Carlisle Regional Medical Center • Hamilton Health Center Holy Spirit–A Geisinger Affiliate • Penn State Milton S. Hershey Medical Center Pennsylvania Psychiatric Institute • PinnacleHealth System October 2015 Table of Contents Introduction ......................................................................................................................................3 Regional Community Health Needs .................................................................................................. 10 Priority #1: Access to Health Services ................................................................................................ 10 Priority #2: Behavioral Health Services ............................................................................................. 26 Priority #3: Healthy Lifestyles ........................................................................................................... 31 Conclusions & Recommendations ..................................................................................................... 42 Appendices ...................................................................................................................................... 44 Appendix A: Project Mission ............................................................................................................. 45 Appendix B: Process Overview ......................................................................................................... 46 Appendix C: The Collaborative Overall Study Area Community Definition .......................................... 77 Appendix D: PinnacleHealth System Community Definition ............................................................... 81 Appendix E: The Collaborative Overall Study Area Community Stakeholders ..................................... 84 Appendix F: PinnacleHealth System .................................................................................................. 86 Appendix G: The Collaborative ......................................................................................................... 87 Appendix H: Truven Health Analytics ................................................................................................ 88 Appendix I: Tripp Umbach ................................................................................................................ 91 2 | P age Introduction To better serve the needs of community residents in South Central Pennsylvania, PinnacleHealth System partnered with Carlisle Regional Medical Center, Hamilton Health Center, Holy Spirit–A Geisinger Affiliate, Penn State Milton S. Hershey Medical Center, and the Pennsylvania Psychiatric Institute to form a community group, collectively known as The Collaborative. PinnacleHealth System, as a member of this Collaborative, completed a comprehensive community health needs assessment (CHNA) to fulfill its mission and goals. The Patient Protection and Affordable Care Act (PPACA) has changed how individuals are obtaining care and has modified how healthcare is delivered. Reducing healthcare costs, greater care coordination, and better care/services are some goals of the PPACA. Healthcare organizations and systems are striving to improve the health of the community they serve. Collaborating with local, state and national partners, and government officials can provide opportunities for continued high-quality programs and services in the region. In 2012, PinnacleHealth System completed a CHNA on Cumberland, Dauphin, Lebanon, Perry, and York counties, (particularly, Northern York).1 These counties were specifically identified as regions that fell under PinnacleHealth System‘s service area.2 The 2015 assessment focused on the same counties. In addition, the same project component pieces were completed with the exception of a new federal requirement to collect public feedback on the 2012 CHNA and implementation plan (this project piece was known as public commentary). With the completion of two CHNA cycles, Tripp Umbach provided trending data (when applicable) to view movements and changes in community respondents’ behaviors. The comprehensive CHNA identified and prioritized community health needs. The project component pieces involved to reach the regional community health needs included the collection of secondary data from local, state, and national resources, community stakeholder interviews, hand-distributed surveys, health provider surveys, and community forums. A provider resource inventory was also part of the CHNA. The resource inventory highlights programs and services within the five-county focus area. The inventory identifies the range of organizations and agencies in the community that are serving the various target populations within each of the priority needs. It provides program descriptions, contact information, and the potential for coordinating community activities by creating linkages among agencies. 1 The Collaborative identified Northern York County as their area of focus within York County. The Community Needs Index (CNI) provided zip code level data which were representative of the northern tier of York County. Additional data obtained for York County typically encompassed the whole county overall, unless otherwise noted. 2 The overall study area encompassed five counties: Cumberland, Dauphin, Lebanon, Perry and York. PinnacleHealth’s service area within the report denotes the counties and zip codes which were identified as PinnacleHealth’s service region. The counties that fall under PinnacleHealth’s service area include: Cumberland, Dauphin, Lebanon, Perry, and York counties. The 42 zip codes that fall under PinnacleHealth’s service area can be found in Appendix D. 3 | P age (Information regarding the CHNA process and each of the individual project pieces can be found in Appendix B.) Tripp Umbach facilitated two public input and feedback events involving community organization leaders, government stakeholders, religious leaders, and members of the sponsoring health institutions. The events identified top areas of need, based upon the data collected and presented. Subsequently, a prioritization meeting was held with members of The Collaborative to pinpoint, isolate, and further refine the top three priority areas the health organizations and institutions will tackle. The identified community needs are listed in priority, based on qualitative and quantitative data collected. An implementation phase will be employed by PinnacleHealth System to explore and strategize ways to meet the needs of the community. The regional community health needs based upon results of the 2015 CHNA are illustrated in Figure 1 on the following page. 4 | P age Figure 1: Regional Community Health Needs Priority #1 Priority #2 Priority #3 Access to Health Services Behavioral Health Services Healthy Lifestyles • Primary care • Mental health • Lack of physical activity • Specialty care • Substance abuse • Inadequate nutrition & • Dental care obesity • Smoking Cessation & Prevention In reviewing the demographic profile for PinnacleHealth System’s service area, the region is expected to have a 1.6 percent increase in population from 2014 through 2019; these findings are consistent with the 2012 study. Cumberland County has the highest rate of individuals earning a bachelor’s degree or greater (31.4 percent). On the other hand, Perry County has the highest percentage of individuals without a high school diploma (15.1 percent). The PinnacleHealth System study area has 17.8 percent of households earning less than $25,000 in 2014. This is significantly lower than the rate in Pennsylvania (24.0 percent) and the nation (24.5 percent).3,4 Education is an important investment that can reduce a life of poverty and inequality, and provide a gateway to additional social and environment stabilities. Community stakeholders reported that education is essential. Individuals who are educated tend to lead healthier lifestyles, understand preventive health measures, and have few barriers to access. While health education materials and information are available, the materials presented to community residents must be clear and conveyed at a reading comprehension level easily understood by all residents. In reviewing the population of The Collaborative’s overall study area, all of the counties are expected to have population growth from 2014 to 2019, with the exception of Perry County. Perry County is expected to have a decrease in population of -0.8 percent (See Table 1). 3 Truven Health Analytics 4 The population, household income, and education level demographics data are consistent with the 2012 CHNA study. 5 | P age Table 1: The Collaborative Overall Study-Area Population Overall Cumberland Dauphin Lebanon Perry York Study Pennsylvania County County County County County Area 2014 Total 263,257 265,985 139,474 47,018 436,434 1,053,438 12,791,290 Population 2019 Projected 269,715 268,856 142,540 46,662 441,367 1,067,668 12,899,019 Population # Change + 6,458 + 2,871 + 3,066 - 356 + 4,933 + 14,230 + 107,729 % Change + 2.5% + 1.1% + 2.2% - 0.8% + 1.1% + 1.3% + 0.8% The Collaborative’s overall study area for the 2015 CHNA showed Dauphin County has the highest percentage of individuals earning less than $15,000 in 2014 (10.7 percent) and also showed Dauphin County as being the most racially diverse of the study-area counties, with 17.1 percent of the population identified as Black, Non-Hispanic and 8.1 percent identified as Hispanic.5 The demand for care will increase as PinnacleHealth System‘s population grows and the Baby Boomer generation retires and requires additional health services. It is important to review the Community Needs Index (CNI) scores obtained by Truven Health Analytics.6 The CNI zip code summary provides valuable background information to begin addressing and planning for the community’s current and future needs. The CNI provides greater ability to diagnose community needs as it explores zip code areas with significant barriers to healthcare access. In reviewing the CNI scores for The Collaborative’s overall study area, the top six zip codes that face barriers to healthcare are: 17104 (Harrisburg), 17401 (York), 17101 (Harrisburg), 17046 (Lebanon), 17103 (Harrisburg), and 17403 (York). The CNI scores within these zip codes ranged from 5.0 to 4.4 which represent significant socioeconomic barriers to accessing healthcare (See Map 1). On the opposing spectrum, zip codes 17090 (Shermans Dale), 17319 (Etters), 17009 (Boiling Springs), 17339 (Lewisberry), and 17365 (Wellsville) have CNI scores that ranged from 1.4 to 1.2 indicating a low level of healthcare access issues. The CNI scores for The Collaborative’s overall study area are mapped out (See Map 1) below, providing a geographic representation of the socioeconomic barriers to healthcare access of specific zip codes; and indicating an at-risk population in regards to community health. 5 This finding is consistent with the 2012 CHNA. 6 See Appendix H for additional information regarding CNI. 6 | P age Map 1: The Collaborative’s Overall Study Area 2015 (Community Needs Index Map) Significant socioeconomic barriers Lowest level of socioeconomic barriers For the current study, PinnacleHealth System examined 42 zip codes which represented the community it served. This also represented 80.0 percent of inpatient discharges for the health system. 7 | P age The CNI map below shows areas of significant to lowest socioeconomic barriers within PinnacleHealth System’s study area. The map visually shows zip codes (all in Harrisburg): 17104, 17101, 17103, 17102, and 17113 as regions that face additional barriers to healthcare when compared to the remaining 37 zip codes in PinnacleHealth System’s study area. Conversely, the zip codes that face the least amount of barriers to accessing healthcare are zip codes: 17018 (Dauphin), 17019 (Dillsburg), 17090 (Shermans Dale), 17319 (Etters), and 17339 (Lewisberry) (See Map 2).7 Map 2: PinnacleHealth System Study Area 2015 (Community Needs Index Map) Significant socioeconomic barriers Lowest level of socioeconomic barriers 7 There are five prominent socioeconomic barriers to community health quantified in the CNI they are: Income Barriers, Cultural/Language Barriers, Educational Barriers, Insurance Barriers, and Housing Barriers. Each zip code is assigned a score on a scale of 5.0 to 1.0. A score of 1.0 indicates a zip code with the least need, while a score of 5.0 represents a zip code with the most need. 8 | P age A CHNA was conducted with mutual interests from healthcare institutions and organizations to ultimately address the needs of community residents in Central Pennsylvania. The region faces challenges that will limit the growth and expansion of new programs. Thus, continued collaboration and partnerships with healthcare organizations are vital to PinnacleHealth System’s providing high-quality services and programs to all in the region. This report fulfills the requirements of the Internal Revenue Code 501(r)(3), a statute established within the Patient Protection and Affordable Care Act requiring that nonprofit hospitals conduct CHNAs every three years. The CHNA process undertaken by PinnacleHealth System, with project management and consultation by Tripp Umbach, included extensive input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of public health issues, data related to underserved, hard-to-reach, vulnerable populations and representatives of vulnerable populations served by the hospital. Tripp Umbach worked closely with members of The Collaborative to oversee and accomplish the assessment and its goals. 9 | P age Regional Community Health Needs Priority #1: Access to Health Services Access to healthcare typically refers to the ability and ease in which people can obtain healthcare; it can also refer to utilization or having healthcare coverage. Health services should be effective and pertinent if the population is able to obtain them. Overall access to health services is a challenge for many in the community. Health insurance coverage, affordability, health literacy, navigation through the healthcare system, the availability of physicians, and transportation are issues that prohibit residents from obtaining care and services. However, there are additional layers that affect community residents from gaining access to services that are readily available in South Central Pennsylvania. The collection and analysis of primary and secondary data confirms the difficulties community residents face when trying to obtain healthcare services. Primary Care Health insurance coverage is an essential and critical component to receiving and obtaining primary care. Individuals who lack health insurance do not receive the same amount of services and care and tend to have poor health outcomes and more severe illnesses. High deductibles, out-of-pockets costs, and providers accepting only certain types of insurance impact the frequency of residents obtaining services. The populations most affected by limitations in health coverage are low-income/economically challenged individuals and the vulnerable populations. Prior to the implementation of the PPACA coverage expansion in 2013, over 1.2 million people were uninsured: 11.0 percent for Pennsylvania with a national uninsured average of 15.0 percent. Among the 89.0 percent of Pennsylvanians with insurance in 2013, over six in 10 (62.0 percent) were covered under an employer plan. One in five Pennsylvanians (20.0 percent) were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) (See Chart 1). 8 8 The Henry J. Kaiser Family Foundation: http://kff.org/health-reform/fact-sheet/the-pennsylvania-health-care- landscape/ 10 | P age