.5%

8.0%

Felt sad or hopeless every day for 2 or more weeks

27.7%

27.6%

31.5%

Seriously considered attempting suicide

16.8%

16.1%

17.2%

Made a plan about how they would attempt suicide

12.0%

12.0%

13.6%

Attempted suicide

Tobacco Use

45.0%

N/A

Carried a weapon

Mental Health

5.5%

United States 5.9%

Delaware

7.6%

7.2%

7.4%

Ever tried cigarette smoking

21.0%

22.7%

28.9%

Currently smoked cigarettes

5.9%

6.2%

8.8%

Ever used an electronic vapor product

38.4%

37.9%

42.2%

Currently used an electronic vapor product

13.9%

13.6%

13.2%

Currently used smokeless tobacco

2.7%

3.5%

5.5%

Currently smoked cigars

6.6%

7.3%

8.0%

Ever drank alcohol

59.2%

59.5%

60.4%

Currently drank alcohol

28.2%

28.7%

29.8%

Current binge drinking

14.5%

14.9%

13.5%

Ever used marijuana

47.3%

44.1%

35.6%

Currently used marijuana

29.1%

26.1%

19.8%

2.4%

2.9%

4.8%

1.3%

1.6%

1.7%

1.6%

1.7%

2.5%

3.0%

3.0%

4.0%

Alcohol and Ever used cocaine Other Drug Ever used heroin Use Ever used methamphetamines Ever used ecstasy Ever took steroids without a prescripotion

2.2%

2.3%

2.9%

Ever took prescription pain medicine without a prescription

10.4%

10.1%

14.0%

Offered, sold, or given an illegal drug on school property

17.2%

16.8%

19.8%

Source: Centers for Disease Control and Prevention, 2018, and DDHS, 2018.

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APPENDIX B – SECONDARY DATA ASSESSMENT Exhibit 37: Youth Risk Behavior Surveillance System, High School, 2017 (continued) (Shading Denotes Statistic is Worse than National Rate) Indicator Category

New Castle County 45.7%

45.4%

United States 39.5%

Currently sexually active

33.7%

33.4%

28.7%

Used a condom during last sexual intercourse Did not use any method to prevent pregnancy during last sexual intercourse

56.7%

52.7%

53.8%

14.5%

16.5%

13.8%

Did not drink soda or pop in past seven days

33.8%

31.8%

27.8%

Ate breakfast everyday in past seven days Not physically active for a total of at least 60 minutes on at least one day past week Not physically active for a total of at least 60 minutes on at least five days past week Played a video game or used a computer for at least three hours daily

39.0%

39.0%

35.3%

18.0%

17.0%

15.4%

43.3%

43.5%

46.5%

45.1%

44.6%

43.0%

Watched television at least three hours daily

24.2%

23.6%

20.7%

Indicator Ever had sexual intercourse

Sexual Behaviors

Dietary Behaviors

Physical inactivity

Played on at least one sports team Prevalence Were overweight of Obesity Described themselves as slightly or very overweight Asthma Sleep

53.3%

54.3%

N/A

15.1%

14.8%

N/A

16.6%

15.6%

55.7%

Were obese

Delaware

33.9%

33.4%

31.5%

Ever had asthma

23.7%

24.3%

22.5%

Got eight or more hours of sleep on average

20.9%

23.8%

25.4%

Source: Centers for Disease Control and Prevention, 2018, and DDHS, 2018.

Description Exhibit 37 provides statewide data from the Delaware Youth Risk Behavior Survey (YRBS), part of a nationwide surveying effort led and funded by the Centers for Disease Control and Prevention (CDC) to monitor student health risks and behaviors in six categories, including: • • • • • •

Weight and diet Physical activity Injury and violence Tobacco use Alcohol and other drug use Sexual behaviors.

Light grey shading highlights indicators found to be worse than the national average; dark grey shading highlights indicators more than 50 percent worse than the national average.

89

APPENDIX B â&#x20AC;&#x201C; SECONDARY DATA ASSESSMENT Observations â&#x20AC;˘

The percentage of high school students in both New Castle County and Delaware compared unfavorably to United States averages for the following indicators: o o o o o o o o o o o o

Currently using an electronic vapor product Current binge drinking Ever used marijuana Currently using marijuana Ever had sexual intercourse Currently sexually active Not using any method to prevent pregnancy during last sexual intercourse Not physically active for at least an hour for one day in past week Played a video game or used a computer for at least three hours daily Described selves as slightly or very overweight Ever had asthma Got eight or more hours of sleep on average.

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APPENDIX B – SECONDARY DATA ASSESSMENT

Food Deserts Exhibit 38: Food Deserts, 2017

Source: Microsoft MapPoint and U.S. Department of Agriculture, 2017.

Description Exhibit 38 shows the location of “food deserts” in the 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 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 91

APPENDIX B – SECONDARY DATA ASSESSMENT •

Several census tracts New Castle County have been designated as food deserts, particularly within Community 1.

Medically Underserved Areas and Populations Exhibit 39: Medically Underserved Areas and Populations, 2018

Source: Microsoft MapPoint and HRSA, 2018.

Description Exhibit 39 illustrates the location of Medically Underserved Areas (MUAs) and Medically Underserved Populations (MUPs) in the community.

Medically Underserved Areas and Populations (MUA/Ps) are designated by the Health Resources and Services Administration (HRSA) based on an “Index of Medical Underservice.” The index includes the following variables: ratio of primary medical care physicians per 1,000 population, infant mortality rate, percentage of the population 92

APPENDIX B – SECONDARY DATA ASSESSMENT with incomes below the poverty level, and percentage of the population age 65 or over.9 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.” 10 Observations •

9

There are several census tracts in New Castle County that have been designated

by HRSA as Medically Underserved Areas. Medically Underserved Areas are present in Community 1 in areas proximate to the Wilmington Hospital, and in the northern area of Community 2.

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

10Ibid.

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APPENDIX B â&#x20AC;&#x201C; SECONDARY DATA ASSESSMENT

Health Professional Shortage Areas Exhibit 40A: Primary Care Health Professional Shortage Areas, 2018

Source: Health Resources and Services Administration, 2018.

94

APPENDIX B â&#x20AC;&#x201C; SECONDARY DATA ASSESSMENT Exhibit 40B: Dental Care Health Professional Shortage Areas, 2018

Source: Health Resources and Services Administration, 2018.

Description Exhibits 40A and 40B show the locations of federally-designated dental care HPSA Census Tracts.

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 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.

95

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.” 11 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.” 12 Observations

11

•

Several census tracts in New Castle County have been designated as primary care HPSAs, particularly in Community 1.

•

Several census tracts in Community 1 have been designated as dental care HPSAs.

•

In addition to the census tracts designated as Dental Care HPSAs, the LowIncome Population of Wilmington has been designated as a Dental Care HPSA as well.

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

12Ibid.

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APPENDIX B – SECONDARY DATA ASSESSMENT

Ambulatory Care Sensitive Conditions Description ACSCs are health “conditions for which good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease.” 13 As such, rates of hospitalization for these conditions can “provide insight into the quality of the health care system outside of the hospital,” including the accessibility and utilization of primary care, preventive care and health education. Among these conditions are: angina without procedure, diabetes, perforated appendixes, chronic obstructive pulmonary disease (COPD), hypertension, congestive heart failure, dehydration, bacterial pneumonia, urinary tract infection, and asthma.

Disproportionately high rates of discharges for ACSC indicate potential problems with the availability or accessibility of ambulatory care and preventive services and can suggest areas for improvement in the health care system and ways to improve outcomes.

Observations •

Christiana Care staff analyzed inpatient discharges by zip code and quantified the number that are associated with ACSCs. According to this analysis, 22 percent of Christiana Care’s discharges from residents of Community 2 were associated with ACSCs; 26 percent from residents of Community 1.

•

ACSC statistics typically are presented on a per-capita basis. However, because the analysis only included Christiana Care discharges (rather than discharges from all hospitals that serve New Castle County), per-capita rates could not be calculated reliably.

•

Nevertheless, the 22 to 26 percent of discharges statistics are well above levels reported by other hospitals and health systems.

Findings of Other Assessments Delaware State Health Improvement Plan, 2017

Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators.

13

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APPENDIX B – SECONDARY DATA ASSESSMENT The Delaware Public Health Institute (DPHI) conducted the Delaware State Health Needs Assessment (DSHNA) from April to November, 2016 to “identify local and statewide trends for the identification and prioritization of strategies that address critical health needs.” The DSHNA identified four priority areas of focus, and provided additional sub-focus areas within each, as follows: 1. Chronic Disease o Heart disease o Diabetes o Asthma.

Statewide, key priorities are reducing obesity and lung disease; and increasing access to healthy foods, community health workers, care coordination, remote patient monitoring, and access to dental and primary care.

2. Maternal and Child Health o Teen pregnancy o Premature births o Low birth weight infants.

Other priorities are to incorporate messaging in the educational setting, reduce the cost of care, and increase access to preventive services.

3. Substance Use Disorders o Opioid epidemic o Accidental overdose o Tobacco and e-cigarette use.

Statewide, there is a need for additional substance use disorder treatment programs and resources. Prescription monitoring and proper disposal, early detection and supportive resources, and a public media campaign would be excellent steps. Additionally, universal education for health care providers about identifying substance use disorder and trauma-informed care is needed.

4. Mental Health o Diagnosis, particularly among youth o Suicide and suicide ideations o Impact of trauma.

Improved mental health screening, detection, and early intervention across the state is needed to identify risk factors for both suicide and other mental health disorders.

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APPENDIX C â&#x20AC;&#x201C; COMMUNITY INPUT PARTICIPANTS

APPENDIX C â&#x20AC;&#x201C; COMMUNITY INPUT PARTICIPANTS Individuals from a wide variety of organizations and communities participated in the interview process (Exhibit 41).

Exhibit 41: Interviewee Organizational Affiliations Organizations Advocate for the Deaf Community, RN Delaware Coalition Against Domestic Sign Language Interpreter Violence AIDS DE Delaware College of Art and Design Delaware Community Reinvestment AmeriHealth Caritas Delaware Action Council Be Ready Community Development Delaware Health and Social Services Corporation Beautiful Gate Outreach Center Delaware Project LAUNCH

Parents as Teachers Public Allies DE Red Clay Consolidated School District Rockford Center - Private Psychiatric Facility Rodel Foundation DE

Beebe Healthcare

Delaware Public Health

St. Francis Hospital

BlindSight Delaware

St. Patrick's Center

Brandywine Women's Health

Department of Corrections Division of Medicaid & Medical Assistance Elsmere Presbyterian Church

Cancer Care Connection

Family Counseling Center at St. Paul's The Ministry of Caring

Brandywine School District

Central Baptist Community Development Corporation Child Inc.

State Representative Sunday Breakfast Mission

First & Central Presbyterian Church

United Way of Delaware

First State Community Action Agency

University of Delaware

Choir School of Delaware

Food Bank of Delaware

Urban Acres

Christiana Care Health System

Habitat for Humanity NCC

Westside Family Healthcare

City of Wilmington Clarance Fraim Club - Boys and Girls Clubs Connections

Hanover Presbyterian Church

Wilmington City Council

Las Americas Aspira Academy

Wilmington Library

Latin American Community Center

Wilmington Mayor's Office

Corner2Corner

Life Health Center

Cornerstone West CDC

Nemours Children's Health System

Wilmington Parks and Recreation Wilmington Police Department, Victim Services

DE Community Legal Aid Society

New Castle County Police Department YMCA of Delaware

Delaware Academy of Medicine Delaware Breast Cancer Coalition

Newark Police Department (Victims Services Coordinator) Open Arms Adoption

99