Download Mercy San Juan Medical Center

Mercy San Juan Medical Center
2013 Community Health Needs Assessment
2013 Community Benefit Implementation Plan
Table of Contents
I. 2013 Mercy San Juan Medical Center (MSJMC) Community Health Needs
Assessment Summary: An assessment of the Hospital’s Service Area in
Sacramento County conducted jointly by Mercy San Juan Medical Center,
Valley Vision and Community Stakeholders
Description of the Community Served by the Hospital
The Assessment Team
How the Assessment was Conducted
Health Needs Identified
Community Assets Identified
II.
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5
6
10
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Mercy San Juan Medical Center of Sacramento Implementation Strategy and
Community Benefit Plan Summary
Summary
Target Areas and Population
How the Implementation Strategy Was Developed
Major Needs and How Priorities Were Established
Description of What Mercy San Juan Medical Center
Will Do to Address Community Needs
Action Plans
Next Steps for Priorities
Priority Needs Not Being Addressed and the Reasons
Approval
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25
27
27
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34
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Appendices
Appendix A: List of Key Informants for Mercy San Juan Medical Center CHNA
Appendix B: Health Assets Table for Mercy San Juan Medical Center Service Area
Attachment: 2013 Mercy San Juan Medical Center Community Needs Assessment
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2013 Mercy San Juan Medical Center
Community Health Needs Assessment Summary:
An Assessment of the Hospital’s Service Area in Sacramento County conducted jointly by
Mercy San Juan Medical Center, Valley Vision and Community Stakeholders
Beginning in early 2012 through February 2013 an assessment of the health needs of residents
living in the service area of Mercy San Juan Medical Center, a member of Dignity Health, was
completed by the Hospital, Valley Vision, Inc., and community stakeholders. Mercy San Juan
Medical Center is located in the northern Sacramento County suburbs, serving major
communities that include Citrus Heights, Fair Oaks, North Highlands, Carmichael, Antelope,
Roseville, and other neighboring cities.
Description of Community Served by the Hospital
Defining the Hospital Service Area (HSA). Mercy San Juan Medical Center’s HSA was
determined by analyzing patient discharge data. Dignity Health defines communities as
geographic areas served by its hospitals, which are considered primary service area. The HSA is
based on a percentage of hospital discharges and is also used in various other departments of the
system and hospital, including strategy and planning. The HSA is depicted in the map below:
Map of Mercy San Juan Medical Center service area
3
Description of the Community. The Sacramento community faces an unprecedented lack of
access to safety net health services. The region’s safety net is characterized by a “fragmented
group of small and financially fragile health centers that together offer limited outpatient
capacity.” 1 A recent market analysis commissioned by Sierra Health Foundation in Sacramento
identified critical issues impacting the region’s safety net performance and sustainability,
including:
1. The primary care capacity of community health centers and emergency departments to
treat the safety net population has grown, but without further efforts will likely reach
capacity prior to 2016.
2. Currently, the safety net is overly dependent on expensive hospitals, and emergency
departments (EDs), in particular, to provide outpatient care.
3. The number of community health centers in the Sacramento region has grown over the
past few years, but falls significantly short of many other similar-sized regions in
California.
4. Roughly half of the region’s community health centers are financially challenged.
Expenses consistently exceed revenues.
5. The region continues to struggle to respond to unmet needs for physical and mental
health care for its underserved residents who are reflecting a growing level of chronic
disease, including asthma, diabetes and high blood pressure, and are more at risk due to
factors that include obesity and smoking. 2
With Health Reform quickly approaching in 2014, it is imperative that the Sacramento region
step up efforts to address the many vulnerabilities and inadequacies of its safety net, while
building on its strengths.
Community Demographics Mercy San Juan Medical Center’s community is expansive and
comprised of 22 zip codes. Demographics for the community served by the hospital are as
follows:
•
Population: 852,218
o Under 18 = 25.3%
o 18-34 = 23.8%
o 35-64 = 38.6%
o 65+ = 12.4%
1
California Healthcare Foundation, Sacramento Powerful Health Systems Dominate a Stable Market.
http://www.chcf.org/publications/2009/07/sacramento-powerful-hospital-systems-dominate-a-stablemarket#ixzz1t5kNz6tN
2
Sierra Health Foundation Regional Health Care Partnership Market Analysis, January 2012.
4
•
•
•
•
•
•
Diversity:
o Caucasian: 62.9%
o Hispanic: 18.1%
o Asian: 8.3%
o African American: 6%
o American Indian/Alaska Native & Other: 4.8%
Average Income: $71,938
Uninsured: 18.68%
Unemployment: 6.9%
No High School Diploma: 11.3%
Medicaid Patients: 16.24%
The Assessment Team
The Community Health Needs Assessment (CHNA) was conducted through a participatory team
process led by community benefit staff of Mercy San Juan Medical Center, and Valley Vision,
Inc., a community service organization dedicated to improving quality of life in the greater
Sierra, Sacramento, and San Joaquin regions. Valley Vision (www.valleyvision.org) is a nonprofit 501(c)(3) research and consulting firm serving a broad range of communities across
Northern California. The organization’s mission is to improve quality of life through the delivery
of high-quality research on important topics such as healthcare, economic development, and
sustainable environmental practices. Using a community-based participatory orientation to
research, Valley Vision has conducted multiple CHNAs across an array of communities for over
seven years.
A team of experts from multiple sectors within the Hospital’s service area was assembled to
conduct the assessment, including: 1) a local public health expert with over a decade of
experience in conducting CHNAs; 2) a geographer with expertise in using GIS technology to
map health-related characteristics of populations across large geographic areas, and 3) local
public health practitioners and consultants to collect and analyze data.
Community-Based Participatory Research Approach. The assessment followed a
community-based participatory research approach for identification and verification of results at
every stage of the assessment. This orientation built capacity and enabled beneficial change
within the Hospital CHNA workgroup, and the community members for which the assessment
was conducted. Including participants in the process allowed for a deeper understanding of the
results.
CHNA Workgroup. The CHNA workgroup, comprised of Hospital community benefit
representatives, other health systems, and Sierra Health Foundation, was an active contributor to
the CHNA process. Using the community-based participatory research approach, monthly
meetings were held with the workgroup at each critical stage in the assessment process. In
addition, data was collected from over 70 attendees at multiple Healthy Sacramento Coalition
meetings over a nine-month period, allowing for identification of potential data sources, key
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informants, and focus groups. This data, combined with demographical data, informed the
location and selection of key informants that participated in the assessment. Key informants
included health and community experts such as the Sacramento County Public Health Officer,
the Sacramento City Unified School District Chief Family and Community Engagement Center
Officer, and physicians and leaders of community health and social service organizations.
How the Assessment was Conducted
“Health Need” and Objectives of the Assessment. The CHNA was anchored and
guided by the following objective:
In order to provide necessary information for the Mercy San Juan Medical Center
community health improvement plan, identify communities and specific groups within
these communities experiencing health disparities, especially as these disparities relate
to chronic disease, and further identify contributing factors that create both barriers and
opportunities for these populations to live healthier lives.
The World Health Organization defines health needs as “objectively determined deficiencies in
health that require health care, from promotion to palliation.” Building from this, the CHNA
used the following definitions for health need and driver:
Health Need: A poor health outcome and its associated driver.
Health Driver: A behavioral, environmental, and/or clinical factor, as well as more
upstream social economic factors that impact health
Methodology. The assessment used a mixed methods data collection approach that
included primary data such as key informant interviews, community focus groups, and a
community assets assessment. Secondary data included health outcomes, demographic data,
behavioral data, and environmental data.
Unit of Analysis and Study Area. The study area of the assessment included Mercy San
Juan Medical Center’s service area. A key focus was to show specific communities (defined
geographically) experiencing disparities as they related to chronic disease and mental health. To
this end, zip code boundaries were selected as the unit-of-analysis for most indicators. This level
of analysis allowed for examination of health outcomes at the community level that are often
hidden when data are aggregated at the county level. Some indicators (demographic, behavioral,
and environmental in nature) were included in the assessment at the census tract, census block,
or point prevalence level, which allowed for deeper community level examination.
Selection of Data Criteria. Criteria were established to help identify and determine all
data to be included for the study. Data were included only if they met the following standards:
•
All data were to be sourced from credible and reputable sources
6
•
•
Data must be consistently collected and organized in the same way to allow for future
trending
Data must be available at the zip code level or smaller
County, state, and Healthy People 2020 targets (when available) were used as benchmarks to
determine severity. All rates are reported per 10,000 of population. Health outcome indicator
data were adjusted using Empirical Bayes Smoothing, where possible, to increase the stability of
estimates by reducing the impact of the small number problem. To provide relative comparison
across zip codes, rates of Emergency Department (ED) visits and hospitalization for heart
disease, diabetes, hypertension, and stroke were age adjusted to reduce the influence of age.
Primary Data - The Community Voice. Primary data collection included qualitative
data gathered in four ways:
•
•
•
•
Input from the Dignity Health community benefit team
Key informant interviews with area health and community experts
Focus groups with area community members
Community health asset collection via phone interviews and website analyses
Key Informants. Key informants are health and community experts familiar with
populations and geographic areas residing within the Mercy San Juan Medical Center’s service
area. To gain a deeper understanding of the health issues pertaining to chronic disease and
populations living in more vulnerable communities, thirty-one key informants participated in the
CHNA process. Interviews were conducted with these informants using a theoretically grounded
interview guide. Each interview was recorded and content analysis was conducted to identify key
themes and important points pertaining to each HSA geographic area. Findings from these
interviews were also used to help identify communities most appropriate for focus groups. (See
Appendix A for a list of key informants, including professional title, and description of their
knowledge and expertise).
Focus Groups. Members of the community representing subgroups, defined as groups
with unique attributes (race and ethnicity, age, sex, culture, lifestyle, or residents of a particular
area of the HSA), were recruited to participate in a focus group. A standard protocol was used
for the focus group to understand the experiences of these community members as they relate to
health disparities and chronic disease. In all, a total of six focus groups were conducted. Content
analysis was performed on the focus group interview notes to identify salient health issues
affecting these community residents.
Secondary Quantitative Data. Secondary quantitative data used in the assessment are
listed in Tables 1 and 2.
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Table 1: Health outcome data used in the CHNA reported as ED visits, hospitalization, and
mortality
ED and Hospitalization
Mortality
Accidents
Hypertension*
All-Cause Mortality*
Infant Mortality
Asthma
Mental Health
Alzheimer’s Disease
Injuries
Assault
Substance Abuse
Cancer
Life Expectancy
Chronic Lower
Cancer
Stroke*
Liver Disease
Respiratory Disease
Chronic Obstructive
Unintentional Injuries
Diabetes
Renal Disease
Pulmonary Disease
Self-inflicted injury
Diabetes*
Heart Disease
Stroke
Heart Disease*
Hypertension
*Age adjusted by 2010 California standard population
Suicide
Table 2: Socio-demographic, behavioral, and environmental data profiles used in the CHNA
Socio-Demographic
Total Population
Limited English Proficiency
Family Make-up
Percent Uninsured
Poverty Level
Percent over 25 with No Nigh School Diploma
Age
Percent Unemployed
Race/Ethnicity
Percent Renting
Behavioral and Environmental Profiles
Safety Profile
Food Environment Profile
• Major Crime
• Percent Obese/Percent Overweight
• Assault
• Fruit and Vegetable Consumption
• Unintentional Injury
(≥5/day)
• Fatal Traffic Accidents
• Farmers Markets
• Accidents
• Food Deserts
• Modified Retail Food Environment
Index (mRFEI)
Active Living Profile
Physical Wellbeing Profile
• Park Access
• Age-adjusted Overall Mortality
• Life Expectancy
• Infant Mortality
• Health Care Professional Shortage Areas
• Health Assets
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Data Analysis - Identifying Vulnerable Communities. The first step in the process was
to examine socio-demographics in order to identify areas of the HSA with high vulnerability to
chronic disease disparities and poor mental health outcomes. Race/ethnicity, household make-up,
income, and age variables were combined into a vulnerability index that described the level of
vulnerability of each census tract. This index was then mapped for the entire HSA. A tract was
considered more vulnerable, or more likely to have higher unwanted health outcomes than
others, in the HSA if it had higher: 1) percent Hispanic or non-White population; 2) percent
single parent headed households; 3) percent below 125% of the poverty level; 4) percent under
five years old; and 5) percent 65 years of age or older living in the census tract. This information
was used in combination with input from the CHNA workgroup to identify prioritized areas for
which key informants would be sought. The vulnerability index for the HSA is shown below.
Mercy San Juan Medical Center service area map of vulnerability
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Where to Focus Community Member Input? Focus Group Selection. The selection
for the focus group was determined by feedback from key informants and analysis of health
outcome indicators (ED visits, hospitalization, and mortality rates). Key informants were asked
to identify populations that were most at risk for chronic health disparities and mental health
issues. In addition, analysis of health outcome indicators by zip code, race and ethnicity, age, and
sex, revealed communities with high rates that exceeded established benchmarks of the state and
county, as well as Healthy People 2020 targets. This information was compiled to determine the
location of focus groups within the HSA.
Identifying “Communities of Concern”: the First step in Prioritizing Area Health
Needs. To identify Communities of Concern, primary data from key informant interviews,
detailed analysis of secondary data, health outcome indicators, and socio-demographics were
examined. Zip code communities with rates that exceeded county, state, or Healthy People 2020
benchmarks for ED utilization, hospitalization, or mortality were considered. Zip codes with
rates that fell in the top 20% were noted and then triangulated with primary data and sociodemographic data to identify specific Communities of Concern.
What is the Health Profile for Communities of Concern? What are the Prioritized
Health Needs of the Area? Data on socio-demographics of residents living in these
communities, which included socio-economic status, race and ethnicity, educational attainment,
housing status, employment status, and health insurance status, were examined. Area health
needs were determined via in depth analysis of qualitative and quantitative data, and then
confirmed by socio-demographic data. As noted earlier, a health need was defined as a poor
health outcome and its associated driver. A health need was included as a priority if it was
represented by rates worse than the established quantitative benchmarks or was consistently
mentioned in the qualitative data.
Health Needs Identified
Analysis of data revealed five Communities of Concern listed in Table 3.
Table 3: Identified Communities of Concern for Mercy San Juan Medical Center Service Area
Zip
Community Name
County
2010 Population*
95660
North Highlands
Sacramento
30,714
95673
Rio Linda
Sacramento
15,455
S. Del Paso Heights, Arden
95815
Arcade, N. Sacramento Areas
Sacramento
24,680
95821
North Watt, Marconi Area
Sacramento
33,550
95838
Dell Paso Heights Area
Sacramento
36,764
95841
Foothill Farms Area
Sacramento
19,448
Total Population in Communities of Concern
160,611
(*Source: 2010 Census data)
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The six Communities of Concern in Mercy San Juan Medical Center’s service area are home to
more than 160,000 residents. The Communities of Concern consist of zip codes that include the
areas of North Highlands, Rio Linda, North Sacramento, North Arden Arcade, Del Paso
Heights/Robla, and the Interstate 80 corridor southeast of North Highlands and Foothill Farms.
While much of the Communities of Concern are urban areas, other areas such as Rio Linda are
fairly rural.
Socio-demographic Profile of Communities of Concern. Socio-demographic
conditions, commonly referred to as social determinants of health, help predict which
communities in a broad geographic area are most susceptible to poor health outcomes. Table 5
below describes the socio-demographic profile of each Community of Concern for Mercy San
Juan Medical Center’s service area.
% No health
insurance
% Residents
Renting
95660
7.5
51.1
8.0
26.6
43.3
25.2
95673
7.4
14.7
28.4
2.2
32.5
19.3
95815
68.3
11.5
36.7
51.7
36.2
13.1
95821
6.2
13.5
38.9
6.5
22.8
39.5
95838
74.8
11.7
29.8
43.7
30.2
9.1
95841
7.5
34.8
6.3
24.6
37.5
14.9
National
8.7
15.1
31.2
12.9
-8.7
State
---19.4
--(Source: Dignity Health Community Benefit, CNI data, 2011)
% Unemployed
% pop over age 5
with limited Eng
% Non-White
Hispanic
% over 25 with no
high school
diploma
% Families in
poverty female
headed
% Families in
poverty w/ kids
% Households in
poverty over 65
headed
Table 4: Socio-demographic characteristics for HSA Communities of Concern compared to
national and state benchmarks
17.4
14.2
18.0
13.0
14.9
10.0
7.9
9.8
30.1
18.8
43.8
31.7
33.5
30.5
16.3
21.6
43.0
27.7
63.8
55.6
48.6
61.8
---
As noted earlier, these six zip codes are home to over 160,000 residents. Data indicated that
these areas of the HSA were highly diverse, with a large number of areas with high rates of
poverty, low educational attainment, high unemployment, high un-insurance rates, and a high
number of residents renting their homes. Three of the six zip codes had over 50% of residents
reporting to be either non-White or Hispanic. Within the Communities of Concern, zip code
95815 had the highest percent of residents over the age of five with limited English proficiency
at 13.1%.
All six zip codes had a higher percent of single female-headed households living in poverty than
the national average of 31.2%. Two of the six Communities of Concern, 95815 and 95838, had a
higher percent of residents over age 65 years living in poverty compared to the national
benchmark of 9%. All but one of the six zip codes had a percent of families with children living
in poverty higher than the national average of 15%, with the percent in 95815 being more than
double this national average.
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All zip code Communities of Concern had a higher percent of residents over the age of 25 years
without a high school diploma compared to the national average, with the highest being 36.2 %
in 95815. Three of the zip codes had a higher unemployment rate of 9.8% when compared to the
state. All of the zip codes had a higher percent of uninsured residents (16.3%) compared to the
national rate, with two zip codes having rates more than twice the national benchmark. Looking
at the percentage of residents in a zip code who rent versus own their place of residence provides
insight into a community’s health and financial stability. The percent of residents who rent in the
six HSA Communities of Concern all exceeded the national average, ranging from 27.7% in
95673 to 63.8% in 95815.
Priority Health Needs for Mercy San Juan Medical Center. The top health needs
identified through the analysis of both quantitative and qualitative data are listed below. All
needs are noted as a “health driver,” or a condition or situation that contributed to a poor health
outcome. Health outcome results follow the list below:
•
•
•
•
•
•
•
•
•
•
Access to primary care and preventative services
Access to mental health and substance abuse services
Access to specialty care
Access to affordable fresh fruits and vegetables
Safe places to be active
Improved transportation services
Education on health, wellness, and nutrition
Cultural competence in providers
Basic needs including adequate shelter and food
Access to dental care
Health Outcomes - Diabetes, Heart Disease, Stroke, and Hypertension. Diabetes,
heart disease, stroke, and hypertension were consistently mentioned in the qualitative data as
conditions affecting many area residents. Examination of morality rates, as well as ED visits and
hospitalization showed rates in these zip codes were drastically higher than the established
benchmarks. Bolded rates are those that were worse than the county, state, or Healthy People
2020 benchmark.
Table 5: Mortality, ED visit, and hospitalization rates for diabetes compared to county, state, and
Healthy People 2020 benchmarks (rates per 10,000 population)
Diabetes
Zip Code
95660
95673
95815
95821
95838
95841
Sacramento County
CA State
Healthy People 2020
Mortality
1.9
1.6
2.4
2.9
2.1
2.0
1.8
1.8
6.6
ED Visits
389.8
274.6
422.1
293.7
420.9
330.4
257.4
188.4
--
Hospitalization
276.7
243.4
296.5
196.5
345.9
243.4
198.8
190.9
--
(Sources: Mortality: CDPH, 2010; ED Visits and hospitalization: OSHPD, 2011)
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All but one zip code had rates of ED visits and hospitalization for diabetes that were higher than
both the county and state benchmarks, with three zip codes having rates of ED visits for diabetes
two times greater than the state benchmark. An examination of diabetes rates by zip code and
race and ethnicity revealed that Blacks consistently had ED visit and hospitalization rates due to
diabetes that were drastically higher than any other population group. Whites had the second
highest rates of diabetes-related ED visits and hospitalization. For example, zip code 95821 had a
rate of ED visits due to diabetes that was 914.1 per 10,000 in Blacks and 298.7 per 10,000 in
Whites.
Diabetes was the most frequently discussed health condition among key informant interviews
and focus groups. Participants described difficulties in obtaining regular checkups, the high cost
of medications and equipment, and a lack of available diabetes education and support services.
Table 6: Mortality, ED visit, and hospitalization rates for heart disease compared to county, state,
and Healthy People 2020 benchmarks (rates per 10,000 population)
Zip Code
Mortality
ED Visits
Hospitalization
15.6
95660
212.8
292.3
21.4
95673
186.6
331.8
21.8
95815
185.5
341.0
26.4
95821
164.7
222.7
Heart Disease
16.5
95838
198.7
352.0
15.9
95841
157.8
282.6
Sacramento County
12.4
236.6
152.6
CA State
11.5
93.1
218.4
Healthy People 2020
10.1
--(Sources: Mortality, CDPH 2010; ED visits and hospitalization, OSHPD, 2011)
All six zip codes had mortality rates due to heart disease that exceeded the Healthy People 2020
benchmark, as well as county and state benchmarks. Zip code 95821 had the highest rate, with
26.4 deaths per 10,000. All zip codes had rates of ED visits for heart disease that were higher
than county and state benchmarks, and five of the six zip codes had rates of hospitalization due
to heart disease that surpassed county and state benchmarks. In looking at rates of ED visits and
hospitalization due to heart disease, Blacks and Whites had the highest rates, with rates in Blacks
slightly higher than those in Whites. Key informants and focus group participants frequently
cited heart disease as a common health problem within the community.
13
Table 7: Mortality, ED visit, and hospitalization rates for stroke compared to county, state, and
Healthy People 2020 benchmarks (rates per 10,000 population)
Zip Code
Mortality
ED Visits
Hospitalization
95660
4.1
32.5
69.1
95673
2.7
20.4
68.9
95815
4.4
30.5
86.5
95821
51.0
6.0
30.6
Stroke
95838
4.8
23.2
79.4
95841
4.9
22.5
66.5
Sacramento County
3.9
26.7
59.3
CA State
3.5
16.2
51.8
Healthy People 2020
3.4
--(Sources: Mortality, CDPH 2010; ED visits and hospitalization, OSHPD, 2011)
All but one zip code had mortality rates due to stroke that were above the Healthy People 2020
target, as well as county and state benchmarks. All six zip codes had rates of heart diseaserelated ED visits that were above the state benchmark, with zip codes 95660, 95815, and 95821
having rates approximately twice the state benchmark. Five of the six zip codes had rates of
hospitalization for heart disease that were above the state benchmark. An examination of ED
visits and hospitalization by race and ethnicity revealed that Blacks had the highest rates,
followed by Whites.
Table 8: ED visit and hospitalization rates for hypertension in compared to county and
state benchmarks (rates per 10,000 population)
Zip Code
ED Visits
Hospitalization
95660
721.2
514.1
95673
532.4
512.3
95815
705.7
560.0
95821
367.2
587.5
Hypertension
95838
697.1
562.6
95841
638.9
490.6
Sacramento County
513.9
395.2
CA State
365.6
380.9
(Sources: ED visits and hospitalization, OSHPD, 2011; Population, US Census Bureau, 2010)
All six Communities of Concern had rates of hypertension-related ED visits substantially above
county and state benchmarks, with 95660 having the highest rate, with 721.2 per 10,000. Five of
the six zip codes had rates of hospitalization for hypertension that exceeded county and state
benchmarks. Looking at subgroup rates, ED visits due to hypertension were highest in the Black
population, followed by Whites. As an example, the rate for hypertension-related ED visits for
Blacks in 95660 was 1444.5 per 10,000; nearly four times the state rate. When examining rates
of hospitalization for hypertension, rates for Blacks and Whites were similar, with rates for
Blacks being slightly higher. Hypertension was frequently discussed in key informant interviews
and focus groups.
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Mental Health, Substance Abuse and Self-Inflicted Injury. Area experts and
community members consistently reported the immense struggle HSA residents had in
maintaining positive mental health and accessing treatment for mental illness. Such struggles
ranged from the stress brought on by personal and financial pressures to the management of
severe mental illness. Table 9 provides data on ED visits and hospitalization related to mental
illness.
Table 9: ED visit and hospitalization rates for mental health compared to county and state
benchmarks (rates per 10,000 population)
Zip Code
ED Visits
Hospitalization
95660
300.6
275.5
95673
217.2
261.1
95815
268.1
304.8
Mental Health
95821
352.1
313.0
95838
206.9
232.2
95841
316.2
320.8
Sacramento County
229.0
218.3
CA State
130.9
182.1
(Sources: ED visits and hospitalization, OSHPD, 2011)
All Communities of Concern had rates of ED visits and hospitalization due to mental health
clearly above the county and state benchmarks. Four of the six zip codes had rates between two
and three times the state benchmark for ED related visits. In examining subgroup data, Blacks
and Whites had relatively similar rates for ED visits and hospitalization related to mental health.
Key informants and focus group participants frequently cited mental health issues as being
widespread within the community. Depression and anxiety were most commonly discussed
mental health issues, but bipolar disorder, schizophrenia, and post-traumatic stress disorder were
also mentioned. Adding to the challenge of dealing with mental illness, key informants and focus
groups stressed the challenges associated with obtaining mental health care in an area lacking
adequate mental health resources. One key informant explained, “We are inundated with people
because the follow-up, getting their meds, you know their regular maintenance has been
removed because of closure of [mental health] clinics” (KI_Sacramento_15). Additionally,
health experts and community members emphasized the large number of individuals who do not
seek treatment for mental health conditions due to a variety of reasons, including lack of
insurance coverage and societal and cultural stigmas surrounding mental illness.
As Table 10 shows, rates of substance abuse-related ED visits and hospitalization were
substantially elevated in the Communities of Concern. All six zip codes had rates of ED visits for
substance abuse that twice exceeded the county benchmark, with zip code 95815 having a rate
over 3.5 times the state rate. All six zip codes had rates of hospitalization for substance abuse
that exceeded the county rate and state benchmarks. Blacks had the highest rates of ED visits and
hospitalization for substance abuse, followed by Whites. In zip code 95815, the rate of ED visits
for substance abuse in Blacks was 1601.5 per 10,000 and in Whites 1526.3 per 10,000,
approximately seven times the state benchmark.
15
Key informants and focus groups commonly reported that substance abuse is a major issue
within the community. Alcohol abuse, illicit drug use, and prescription drug addiction were all
cited as major issues. Key informants and focus group participants discussed the lack of
available substance abuse treatment and support services.
Table 10: ED visit and hospitalization due to substance abuse compared to county and
state benchmarks (rates per 10,000 population)
Zip Code
ED Visits
Hospitalization
95660
586.5
329.4
95673
496.8
273.1
95815
898.3
404.4
Mental Health95821
Substance
651.3
285.8
Abuse
95838
573.2
268.2
95841
561.8
312.7
Sacramento County
406.3
192.3
CA State
232.0
143.8
(Sources: ED visits and hospitalization, OSHPD, 2011)
In addition to mental health issues, suicide was discussed in several key informant interviews
and focus groups. Many key informants and focus groups described the recent economic
downturn, job loss, housing and food insecurity, and lack of medical coverage as factors that
could negatively affect mental health and lead to the problems of suicide and self-injury. A lack
of accessible resources for mental health and substance abuse was also cited as possibly
contributing to suicide and self-injury. One key informant stated, “Once they start cutting back
on the beds and the clinics, in particular these people are out on the streets, but added to that is
the economy and so we are getting a lot of suicide attempts because people have lost their jobs”
(KI_Sacramento_15).
Table 11: Mortality due to suicide and ED visits and hospitalization due to self-inflicted injury
compared to county and state benchmarks (rates per 10,000 population)
Mortality
Zip Code
ED Visits
Hospitalization
95660
1.3
13.1
8.0
95673
1.3
12.6
6.3
Suicide and
95815
1.1
18.4
8.9
Self-Inflicted
95821
1.4
12.6
5.2
Injuries
95838
0.9
9.1
4.6
95841
1.5
25.2
8.0
Sacramento County
1.2
12.0
5.0
CA State
1.0
7.9
4.3
(Sources: Mortality, CDPH 2010; ED visits and hospitalization, OSHPD, 2011)
As Table 11 demonstrates, five of the six zip codes had a rate of ED visits due to self-injury that
exceeded the state benchmark, with the rate in 95841 exceeding this benchmark by over three
times. All six Communities of Concern had rates of hospitalization for self-injury that surpassed
the state and county benchmarks.
16
Respiratory Illness: Chronic Obstructive Pulmonary Disease and Asthma. In an
effort to understand the impact of tobacco and respiratory illness in the HSA, rates of ED visits
and hospitalization related to chronic obstructive pulmonary disease (COPD), asthma, and
bronchitis were examined and are displayed in Table 12. Rates of ED visits and hospitalization
due specifically to asthma are displayed independently in Table 13.
Table 12: ED visit and hospitalization rates for COPD, asthma, and bronchitis compared
to county and state benchmarks (rates per 10,000 population)
Zip Code
ED Visits
Hospitalization
95660
541.0
295.8
95673
378.4
275.2
95815
527.1
289.7
COPD, Asthma,
95821
480.6
256.6
and Bronchitis
95838
410.3
245.1
95841
484.1
269.2
Sacramento County
318.1
195.3
CA State
202.3
156.8
(Sources: ED visits and hospitalization, OSHPD, 2011)
All Communities of Concern had rates of ED visits for COPD that were substantially above the
county and state benchmarks. Five of the six zip codes had rates of ED visits for COPD more
than twice the state benchmark. Blacks had the highest rates of ED visits for COPD. For
instance, the rate of ED visits due to COPD for Blacks in zip code 95821 was 1313.1 visits per
10,000, 6.5 times the state benchmark. However, when examining hospitalization rates for
COPD, Blacks and Whites had relatively similar rates.
Several key informant interviews and focus groups mentioned COPD as a major health issue
within the community.
Table 13: ED visit and hospitalization rates due to asthma compared to county and state
benchmarks (rates per 10,000 population)
Zip Code
ED Visits
Hospitalization
95660
357.5
139.0
95673
236.3
126.8
95815
341.3
130.7
Asthma
95821
314.4
133.3
95838
270.6
123.3
95841
323.8
130.4
Sacramento County
214.9
100.8
CA State
134.9
70.4
(Sources: ED visits and hospitalization, OSHPD, 2011)
In all Communities of Concern, ED visits and hospitalization rates for asthma exceeded county
and state benchmarks. Five of the six zip code communities had rates of ED visits for asthma that
were more than twice the state benchmark. Looking at subgroup rates, Blacks had asthma-related
rates of ED visits that were substantially higher than Whites. This difference between rates was
17
less pronounced in the subgroup rates for hospitalization due to asthma. Asthma was described
as a widespread issue within the community, both in children and adults.
Several key informants and focus groups used asthma as an example to describe how challenging
it is to manage a chronic medical condition when it can be difficult to be seen by a primary
physician and to afford the necessary medications.
Behavioral and Environmental - Safety Profile. Local experts and community
members stressed the impact of safety on the health of the area residents living in the various
Communities of Concern. Examination of safety indicators included looking at local law
enforcement data for the greater Sacramento region as reported by Sacramento Police
Department and the Sacramento County Sheriff’s Department. In addition, outcome safety
indicators of ED visits and hospitalization due to assault and unintentional injury were examined.
Crime Rates. The following map shows major crimes by municipality as reported by
various jurisdictions. Darker colored areas denote higher rates of major crime, including
homicide, forcible rape, robbery, aggravated assault, burglary, motor vehicle theft, larceny, and
arson.
Major crimes by municipality as reported by the
California Attorney General’s Office, 2010
18
Zip codes 95815 and 95838 are located in the City of Sacramento, which has a major crimes rate
of 525.5 crimes per 10,000 residents. Many key informant interviews and focus groups discussed
crime as a key problem within the Communities of Concern.
Community members mentioned crime as a deterrent to utilizing parks and exercising outdoors.
Key informants and focus group participants also discussed the effects of crime on mental health
and wellbeing, expressing concern over violence witnessed by children, the potential for posttraumatic stress disorder, and noting that some area residents are hesitant to leave their houses.
One key informant explained, “because of the economy [...] there’s more violent crimes, people
are turning to crime to make ends meet and you know, two years ago we hardly ever got gang
activity coming in. [...] We have a lot of that now. [...] probably everyday there’s either a
stabbing or a shooting” (KI_Sacramento_15).
Assault and Unintentional Injury. All except one Community of Concern had rates of
ED visits and hospitalization for assault that exceeded county and state benchmarks. In
particular, zip code 95815 had the highest rates, with ED visits for assault more than double the
state benchmark and a rate of hospitalization for assault more than triple the state benchmark. As
explained in the crime section above, multiple key informants and focus group participants
perceived their neighborhoods to be unsafe.
Table 14: ED visit and hospitalization rates for assault compared to county and state
benchmarks (rates per 10,000 population)
Zip Code
ED Visits
Hospitalization
95660
52.0
7.5
95673
3.9
32.2
95815
80.2
13.7
Assault
95821
50.6
6.7
95838
54.0
9.7
95841
52.3
10.5
Sacramento County
36.8
5.7
CA State
29.4
3.9
(Sources: ED visits and hospitalization, OSHPD, 2011; Population, US Census Bureau, 2010)
Unintentional Injury. Unintentional injuries are the fifth leading cause of death in the
nation and the first leading cause of death in those under the age of 35. Five of the six zip codes
exceeded the county mortality rate for unintentional injury, with the rate in zip code 95660 at 6.4
deaths per 10,000, more than twice the state benchmark. All six zip codes had rates of ED visits
and hospitalization for unintentional injury that clearly surpassed the county and state
benchmarks.
19
Table 15: Mortality, ED visit, and hospitalization rates for unintentional injury compared to
county and state benchmarks (rates per 10,000 population)
ED Visits
Hospitalization
Mortality
95660
6.4
993.0
223.1
95673
3.7
867.2
242.7
95815
4.7
1110.3
228.5
Unintentional
95821
3.6
901.9
208.1
Injury
4.2
95838
873.5
180.8
3.2
95841
920.2
222.3
3.4
Sacramento County
728.2
174.3
CA State
2.7
651.8
154.6
Healthy People 2020
3.4
--(Sources: Mortality, CDPH 2010; ED visits and hospitalization, OSHPD, 2011)
Zip Code
Fatality/Traffic Accidents. The following map examines 2010 fatal traffic accidents and
Table 16 examines bicycle accidents and accidents involving an automobile versus a bicycle or
pedestrian. Locations of traffic accidents resulting in a fatality are noted only for the Mercy San
Juan HSA, and accidents that occurred beyond the HSA boundaries are not shown. Accidents
resulting in a fatality, especially those on city streets, contribute to residents’ perception of safety
when traveling through the community, especially for area residents who rely on public,
pedestrian, or bicycle travel.
Fatal Traffic accidents resulting in fatalities as reported by the National
Highway Transportation Safety Administration, 2010
20
Table 16: ED visit and hospitalization rates for accidents compared to county and state
benchmarks (rates per 10,000 population)
Zip Code
ED Visits
Hospitalization
95660
24.3
2.8
95673
19.4
2.9
95815
35.7
3.4
95821
Accidents
23.2
3.2
95838
21.3
2.9
95841
1.2
18.6
Sacramento County
17.4
2.8
CA State
15.6
2.0
(Sources: Mortality, CDPH 2010; ED visits and hospitalization, OSHPD, 2011)
When excluding accidents occurring on major highways, there were fatal accidents in five of the
six zip code Communities of Concern in the year 2010. Examination of rates of ED visits related
to bicycle accidents and accidents involving an automobile versus a bicycle or pedestrian
demonstrated that all zip codes had rates that exceeded the county and state benchmarks, with zip
code 95815 having a rate more than double the state benchmark. Five of the six zip codes had
rates of hospitalization related to bicycle accidents and accidents involving an automobile versus
a bicycle or pedestrian that surpassed the state benchmark.
Several key informants and focus group participants discussed their perceptions of the area
roadways, with one stating, “The children can’t ride their bikes because it is not safe. That was
another comment that was made from one of my patients. She moved, actually, from the area
because she said her 10-year old wanted to ride his bike to school. But there had been too many
vehicle to pedestrian accidents that she couldn’t let him ride” (KI_Sacramento_7). This key
informant brought up yet another safety concern among area residents, stating, “where are they
going to exercise? I mean they’ve got stray dogs running around, they’ve really got no place to
go when they are in the inner city” (KI_Sacramento_7). Yet, many residents are forced to walk
or bike, with the same key informant noting, “I had a gentleman that walked from North
Sacramento to where our clinic is in Oak Park [...] And that was his only way to get there was to
walk” (KI_Sacramento_7). She explained that, “Even though we bus access, a lot of our families
can’t afford bus tickets” (KI_Sacramento_7).
Food Environment. An examination of the food environment in the Communities of
Concern showed that approximately 24% of residents in each zip code are obese and
approximately 29% of residents are overweight. In all six zip codes, more than 50% of residents
reported not eating at least five servings of fruits or vegetables daily (5-a-day) as recommended
by the state. Five of the six zip codes have federally designated food desert tracts located within
their boundaries. Such tracts are designated by the federal government as census tracts in which
at least 500 people and/or 33% of the population have low access to “healthy food.” Only one of
the six zip codes, 95838, had a farmers market located within the zip code boundary.
21
Table 17: Percent obese, percent overweight, percent not eating at least five fruits and vegetables
daily, presence (x) or absence (-) of federally defined food deserts, and number of farmers’
markets
%
%
% no
Food Farmers
Zip Code
Obese Overweight
5-a-day
Desert Markets
95660
28.9
55.6
x
0
25.2
95673
21.7
31.5
55.5
x
0
95815
29.9
55.1
x
0
26.2
Food
95821
29.8
54.4
x
0
25.4
Environment
95838
24.1
28.2
56.9
x
1
95841
24.4
28.9
54.9
0
-----Sacramento County
CA State
24.8
----[Sources: % Obese & overweight, fruit & vegetable consumption: Healthy City
(www.healthycity.org), 2003-2005; Food deserts: Kaiser Permanente CHNA Data Platform/US
Dept. of Agriculture, 2011; Farmers markets: California Federation of Certified Farmers
Markets, 2012]
Retail food. The data displayed below provides information about the availability of
health foods in the HSA. The map shows the modified Retail Food Environment Index (mRFEI),
which is the proportion of healthy food outlets to all available food outlets by census tract.
Lighter areas indicate greater access to health foods and the darkest areas indicate no access to
health foods.
Modified Retail Food Environment Index (mRFEI) by census tracts, 2011
22
The above data indicated that the Mercy San Juan Medical Center HSA Communities of Concern
had a very mixed retail food environment. While some areas had high or good access to healthy
foods, others areas had fair to poor access and portions of 95660 and 95841 contain areas with
census tracts characterized as having no access to healthy foods.
These findings were confirmed by the qualitative data. Many area residents reported that they
have difficulty obtaining fresh foods for reasons including lack of nearby grocery stores, cost,
and poor quality of available produce. One focus group participant stated, “We got all the liquor
stores you want. We don’t have any grocery stores. We have got fast food restaurants up and
down the street. We don’t have a grocery store” (FG_Sacramento_3). Beyond the issue of access
to healthy foods, one key informant explained that many residents struggle to afford enough
food, let alone healthy food. “I would say that at least 70% of my families right now [...] When I
ask them there is an average of 4 to 5 days per month where they don’t have access to food. And
that is even when they are receiving EBT and WIC” (KI_Sacramento_16).
Active Living. One of the largest barriers to engagement in physical activity is access to
a recreational area. The following map profiles the percent of the population in census tracts
within the Communities of Concern that live within one-half mile of a recreational park.
Percent population living in census tract within one-half mile of park
space (per 10,000), 2010
23
Park access is extremely variable within the Mercy San Juan Medical Center HSA Communities
of Concern. While some areas have a large percentage of the population living within one-half
mile of a park, many areas have a moderate percentage living near to a park, and others have no
parks nearby. Key informants and focus group participants explained that while a neighborhood
may have access to a nearby park, safety is often a concern, as many parks having gang and drug
problems.
Physical Wellbeing. Age-adjusted all-cause mortality rates are a major indicator of the
health of a community. All six zip codes had an age-adjusted all-cause mortality rate that
exceeded county and state benchmarks, with zip code 95815 having the highest age-adjusted
overall mortality rate at 90.7 deaths per 10,000.
All six zip codes had an average life expectancy at birth lower than the state benchmark of 80.4
years and national benchmark of 78.6 years. Two zip codes in particular had low life
expectancies—74.6 years in 95815 and 74.8 in 95838.
Infant mortality is a leading health status indicator of a community. Four of the six zip code
Communities of Concern had infant mortality rates exceeding the county benchmark of 5.2
deaths per 1,000 live births.
Table 18: Age-adjusted all-cause mortality, life expectancy at birth, and infant mortality
rates (all cause mortality rate per 10,000 population, life expectancy in years, and infant
mortality rate per 1,000 live births)
Age-Adjusted
Life Expectancy
Zip Code
All Cause
Infant Mortality
at Birth*
Mortality
95660
5.0
79.6
76.8
95673
75.1
76.5
5.7
95815
90.7
74.6
5.7
95821
78.3
75.1
5.9
95838
88.3
74.8
6.4
95841
5.0
70.5
77.3
63.3
-5.2
Sacramento County
CA State
-80.4
-National
78.6
Healthy People 2020
--6.0
(Sources: 2010 CDPH and 2010 Census data; Population, US Census Bureau, 2010; rates
calculated)
Community Assets Identified
Communities require resources in order to maintain and improve their health. These
include health related assets including health care professionals and community-based nonprofit
organizations. An assessment of these resources revealed nearly 40 assets that provide Mercy
24
San Juan Medical Center opportunities for partnership in addressing some of the health needs
identified in this report. A full listing of health assets in the HSA can be found in Appendix B.
Mercy San Juan Medical Center
Implementation Strategy and Community Benefit Plan
Summary for FY 2013 – 2015
For decades, Mercy San Juan Medical Center has been meeting the health needs of residents in
the northern Sacramento County suburbs, including the following major communities: Citrus
Heights, Fair Oaks, North Highlands, Carmichael, Antelope, and Roseville. Established in 1967,
Mercy San Juan Medical Center is located at 6501 Coyle Avenue, in Carmichael, CA. The
hospital has 2,379 employees, 370 licensed acute care beds, and 35 Emergency Department beds,
including four Fast Track beds.
The hospital holds a Level II trauma designation and is recognized nationally as a leader in
trauma care. Tertiary care specialties at Mercy San Juan Medical Center include a 26-bed
Neonatal Intensive Care Unit that is ranked among the best in the world for survival rates of
premature infants, bariatric surgery program, and da Vinci and other robotic surgical systems.
The hospital is also well respected for its work in collaboration with Mercy General Hospital to
provide care for complex diseases affecting the brain in the Mercy Neurological Institute of
Northern California.
Through its mission, Mercy San Juan Medical Center is committed to furthering the healing
ministry of Jesus, dedicating resources to: delivering compassionate, high-quality, affordable
health services; serving and advocating for our sisters and brothers who are poor and
disenfranchised; and partnering with others in the community to improve the quality of life. The
Hospital carries out this mission daily by striving to address the needs of a region.
This report summarizes the plans for Mercy San Juan Medical Center to sustain and build upon
community benefit programs that address priority health needs identified in the 2013 Community
Health Needs Assessment (CHNA), and to engage with the community in developing new
offerings that respond to needed care and services.
Target Areas and Populations
As outlined in the summary assessment, the 2013 CHNA identified six zip codes within Mercy
San Juan Medical Center’s service area as Communities of Concern. More than 160,000 county
residents live within these communities. The Communities of Concern consist of zip codes that
include the areas of North Highlands, Rio Linda, North Sacramento, North Arden Arcade, Del
25
Paso Heights/Robla, and the Interstate 80 corridor southeast of North Highlands and Foothill
Farms. While many of the Communities of Concern are in urban areas, other areas such as Rio
Linda are fairly rural. The six Communities of Concern are highly diverse, with a large number
of areas with high rates of poverty, low educational attainment, high unemployment, high uninsurance rates, and a high number of residents renting their homes. Three of the six zip codes
had over 50% of residents reporting to be either non-White or Hispanic. Within the Communities
of Concern, zip code 95815 had the highest percent of residents over the age of five with limited
English proficiency at 13.1%.
All six zip codes had a higher percent of single female-headed households living in poverty than
the national average of 31.2%. Two of the six Communities of Concern, 95815 and 95838, had a
higher percent of residents over age 65 years living in poverty compared to the national
benchmark of 9%. All but one of the six zip codes had a percent of families with children living
in poverty higher than the national average of 15%, with the percent in 95815 being more than
double this national average. All zip code Communities of Concern had a higher percent of
residents over the age of 25 years without a high school diploma compared to the national
average, with the highest being 36.2 % in 95815. Three of the zip codes had a higher percent
unemployment compared to the state at 9.8%. All of the zip codes had a higher percent uninsured
compared to the national rate at 16.3%, with two zip codes having rates more than twice national
benchmark. Looking at the percentage of residents in a zip code who rent versus own their place
of residence serves as a barometer for a community’s health and financial stability. The percent
of residents who rent in the six HSA Communities of Concern all exceeded the national average,
ranging from 27.7% in 95673 to 63.8% in 95815.
Diabetes, heart disease, stroke, and hypertension were consistently mentioned in the qualitative
data as conditions affecting many area residents. All but one zip code had rates of ED visits and
hospitalization for diabetes higher than both the county and state benchmarks, with three zip
codes having rates of ED visits for diabetes two times greater than the state benchmark. Diabetes
was the most frequently discussed health condition among key informant interviews and focus
groups. Participants described difficulties in obtaining regular checkups, the high cost of
medications and equipment, and a lack of available diabetes education and support services.
Area experts and community members consistently reported the immense struggle they had in
maintaining positive mental health and accessing treatment for mental illness. Such struggles
ranged from the stress brought on by personal and financial pressures to the management of
severe mental illness. In addition, key informants and focus groups commonly reported that
substance abuse is a major issue within the community. Community members also mentioned
crime as a deterrent to utilizing parks and exercising outdoors, discussing the effects of crime on
mental health and wellbeing, expressing concern over violence witnessed by children, the
potential for post-traumatic stress disorder, and noting that some area residents are hesitant to
leave their houses.
A priority for Mercy San Juan Medical Center is to focus on populations with the greatest need;
thus the Hospital will place increased emphasis on addressing health issues in the Communities
of Concern for community benefit planning and implementation purposes.
26
How the Implementation Strategy Was Developed
The 2013 CHNA informed Mercy San Juan Medical Center’s implementation plan.
Additionally, a review of existing community benefit programs and services was conducted to
compare current programs and services against CHNA priorities. The Hospital had a leading role
in the development of the CHNA in partnership with numerous community leaders and health
providers. The Community Health Committee (a committee of the Dignity Health Sacramento
Service Area Community Board), which is made up of both Hospital and community leaders and
stakeholders, was engaged in developing the implementation strategy. Strategy is discussed at
the Community Board level, and both the new 2013 CHNA findings, and implementation
strategy, will be shared and discussed in community forums, with nonprofit agencies, public
officials and other community leaders.
Major Needs and How Priorities Were Established
The 2013 CHNA, and existing programs and services being provided by Mercy San Juan
Medical Center provided a baseline for establishing priorities. The CHNA process involved a
rigorous community-based participatory research approach that engaged both public health
experts and community members, utilizing a mixed methods data collection methodology that
included primary and secondary data collection. As outlined in the summary assessment, 10
health needs were identified as priority health needs in the CHNA within Mercy San Juan
Medical Center’s service area, with these needs greater in six Communities of Concern.
The Dignity Health Sacramento Service Area Community Health Committee went through a
process of review and evaluation to compare the CHNA findings to community benefit programs
and services currently provided by the Hospital, and to determine gaps in services that required
attention. Each CHNA priority health need was weighed against criteria that included:
•
•
•
•
•
•
•
•
•
•
How does what the Hospital experiences from an ED and inpatient admissions standpoint
correspond to the CHNA?
What is being done currently by the Hospital in response to the identified priority health
needs?
What health needs are other community-based provider organizations currently
addressing?
Where are there gaps in care?
Which gaps reflect the greatest risk for residents?
Where are the gaps greatest?
In addition to the significant charity care, Medi-Cal, other government-funded programs,
and community services being provided, what level of resources might be available by
the Hospital to expand or develop new initiatives to respond to these gaps?
How might the Hospital collaborate with the community to best leverage resources to
better meet health needs?
What community provider partners are available?
Which priority health needs align most with the clinical expertise of the Hospital?
27
A comparison of existing community benefit programs and services currently being offered
reflects that Mercy San Juan Medical Center is currently addressing a significant number of the
priority health needs identified through the assessment. In addition to charity care, care for the
indigent, un-funded care to the Medi-Cal population, and various other community benefit
services, emphasis by the Hospital continues to be placed on the priority areas of access to
mental health, access to primary health care services, access to health prevention and education
programs, and safety.
Several implementation strategies have been established that will enhance and build upon
existing efforts, focusing on the following priority health needs, with particular emphasis on the
six Communities of Concern identified.
1.
2.
3.
4.
5.
6.
Lack of access to primary care and preventative services
Lack of access to mental health and substance abuse services
Lack of access to specialty care
Improved transportation services
Education on health, wellness, and nutrition
Basic needs including adequate shelter and food
Description of What Mercy San Juan Medical Center
Will Do to Address Community Needs
The Dignity Health Sacramento Service Area Community Health Committee provides regular
oversight to ensure priority health needs continue to be a top focus for planning and
programming. Monthly, the Committee also reports to, and discusses issues and priorities
with, the full Community Board and Hospital leadership. The planning process also includes
stakeholders in the community who have expertise in those areas that have been identified as
priorities in the CHNA. Specific actions relative to strategies previously identified are outlined
below.
Action Plans
1.
Lack of access to primary care and preventative services. The CHNA identified a
number of significant barriers that contribute to poor access, including:
a. Lack of providers who accept Medi-Cal (possibly due to reimbursement rate)
b. Clinics struggle to meet demand for services
c. Residents have extreme difficulty getting referrals for specialty care
d. Residents experience long wait times to secure appointments and be seen
e. Lack of management of chronic conditions requiring specialty services
f. Uncoordinated referral systems between safety net providers
These contributors are also impacting ED operations at Mercy San Juan Medical Center;
59% of visits to the ED are for primary care as determined by discharge diagnoses. Mercy
28
San Juan Medical Center is working in partnership with community-based nonprofit
providers to address this priority health need in several ways.
A.
Increase Primary Care Capacity
Mercy San Juan Medical Center along with Mercy Hospital of Folsom have partnered
with WellSpace Health (formerly The Effort) to increase access to primary care services
in the communities served by Mercy San Juan Medical Center. WellSpace Health is one
of five Federally Qualified Health Centers (FQHC) operating clinics in the region. Under
the agreement, Mercy Hospital of Folsom and Mercy San Juan Medical Center are
making a $2.8 million investment in WellSpace Health over a three year time period that
will enable the organization to significantly accelerate its strategy to build three new full
scope health centers. These centers will be established in the cities of Rancho Cordova,
Carmichael and Folsom; areas of the region that lack safety-net services.
Within FY2014, WellSpace Health will have the Carmichael site open. Through a
collaborative effort of outreach and education, patients utilizing the Mercy San Juan
Medical Center who lack a primary care provider will be directed to the WellSpace
Health center. As part of the strategic initiative, the clinic will be less than two miles
from the Hospital to ensure accessibility and to minimize transportation as a barrier.
Collaborating with WellSpace Health presents a unique opportunity that is aligned with
Dignity Health’s mission to care for the poor, responds to the most pressing priority of
the region to build safety net capacity, and better positions both the hospitals and
WellSpace Health for Health Reform in 2014. The new health centers will help change
the face of the region’s safety net, building capacity to serve an additional 35,000 new
patients. The Hospitals and WellSpace Health are now developing plans for integration,
that include care coordination and technology connectivity in order to assist and monitor
the health outcomes of patients.
B.
Patient Navigator Program
In collaboration with three other affiliate hospitals, Mercy San Juan Medical Center is
partnered with Health Net and Sacramento Covered, to implement an Emergency
Department Patient Navigator Program to assist underserved patients in accessing
primary care and to address needed care coordination. This is a groundbreaking program
for Sacramento that brings hospitals, providers and the nonprofit community together in
partnership to address access and care coordination for the underserved patient
population. Key elements of this new program include:
• Onsite assistance to patients prior to discharge from the ED during business hours
to connect/reconnect patients to their PCP and other services (i.e. specialty care
recommended by PCP, social support), or to find patients a PCP or medical home
in a community clinic (leveraging The Effort’s new health centers)
• Next day phone outreach to patients admitting to the ED after hours (template to
identify patients and obtain demographics already incorporated into MS4 system
through existing pilot program)
• Patient assistance/navigation services include:
o Assist patients in determining their PCP and/or in finding a PCP or clinic
29
o Assist patients in reassignment to a new PCP when necessary
o Make timely follow-up appointments for patients with PCP/clinic (and
other appointments as needed and/or recommended by PCP)
o Conduct follow up reminder calls to patients for appointments, and stay
connected to patients throughout cycle
o Place special emphasis on frequent ED users (multiple readmits)
o Educate patients on current health plan coverage including resources
available
o Enroll patients in Dignity Health’s no-cost community services, including
the Chronic Disease Self-Management and Diabetes Self-Management
Healthier Living Programs, and CHAMP (CHF) program
o Connect patients to resources offered by partner organizations
o Determining eligibility for patients with no coverage
o Assist with retention of coverage
o Assistance with other public benefits such as CalFresh
o Share patient ED health data with PCPs/clinics
o Ensure patients have transportation to appointments
o Assess patient satisfaction with levels of care
C.
Dignity Health Community Grants Program
The Hospital has restructured its annual grants program to foster collaboration among
community based nonprofit provider organizations. Organizations are being asked to
work together to develop innovative partnership programs that provide a continuum of
care for a specific target population. One partnership program for example, involves
Twin Lakes Food Bank, Powerhouse Ministries, Orangevale Food Bank, and WellSpace
Health. The aim of this collaborative is to improve the health and quality of life for
families who are struggling in their community, particularly those with behavioral or
chronic health issues; through coordinated care, case management and access to the
services each agency offers, clients will feel cared for and supported as they improve
their health outcomes. The Hospital will also begin to place emphasis through the grants
program on the Communities of Concern that were identified in the assessment.
D.
Established Programs to Increase Access to Care
The Hospital will continue to provide several well-established core services that address
access to care, including:
•
An Enrollment Assistance program to help uninsured patients enroll in
government sponsored health insurance programs, successfully serving hundreds
of individuals and families each year in getting coverage.
•
A lead role in the Sacramento Region Health Care Partnership, created by
Congresswoman Doris Matsui and Sierra Health Foundation, and focused on
building capacity for care in the region’s safety net. The Hospital has also focused
significant funding on capacity building efforts.
30
2.
Lack of access to mental health treatment and alcohol/drug abuse treatment and
prevention programs. Mercy San Juan Medical Center, along with its affiliate hospitals
in the region, takes a lead role with the California Hospital Council in the Community
Mental Health Partnership to advocate for reinstatement of Sacramento County mental
health services. This partnership was developed in response to county budget cuts that
eliminated 50 beds in its residential treatment facility, resulted in the closure of the crisis
stabilization unit, and reduced numerous other mental health services, which created a
crisis in the region. Several positive steps have been made to reinstate critical services.
The County is reopening its crisis stabilization unit on a limited basis, and has increased
some beds for residential treatment. Other initiatives include:
•
ReferNet. Mercy San Juan Medical Center has established a partnership with
community-based mental health provider El Hogar, to provide a seamless way for
individuals who admit to the emergency department with mental illness and
substance abuse issues to receive immediate and ongoing outpatient care and
treatment. This partnership has been expanded to include nonprofit community
provider, Clean and Sober, which adds a more comprehensive level of care.
•
Establishment of WellsSpace Health Center in Carmichael which will increase
services including mental health treatment and alcohol/drug abuse treatment and
prevention programs. WellSpace Health has established themselves as a premiere
mental health provider in the Sacramento region. Through their expansion,
services will be offered in the communities served by Mercy San Juan Medical
Center.
The Hospital will continue to provide several well-established core services that
address mental health and substance abuse, including:
•
The Interim Care Program (ICP) responds to the mental health, substance
abuse treatment, and social needs of homeless individuals upon discharge from
the hospital. In addition to care, the ICP offers safe shelter, food, healthcare
coordination and case management services through a unique partnership with
one of the region’s federally qualified health centers, WellSpace Health (formerly
The Effort), as well as the Salvation Army, Sacramento County and other health
systems in the region.
•
Through Mercy Perinatal Recovery Network (PRN), pregnant women and new
mothers battling substance abuse learn to overcome their addictions, deliver
healthier babies, prevent their children from being placed in foster care, and live a
higher quality and more productive life. Mercy PRN is a drug and alcohol
recovery treatment program for vulnerable, at-risk women and their children
offered in a home-like environment. Nationally, approximately 37% of
individuals who begin substance abuse treatment complete 90 days, which is the
benchmark for greater success in achieving long term sobriety. Over 70% of the
women entering treatment at Mercy PRN complete 90 days of treatment.
31
•
3.
4.
The Hospital has, and will continue to provide psychiatric consultations to all
patients admitting to the emergency departments because of the limited mental
health services available in the County. Thousands of patients receive this service
every year.
Lack of access to specialty care. Mercy San Juan Medical Center will continue to work
collaborately with other health systems and community organizations on initiatives that
address access to specialty care, including:
•
The SPIRIT program is a long-time partnership program that recruits volunteer
physicians and health providers from throughout the region to provide medical
care to the underserved, mainly specialty care that would otherwise not be
available. Physicians provide treatment for allergies and asthma, dermatology,
endocrinology, gynecology, neurology, ophthalmology, orthopedics, plastic
surgery, rheumatology, and hernia and cataract surgeries. Mercy San Juan
Medical Center, in partnership with other health systems, will provide additional
case management services to the SPIRIT program to increase capacity.
•
The Hospital is currently engaged in reducing readmission rates for Congestive
Heart Failure (CHF), Acute Myocardial Infarction (AMI) and Pneumonia (PNE).
The Readmission Committee has established a pilot program for patients
admitting to the Emergency Department for CHF. Through collaboration with
WellSpace Health, Congestive Heart Active Management Program, or CHAMP®
(described below), Referral Network (transitioning into the Patient Navigation),
and the Hospital discharge nurses, patients are scheduled with follow-up visits to
a Primary Care Provider and enrolled in CHAMP to help ensure they have the
necessary resources to manage their CHF and establish a care plan with their PCP.
Mercy San Juan is currently revising their pharmaceutical process to make certain
patients have their medication to manage CHF at or close to the time of discharge.
Improved transportation services. Mercy San Juan Medical Center is currently
working to ensure transportation resources are readily available, specifically to the
Communities of Concern identified through the CHNA.
•
The Patient Navigator Program (described under access to primary care) will
provide assistance for patients to attend primary care and specialty appointments.
Navigators will provide bus tokens or arrange for taxi transportation when patient
has not other means. Navigators will also provide patients with information on
bus routes to and from appointments to ensure transportation does not remain a
barrier.
•
When developing the agreement with WellSpace Health, location was a major
component when choosing the location. In alignment with the priority needs, the
Hospital required that the new site be in close proximity to Mercy San Juan
Medical Center. The space selected is within two miles of the Hospital and on an
easily accessible bus route.
32
5.
Education on health, wellness, and nutrition. In collaboration with other affiliate
hospitals, Mercy San Juan Medical Center will further grow its Chronic Disease SelfManagement and Diabetes Self-Management programs - Healthier Living - modeled
after the evidence-based Stanford model; targeting these programs specifically for those
living within Communities of Concern. These programs, taught in both English and
Spanish, are designed to provide patients who have chronic diseases with the knowledge,
tools and motivation needed to become proactive in their health. The workshops are
offered in both clinical and community settings.
The Hospital is also working with the Healthy Sacramento Coalition, which was
established by Sierra Health Foundation after receipt of Community Transformation
Grant funding. The coalition’s policy workgroup has recommended that Healthier Living
be adopted as one of several region-wide Preventive Services Policies.
Another long-standing and effective program offered by the Hospital is the Congestive
Heart Active Management Program, or CHAMP® program, which engages all
Dignity Health member hospitals in Sacramento, as well as in other surrounding counties.
CHAMP® provides support and assistance for patients who suffer from heart failure, and
responds to a priority health issue of heart disease. The program keeps patients linked to
the medical world once they leave the hospital through symptom and medication
monitoring and education. The program also provides education and health screenings in
the community. Consistently, the program achieves an 80 percent or better reduction in
hospital readmissions by participants each year.
SAFE KIDS, a core program for Mercy San Juan Medical Center, is a group of
healthcare, law enforcement, fire department and other community members who work
together to raise the public awareness of child safety including car seat education and seat
belt safety. The Car Seat program is part of Mercy San Juan Medical Center’s Trauma
Prevention Program, which provides outreach, education and car seats to parents,
caregivers and children to prevent serious injury and deaths. Mercy San Juan Medical
Center is the only organization offering car seat education to the three largest nonEnglish speaking cultures in the area – Hispanic, Russian and Hmong. This includes Safe
Kids Car Seat Classes and Health/Safety Education at no cost to families with children
living in poverty and to families with children in immigrant communities, where the need
is greatest. Safe Kids health and safety fairs are part of the overall Safe Kids program
sponsored by Mercy San Juan Medical Center. They provide a venue to provide safety
education to parents, care-givers and children in the community.
6.
Basic needs including adequate shelter and food. Mercy San Juan Medical Center, as
part of Dignity Health’s regional initiatives, will continue to provide established services
that address basics needs such as adequate shelter and food, including:
•
The Interim Care Program (ICP), mentioned previously, responds to basic
needs such as safe shelter, food, healthcare coordination and case management
33
services through a unique partnership with WellSpace Health, the Salvation
Army, Sacramento County and other health systems in the region.
Next Steps for Priorities
For each of the priority areas listed above, Mercy San Juan Medical Center will work with the
Community Health Committee of the Board, and established partners, while seeking new
partnerships with others in the community, to create opportunities for enhancing services.
Emphasis will be placed on developing and/or improving methodologies for measuring goals and
objectives in order to appropriately measure health outcomes. Attention will be on plans for
outreach and expansion of services in the Communities of Concern.
Priority Needs Not Being Addressed and the Reasons Why
The Hospital responds to priority health needs in many ways, and in times that are critical for
patients in crisis. In addition to charity care, indigent care, and un-funded care for the Medi-Cal
population, a significant number of programs and services offered address the priority needs
identified in the 2013 CHNA. The needs in the County are monumental and Mercy San Juan
Medical Center does not have the available resources to develop and/or duplicate initiatives to
meet every priority identified, which makes collaboration with community assets critical. The
Hospital does not have the expertise to address dental care, and First 5 Sacramento Commission,
WellSpace Health, Health and Life Organization, and the Sacramento District Dental Society are
already providing dental care. Mercy San Juan Medical Center has, and will continue to provide
support to enhance these efforts. The Hospital does not at this time have resources to address the
need for healthy foods. This is a need that Kaiser Permanente North is addressing in northern
region through its Healthy Eating Active Living (HEAL) Program.
34
Appendix A: List of Key Informants for Mercy San Juan Medical Center CHNA
Name & Title
Katy Robb, Social Worker
Danielle Lawrence, Social
Workers
Linda Burkholder,
Director of Family
Support Services
Christine Gonzales, FRC
Coordinator
Michelle Allee, Team
Leader
Gina Warren, Pharmacist
Roman Romaso, Executive
Director
Tasha Bryant, Manager of
Clothing Program
Lorena Carranza, Manager
of Parent Education
Program
Genevieve Diegnan
Program Director
Marty Keale, Executive
Director
Dr. Patricia Samuelson,
Physician
Abraham Daniels,
Program Officer
Carolyn Martin, Executive
Director
Sister Libby Fernandez,
Executive Director
Health Navigators Group
Carol Mennel, Nursing
Administrator
Dr. Olivia Kasirye,
Public Health Officer
Dr. Leonard Ranasinghe,
Physician
Carol Moses, Pastor
Denise Aldred, Manager
Marcella Gonsalves,
Program Administrator
Agency
Mutual Assistance Organization
Mutual Assistance Organization
Folsom Cordova Unified School
District
Area of Expertise
Community health; social
support services
Community health; social
support services
Community health
Birth and Beyond- The Effort
North Highlands
Birth and Beyond- The Effort
North Highlands
Primary Health Services
Community health services
Sacramento Food Bank
Community support services
Community health services
Slavic Assistance Network
Chronic disease management,
Community health
Community health
Sacramento Food Bank
Community support services
Sacramento Food Bank
Capitol Community Health
Network
Mercy Clinic Norwood
Sierra Health Foundation
California Tobacco Control
Alliance
Loaves and Fishes Homeless
Clinic
Capitol Community Health
Network
Mercy San Juan
Sacramento County
Community support services
Community health
Community clinic services
Community health
Tobacco Prevention
Community health clinic for
homeless services
Community health, patient
navigation
Emergency care
Community health
Natomas Crossroads Clinic
Community health clinic
Natomas Crossroads Clinic
Health Education Council
Community health clinic
Community health promotion
Natomas Crossroads Clinic
Community health clinic
35
Dr. Jonathan Porteus, CEO
Robert Sanger, Executive
Director
Koua Franz, Chief Family
and Community
Engagement Center
Officer
Dr. Catherine Vigran,
Physician
The Effort, Inc.
Folsom Cordova Community
Partnership
Sacramento City Unified School
District
Community health
Community health
Kaiser Permanente
Community health
School health, family health
36
Mercy San Juan Hospital
American Diabetes
Association
Birth & Beyond -North
Highlands
Child Abuse Prevention
Center
Family Resource Center North Highlands
Mercy Clinic - North
Highlands
New Testament Baptist
Church
The Effort - North Highlands
Community Health Center
Alchemist Community
Development Corporation
American Heart Association,
Sacramento
Center for AIDS Research, Ed
and Srvs (CARES)
Center for Community Health
and Well Being
Central Downtown Food
Basket
Clean and Sober Homeless
Recovery Communities
Clinica Tepati
95608
95660
S, M
95660
S, M
95660
95660
95660
S, M
S, M
E
S,
M
S,
M
S,
M
S,
M
S,
M
S,
M
S,
M
S,
M
95811
95811
95811
S, M
S,
M
S,
M
95811
95811
95811
95811
95811
Dental
Specialty
Medical
Services
Tobacco
Substance
Abuse
Nutrition
Mental Health
P
P
C
C,
E,
P
E
P
I
P
C,
M
P
P
I
C
P
P
I
I
P
E
I, C
E
C
I
R
I
P
P
S,
M
C
P
R
Women's health
yes
yes
P, CM
P
yes
no
E
C
R
R
S,
M
S, M
Loaves and Fishes
Diabetes
Primary, specialty, emergency care, lab, pharmacy, imaging (full service medical and
hospital services)
95660
95660
Hypertension
Name
Asthma/Lung
Disease
Zip Code
Appendix B: Health Assets Table for Mercy San Juan Medical Center Service Area
HIV testing,
primary
care,
pharmacy,
gynecology
Pre/post
natal care,
STD testing,
gyn services
Primary
care,
diagnostics,
prescription
drugs,
specialty
referrals
HIV/AIDS
specialty
medical care,
dermatologist,
chiropractor,
case
management
Prenatal, family
planning, health
care,
transportation
12 step based
residential
communities for
formerly
homeless
Dermatology,
women's health,
low cost
radiology,
ophthalmology
referrals
Immunizations
(School-aged
children)
no
yes
no
no
no
no
no
37
Sacramento Native American
Health Center, Inc
95811
S, M
95811
S, M
The Birthing Project Clinic
The Effort - J Street
Community Health Center
95811
95811
S, M
YWCA
Breathe California of
Sacramento-Emigrant Trails
95811
95814
E
E,
P,
M,
C
S,
M
S,
M
S,
M
E
R
P
P
C
E
M
E, C
P
P
El Hogar Mental Health and
Community Service Center
95814
95814
P
Native TANF Program
Planned Parenthood Mar
Monte - Capitol Plaza Center
Sacramento Chinese
Community Services Center
SCDHHS Anonymous Test Site
95814
95814
95814
95814
95814
I
I
I
S
I
P
R
I
P
I
P, R
P
no
yes
no
no
no
psychiatric
medication
management
Primary
care
Dental
no
Family &
internal
medicine,
chronic
disease mgt
pre/post
natal
services,
gynecology
care, family
planning
services
Primary
care,
pre/perinatal care,
women’s
health,
immunizati
ons
Breast exam
&
mammogra
ms
P
C, P,
CM
Specialty
Medical
Services
Tobacco
C, P
95814
95814
R
E,
C
El Hogar - Regional Support
Team (RST)
95814
free
episodic &
urgent care
P,
C,
C
M
C,
S,
C
M
C,
P,
C
M
Francis House
Guest House Homeless
Services
Legal Services of Northern CA
- (LSNC-Health)
National Hispanic Family
Health Helpline
P
Substance
Abuse
S,
M
Nutrition
S,
M
Mental Health
Hypertension
95811
Diabetes
Mercy Clinic - Loaves & Fishes
Sacramento Gay and Lesbian
Center
Asthma/Lung
Disease
Zip Code
Name
CM
R
no
no
no
no
no
no
P
A
reproductiv
e health
no
yes
no
no
no
38
- HIV/Communicable Disease
Prevention Program
The Salvation Army - Adult
Rehabilitation Center
The SOL project
WALK Sacramento
California Diabetes Program
(Dignity Health)
C.O.R.E Medical Clinic
Clara's House
Midtown Medical Center
Planned Parenthood Mar
Monte - B Street Health Cntr
River City Food Bank
Sacramento Life Center (SLC)
Sutter General Hospital
UC Davis Medical Center
Shriners Hospital for Children
Central Downtown Food
Basket
Central Downtown Food
Basket
Paul Hom Asian Clinic
Pregnancy Consultation
Center
WEAVE
Mercy General Hospital
Sutter Memorial Hospital
AIDS Project
Alternatives Pregnancy
Center
Interim HealthCare/Interim
HomeStyle Services
Wellness and Recovery
Center
Kaiser Permanente
Slavic Assistance Center
95814
95814
95816
S, M
95816
S, M
95816
95816
95816
95816
95816
95817
95817
95819
95819
E
S,
M
E
S,
M
I
S,
M
E
S,
M
S, I
C
R
R
C
E
P
P
I
P
E
I
no
E
I
E
Dental
Specialty
Medical
Services
Tobacco
Substance
Abuse
Nutrition
C
95814
95815
Mental Health
Hypertension
Diabetes
Asthma/Lung
Disease
Zip Code
Name
no
no
Primary
care
primary
care
primary
care
primary
care
Acupuncture
no
no
no
no
no
C
S
no
Primary, specialty, emergency care, lab, pharmacy, imaging (full service medical and
hospital services)
Primary, specialty, emergency care, lab, pharmacy, imaging (full service medical and
hospital services)
Pediatric services including burn care, orthopedics, spinal cord injury, cleft lip/palate
S,
M
no
P
S,
M
no
95819
S, M
95819
95821
C
no
Primary, specialty, emergency care, lab, pharmacy, imaging (full service medical and
hospital services)
Primary, specialty, emergency care, lab, pharmacy, imaging (full service medical and
hospital services)
Physical, speech,
S,
S,
C,
& occupational
S, M
M
M
R
C
P
therapy
95821
S, M
95819
95819
95819
95821
95821
95825
95825
S,
M
E
Primary
Care, S
S
E
I
I
C,
P
C,
P
C
S
Gynecology
no
no
S
E
C
P
Primary, specialty, emergency care, lab, pharmacy, imaging (full service medical and
hospital services)
E
39
Transitional Living and
Community Support
Women's Health Specialists
El Hogar - SeniorLink
HIV/Communicable Disease
Prevention
Sacramento County Chronic
Disease Prevention
Sacramento County Tobacco
Control Coalition
Smile Keepers - Dental Health
Program
St. John's Shelter Program for
Women and Children
Stanford Home for Children
Western Career College
Dental Clinic
Cover the Kids
Healthy Kids, Healthy Future
Stanford Settlement
Stanford Settlement
Natomas Crossroads Clinic
Bayanihan Clinic
Birth & Beyond - North
Sacramento
Birth & Beyond -The
Firehouse
Family Resource Center - The
Firehouse
Greater Sacramento Urban
League
Mercy Clinic - Norwood
Mercy Family Clinic
Mutual Assistance Network
The Salvation Army - Family
Services
95826
95826
E, R
E
E,
R,
P
95833
95833
95833
95834
I
S,M
I
0
1
95838
95838
95838
95838
95838
S, M
S,
M
S,
M
P
P
R
E
R
E
R
S,
M
S,
M
E
I
I
R
Dental
Specialty
Medical
Services
Substance
Abuse
Tobacco
no
no
S, E
C
no
no
no
I
S,
M,
E
P
S, M
no
yes
S,
M
95838
95838
95838
C
E
S,
M
95838
S
P, E
P
95826
no
P
C
95826
S, P
P
E,
R,
P
95826
95833
P
C,
P
95826
95826
Nutrition
E,
P
95825
95825
95826
Mental Health
Hypertension
Diabetes
Asthma/Lung
Disease
Zip Code
Name
P
P
no
P
C, P
C, P
C, P
no
I
Primary
care
Primary
care, lab
tests,
women’s
health
vaccination
R
I
R
Women's health
I
I, R
I
I, R
I
P
no
R
General &
family
Primary &
preventive
healthcare
no
Women's health
Women's health
R
R
Well Women
Visits
40
Heritage Oaks Hospital
95841
River Oak Center for Children
95841
People Reaching Out
95841
C,
P
C,
P
C,
P
P
I, R
I, P
I
C
Dental
Specialty
Medical
Services
Tobacco
Substance
Abuse
Nutrition
Mental Health
Hypertension
Diabetes
Asthma/Lung
Disease
Zip Code
Name
Acute inpatient
programs,
ntensive
utpatient
programs, partial
hospitalization
programs
S=screening services; M=disease management services; E=education services; I=information available; CM=case management;
C=counseling services offered; R=referral services offered; A=advocacy services; P=programs offered
41