Community Health Needs Assessment 2016 Sherman OaksEncino Hospital Community Health Needs Assessment, 2016 CONTENTS EXECUTIVE SUMMARY ............................................................................................................................................. 5 ACKNOWLEDGMENTS ............................................................................................................................................ 11 METHODOLOGY ..................................................................................................................................................... 12 Primary Data ....................................................................................................................................................... 12 Secondary Data ................................................................................................................................................... 12 HOSPITAL AREA DEFINITION .................................................................................................................................. 14 COMMUNITY PROFILE ............................................................................................................................................ 16 Demographic Data .............................................................................................................................................. 16 HEALTH STATUS IN SERVICE PLANNING AREA AND COMPARISON AREAS ............................................................. 23 Asthma ............................................................................................................................................................... 23 Cancers ............................................................................................................................................................... 25 Depression (Medicare Population) ..................................................................................................................... 36 Diabetes .............................................................................................................................................................. 37 Heart Disease (Adult) .......................................................................................................................................... 42 Heart Disease (Medicare Population) ................................................................................................................. 44 High Blood Pressure (Adult) ................................................................................................................................ 45 High Blood Pressure (Medicare Population) ....................................................................................................... 46 High Cholesterol (Adult) ...................................................................................................................................... 47 SHERMAN OAKS HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT 2016 2 High Cholesterol (Medicare Population) ............................................................................................................. 48 Infant Mortality .................................................................................................................................................. 49 Low Birth Weight ................................................................................................................................................ 52 Mortality - Cancer .............................................................................................................................................. 54 Mortality – Heart Disease ................................................................................................................................... 55 Mortality – Homicide .......................................................................................................................................... 57 Mortality – Coronary Heart Disease .................................................................................................................... 58 Mortality –Lung Disease ..................................................................................................................................... 61 Mortality –Motor Vehicle Crashes ...................................................................................................................... 62 Mortality – Pedestrian Motor Vehicle Crashes.................................................................................................... 64 Mortality – Premature Death .............................................................................................................................. 65 Mortality – Stroke ............................................................................................................................................... 66 Mortality – Suicide .............................................................................................................................................. 68 Mortality – Unintentional Injury ......................................................................................................................... 69 Obesity ............................................................................................................................................................... 71 Overweight ......................................................................................................................................................... 75 Poor Dental Health ............................................................................................................................................. 76 Poor General Health ........................................................................................................................................... 78 STI - Chlamydia ................................................................................................................................................... 79 STI – Gonorrhea .................................................................................................................................................. 83 STI – HIV Prevalence ........................................................................................................................................... 85 PRIMARY DATA KEY FINDINGS ............................................................................................................................... 89 SHERMAN OAKS HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT 2016 3 Community Input ................................................................................................................................................ 89 Appendix A .......................................................................................................................................................... 102 STEERING COMMITTEE ..................................................................................................................................... 102 APPENDIX B ......................................................................................................................................................... 103 FOCUS GROUPS ................................................................................................................................................ 103 APPENDIX C ......................................................................................................................................................... 105 COMMUNITY RESOURCES ................................................................................................................................. 105 Appendix D .......................................................................................................................................................... 133 Primary Data Collection Instruments ................................................................................................................ 133 Appendix D 1: Focus Group Questionnaire ....................................................................................................... 134 Appendix D 2: Community Survey Questionnaire ............................................................................................. 137 References ........................................................................................................................................................ 152 SHERMAN OAKS HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT 2016 4 2016 SHERMAN OAKS HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT EXECUTIVE SUMMARY The 2016 Sherman Oaks Hospital (SOH) Community Health Needs Assessment (CHNA) updates the hospital’s 2013 CHNA, and updates conditions found in the community as of 2016. As the process of reviewing and analyzing community needs has progressed, it is clear that while changes have occurred in the San Fernando Valley as a whole, and in Sherman Oaks Hospital’s immediate area, the changes have not been uniform throughout the valley. This Community Health Needs Assessment incorporates data from area-wide analyses provided by the Los Angeles County Department of Public Health (LADPH) Strategic Plan 2013-2017 (Strategic Plan) as well as more focused data concentrating on the area immediately surrounding SOH. Some data is not directly comparable between the two areas, but each discussion provides insight into needs found in the SOH service area. The larger study incorporates zip codes located mostly in the San Fernando Valley, and described by the LADPH as the County of Los Angeles’ Service Planning Area 2 (SPA 2). It is shown in the following map of Los Angeles County. SOH’s approximate location is shown in red. While Sherman Oaks and its surrounding communities are nearly at the center of this area, the community of clients for Sherman Oaks Hospital is a much smaller area. Los Angeles County performed a County Health Survey in 2015 which is very similar to the surveys conducted by KeyGroup and its cooperating agencies in 2016. The results of both surveys are presented along with comments relating the two. Sherman Oaks Hospital contracted KEYGROUP to oversee the process of developing a CHNA directly addressing needs in Sherman Oaks Hospital’s service area. This CHNA is designed to comply with California’s Senate Bill 697 (SB 697) and to meet the requirements under the Patient Protection and Affordable Care Act (ACA). KEYGROUP subcontracted with Valley Care Community Consortium (VCCC) to help conduct the 2016 Community Health Needs Assessment. VCCC has over 15 years of experience in conducting CHNAs in the San Fernando Valley and has significant research SHERMAN OAKS HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT 2016 5 expertise that harnesses the collective wisdom of its membership representing multiple institutions and disciplines. The process and the outcome of the CHNA are described in this report. To better understand the health needs in the hospital service area, KEYGROUP and VCCC reviewed numerous state and county sources. A local literature review was conducted, and community assets and resources were documented. This analysis process concentrated on the whole of SPA 2, and uses data from various years. KEYGROUP also obtained data from focus groups, surveys and data analysis focusing on Sherman Oaks Hospital’s Primary Service Area (PSA). This area is defined as the zip codes from which more than 50% of all discharges originate. This analysis allows for more concentrated focus on needs nearest the hospital, and on health needs that the hospital is most able to address. A map of the PSA as defined by 50% of all discharges in 2014 is shown below. Health needs in the SPA 2 area were identified by KEYGROUP and VCCC through focus groups, key informant interviews and surveys conducted in 2015 and 2016. Much of the use data analyzed is from 2013 and 2014, since that is often the most recent data available. Additional data was obtained from Speedtrack, a data source which obtains utilization information directly from hospitals and aggregates it, while still allowing for small-area analysis with permission from specific hospitals. SOH provided permission, and data on utilization of various hospital services is hospital specific. Some utilization patterns for SOH differ from those of SPA 2 as a whole. Surveys for all of SPA 2 were obtained, and KEYGROUP conducted additional surveys of local respondents. This data was analyzed in terms of overall SPA 2 responses and by segregating the responses from the SOH PSA. Focus Group interviews were conducted by both VCCC and KEYGROUP, with the KEYGROUP focus groups concentrating on issues most important to local participants. Both sets of interviews produced a variety of perceived needs, which were reviewed and winnowed down to the most immediate health needs for the SPA 2 and for SOH’s PSA. The relative importance of various needs differed between the SPA 2 and PSA. Summaries for immediate health needs are provided below, listed in order from highest to lowest priority as listed by respondents in the SOH PSA. Their relative SHERMAN OAKS HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT 2016 6 importance for SPA 2 recipients is noted where appropriate, and the remaining items in the SPA 2 top list are discussed following the SOH items. The SOH focus groups started with over 30 issues and the VCCC groups listed 29. In both cases, the groups narrowed the range significantly, arriving at a top seven. The first two are closely related, although not specifically addressed in SPA 2 discussions. 1. Coordination of Care – Existing payment programs and referral patterns among healthcare providers are highly site-specific, and patients leaving a hospital or other care provider are often also leaving the payment program that covered their care. Any follow- up care is often at the mercy of the entity to which the patient is referred, and often there is little or no coordination regarding care needs and/or regimens to assure maximum recovery. This can result in preventable relapses or complications. Over the past three years, the federal government has attempted to address these issues in many ways, but a true coordination system has yet to be developed. Individual providers are attempting to work across healthcare provider “silos” to organize care coordination programs, but much work remains to be done. 2. Transitions of Care – The actual provision of care is just as fragmented as the payment system that supports it, and patients discharged from hospitals or other care facilities often find themselves at loose ends once they leave the premises. Care coordinators and social service agencies attempt to manage transitions, but their ability to assure appropriate care in offsite situations is constrained by their inability to actively follow clients from the facility to another care site or to home. There are no formal programs to determine that the care settings into which patients are released are the most appropriate, or even adequate. Existing payment programs generally provide no ability to fund follow-up care or patient management programs. Some early systems are being designed to work with the most frequently seen clients to minimize the amount of time they spend in inpatient settings, but funding for such systems is not commonly available, and care providers are developing these systems on their own. 3. Payment Issues – The Affordable Care Act has been very successful in increasing the number of California residents who have health insurance in some form, with one-third of the state’s residents now covered by MediCal and fewer than 12% of the state’s total residents without insurance, down from over 16% three years ago. One side effect of the push to get people insured is that many of the insurance programs developed have been designed with substantial deductibles. So even though more people have insurance, they still face significant costs if they actually use that insurance. Thus, while the proportion of uninsured and self-pay patients decreased and the number of clients with insurance cards has grown, the amount of bad debt from unpaid deductibles and coinsurance has also increased. As insurance rates rise faster than inflation, employers who provide health insurance have increased their deductibles and copays as well. And while the ACA-conforming policies ostensibly cover a wide range of illnesses, SHERMAN OAKS HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT 2016 7 including mental illness, the range of conditions not covered is still large. Finally, the ACA-conforming policies typically do not address the coordination/transition issues discussed earlier. 4. Mental Health - According to the primary data collected via key informant interviews, focus groups and surveys, many of the health care providers identified mental health as a major issue in the Sherman Oaks Hospital service area. Discharge records for 2014 from SOH show that the single most common MS-DRG family is Psychoses (the overall term for mental health issues), accounting for nearly 25% of all discharges for that year. Mental Health was the most commonly cited Health Need by VCCC focus group participants throughout SPA 2, and was also the fourth most-mentioned item, described as “Access to Mental Health Providers”. This condition is often a co-morbidity with other physical ailments. and mental issues existing beside actual physical disabilities complicate treatment for the physical manifestations. While mental health conditions are formally considered equivalent to physical ailments for payment purposes, diagnosis and treatment protocols for them are less well-defined, and most insurers tend to encourage outpatient care for all but the most dangerous mental conditions. Additional problems related to mental health include a high incidence of homelessness and substance abuse, which are not amenable to inpatient treatment and are typically not considered reimbursable services by payors. Since hospitals have no control over patients’ mental illness treatment courses after they are discharged, and compliance with treatment regimens is difficult, patients with mental issues in addition to their physical ills are some of the most often re-admitted clients at any hospital. 5. Diabetes – Diabetes was the physical ailment most commonly cited as an issue by the focus groups at SOH, and the second-most common Health Need cited by SPA 2 focus group respondents. It is a common underlying condition for many other acute admissions to SOH and other hospitals because it presents so many complications that create crisis situations. While it is not one of the most common admission diagnoses, it is one of the most common complications accompanying the admitting diagnosis, and it was among the top ten causes of death cited in the Los Angeles Department of Public Health’s (LADPH) Strategic Plan 2013- 2017 (Strategic Plan). Adult-onset diabetes is largely a lifestyle disease, commonly associated with obesity and lack of exercise. As with mental illness, treatment for diabetes is typically a long-term process and best conducted on an outpatient basis. But as is the case with mental illness, hospitals have little ability to control compliance with treatment regimens and thus, many diabetics find themselves in and out of hospitals as they fail to manage their condition. Diabetes was the second-most cited issue among respondents in VCCC’s Focus Groups. 6. Heart Disease - Cardiovascular disease includes congestive heart failure, heart attack, coronary heart disease/coronary artery disease and stroke. Coronary issues are among the most frequently reported reasons for SOH hospital admissions, and these conditions are similar among other SPA 2 hospitals. Coronary Heart Disease and Stroke are the Number 1 and Number 2 causes of death in the Strategic Plan, and together they represent over half of all deaths due to the top ten causes of death in the county. SHERMAN OAKS HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT 2016 8 7. Lack of Knowledge about Health Services - Knowledge of healthcare needs is both commonly held and highly specialized. Nearly everyone knows that he/she should exercise, eat in moderation and not engage in risky activities. Beyond those basics, knowledge specific behaviors and regimens to maintain good health is less common, and for people with specific health issues, the appropriate actions may not be intuitive. Added to this limited knowledge base is the fact that accessing experts (i.e., physicians, dieticians, etc.) can be costly for those not highly insured. Data is available on websites and various disease-related organizations work to inform the public about their chosen illnesses, but many area residents may not know where to find needed information, or may not feel they can afford to see the appropriate professional. During primary data collection process, health care professionals and service providers shared that there is a lack of knowledge regarding the existing health care services among their constituents. This lack of knowledge regarding low cost health care services makes it difficult for their clients to access the care they need. These seven issues were raised by SOH’s focus groups, and variations of them are present in the VCCC data from SPA 2. The SPA 2 Focus Group’s top ten data also identified some additional issues that affect the greater San Fernando Valley area and residents of SOH’s PSA. 8. Obesity – Although not a specific disease, obesity is a risk factor to other chronic diseases such as hypertension, high cholesterol, heart disease, and diabetes. It is most often addressed by lifestyle changes, but clinical interventions such as bariatric surgery are becoming more common. Unfortunately, the prevalence of obesity is also growing, making it a significant public health issue. 9. Cancer - Cancer is one of the leading causes of death in the U.S. Various types of cancer were three of the top ten causes of death in the Strategic Plan 2017. Cancers can occur in nearly every bodily system, and each type presents unique issues and treatment options. Since each type is tracked separately, the overall impact is understated by the three top causes in the top ten list. The fact that each type of cancer is unique also provides niches allowing hospitals and physicians to specialize in various treatments. 10. Hypertension – Hypertension is often grouped with heart disease, although it is a separate issue, related to constricted blood vessels that cause the heart to work harder to pump blood throughout the body. It is treatable with changes in diet, lifestyle, and if needed, drugs. 11. Substance Abuse Disorder – This category subsumes multiple “substances”, including alcohol, opiates, prescription drugs used off-label, and others, each of which has specific health problems associated with its use. The common factor is that the user does not or cannot control his/her consumption of the substance and thus is amenable to treatment. Each treatment course is unique to the specific problem, but all programs seek to wean the user from the drug and promote a lifestyle free from the abused product. SHERMAN OAKS HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT 2016 9 12. Access to Primary Care – Many of the visits to Emergency Departments result from illnesses or injuries that could be easily treated in a physician’s office or clinic, if one were available. Since many area residents do not have a family physician, and many medical problems occur outside of normal office hours, the ED becomes the primary care provider, at great expense to the client and to the hospital. Provisions of the Affordable Care Act attempt to remedy this problem by getting more residents insured, and connected to a Primary Care Provider (PCP). But while more people have a physician to call, the office hours for most physicians are still limited, and the stock answer to a phone call to almost any physician’s office includes a referral to the nearest emergency room if the call is of a critical nature, or if the office is closed at the time of the call. 13. Poverty – Like Obesity, poverty is not a specific disease, but its presence increases the odds that some ailment will occur. Poverty manifests as difficult lifestyle choices that put people in danger of medical crises such as diabetes, hypertension, and heart attacks, among other ailments. Areas with high poverty rates often have higher crime rates, and fewer sources of healthy food, with an accompanying excess of less-healthy eating options. For the unemployed in poverty, the cost of health insurance is often unmanageable, and despite California’s attempts to draw these residents into MediCal programs or other insurance options, the combination of difficulty getting qualified for benefits and the costs of obtaining care, are still high hurdles for many. The issues above are the consensus issues from many sources that merit the most consideration by hospitals in the area. Each hospital has differing abilities to address each issue. Sherman Oaks Hospital’s Implementation Plan will focus on the issues related to access, mental health and cardiac care. SHERMAN OAKS HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT 2016 10