2019 Community Health Needs Assessment, Study notes of Public Health

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2019 Community Health

Needs Assessment

TABLE OF CONTENTS

• i. EXECUTIVE SUMMARY
• I. INTRODUCTION
  • A. Retrospective Review - 2016 Community Health Needs Assessment
  • B. Retrospective Review - 2016 Implementation Strategy
    • i. Saint Joseph Mercy - Ann Arbor
    • ii. Saint Joseph Mercy - Chelsea
    • iii. Michigan Medicine (University of Michigan Health System)
• II. COMMUNITY SERVED
• III. 2019 CHNA PROCESS AND METHODS USED
  • A. Prioritizing Community Health Needs
• IV. DOCUMENTING AND COMMUNICATING RESULTS
• V. CONCLUSION
  • Appendix A - Community Description Hospitals APPENDIXES
  • Appendix B - Washtenaw County Community Reports Summary (Fall 2018)
  • Appendix C - Mothers Focus Group Data Summary
  • Appendix D - Root Cause Analysis of Three (3) Social Determinants of Health
  • Appendix E - Community Engagement Online Survey
  • Appendix F - Saint Joseph Mercy - Chelsea Community Engagement Meetings
  • Appendix G - Grantee Kick-off Meeting Feedback
• ENDNOTES

I. INTRODUCTION

The Patient Protection and Affordable Care Act (PPACA) of 2010 mandated new IRS requirements for hospitals to: (i) conduct a Community Health Needs Assessment (CHNA) every three years and (ii) adopt an Implementation Plan to address community needs every three years. Both the assessment and plan must be reported in the hospital’s Schedule H 990. The provisions took effect in a hospital’s taxable year beginning after March 23, 2012. Failure to comply could lead to a $50,000 excise tax and possible loss of tax-exempt status. Until 2016, each hospital in Washtenaw County published an individual Community Health Needs Assessment. While each CHNA’s structure and format was unique to the specific hospital, the proximity of the three hospitals resulted in comparable community needs and populations served. Each hospital also utilized the same community level data and surveys to identify these needs. To improve service to the community and to increase the impact of the implementation plan, each hospital made a commitment to come together and publish a collaborative CHNA on behalf of all three hospitals in the area: Saint Joseph Mercy Ann Arbor, Saint Joseph Mercy Chelsea, and the University of Michigan Health System. Representatives from each hospital formed a group titled UNITE (Unified Needs Assessment Implementation Plan Team Engagement) to engage the community and collaborate to assess and address community needs together. The Washtenaw County Health Department also sits at the UNITE table as a critical partner in this work. The first joint plan was published in 2016, and the group re-convened for the 2019 cycle.

A. RETROSPECTIVE REVIEW -

2016 COMMUNITY HEALTH NEEDS ASSESSMENT

Identification and Prioritization of Needs

Members of the UNITE team analyzed data from multiple data sources, community focus groups, and key stakeholder and informant interviews to determine potential priority areas. Potential priority areas were evaluated based on the following agreed-upon criteria, taken from each hospital’s previous criteria, and based on common public health frameworks:

1. Number of people impacted,
2. Severity of the problem,
3. UNITE members’ ability to positively impact the potential priority,
4. UNITE members’ ability to enhance existing resources or complement strategies
5. Alignment with institutional missions, and
6. Likely impact on health equity. Potential priorities were ranked using a point system based on how well the potential priorities met criteria one through five; points were then summed for these criteria. To emphasize criterion six, the UNITE group agreed to separately rank each potential priority and then multiply by a factor reflecting impact on equity for each potential priority, thus allowing for health equity to have a bigger impact in the final selection of top health priorities. If there was a tie, it would be resolved by democratic vote, with one vote per UNITE voting entity (Saint Joseph Mercy Ann Arbor, Saint Joseph Mercy Chelsea, and the University of Michigan Health System).

Ranked potential priorities were then presented to the Washtenaw Health Initiative Steering Committee for review before being presented for approval and adoption to the hospital executive boards of Saint Joseph Mercy Ann Arbor, Saint Joseph Mercy Chelsea, and the University of Michigan Hospitals and Health Centers. The following were presented as potential priority health needs: Oral Health

• Decay-related tooth loss
• Dental care Mental Health
  • Mood disorders
  • Psychoses
  • Anxiety disorders Infant Mortality Cardiovascular Diseases
• High blood pressure
• Stroke Substance Use Disorder
  • Tobacco use
  • Binge drinking
  • Marijuana use
  • Opioid use Unintended Pregnancy Diabetes Obesity Vaccine-Preventable Diseases From these, three top health priorities were adopted by the approval bodies at each institution:

Priority 2: Obesity and Related Illnesses Goal #1: Promote healthy weight and reduce chronic disease risk among youth and adults. Activity #1: Support, maintain, and explore programs that target nutrition education (i.e. Health Exploration Station, ShapeDown, The Farm). Outcome: Over 1,000 students per year participated in youth education at The Farm at St. Joe’s. Additionally, over 250 youth per year participated in ShapeDown weight management programming. As a result of the ShapeDown program in 2017, 55 percent of participants reported that their Body Mass Index (BMI) decreased or remained the same, and self-reported consumption of three or more servings of fruit and vegetables per day went from 37 percent to 70 percent of participants. Activity #2: Through Washtenaw County Coordinated Funders Program Operations grants cycle, finance efforts to reduce food insecurity through local safety net food provision organizations. Outcome: Over $50,000 per year was allocated through Coordinated Funding to support food security initiatives. Each year, SJMHS hospitals return over $500,000 back to local farmers through programming run or supported by hospital sites. Coordinated Funding efforts contributed to a decrease of those reporting food insecurity in the community within the Implementation Plan cycle. Priority 3: Pre-conceptual and Perinatal Health Goal #1: Increase positive outcomes for pre-conceptual and perinatal health. Improve the health and well-being of women, infants, children, and families. Activity #1: Educate expectant mothers on the risks of smoking during pregnancy; continue Centering Pregnancy group pre-natal program. Outcome: Centering Pregnancy 2017 results show the rate of premature babies decreased from 12 percent to 4 percent; low birth weight decreased from 7.8 percent to 4 percent; and 82 percent of mothers reported breastfeeding at hospital discharge. .

Saint Joseph Mercy – Chelsea

Priority 1: Mental Health and Substance Use Disorders Goal #1: Improve health by increasing social support and access to behavioral health services. Activity #1: Expand presence of behavioral health services staff in primary care and community settings. Outcome #1: A Behavioral Health Navigator was deployed in the five communities that make up the SJMC primary service area, to help people access needed mental health services. The BHS Navigator works with safety net providers, schools, primary care physicians, and others who can refer individuals or families in need of support. In the first two years of this program, the Navigator assisted 251 people, and provided education and training for 2,467 people. Outcome #2: SJMC secured grant funding from the Community Mental Health Partnership of Southeast Michigan to bring a Project SUCCESS Counselor to two local school districts. Project SUCCESS is a school-based youth substance abuse prevention program. The counselor conducts screening, facilitates small group work, provides brief individual interventions, and makes referrals to community mental health providers when needed. The counselor also coordinates positive social norm campaigns to promote the fact that most teens do not use drugs or alcohol. Finally, the counselor conducts educational sessions for students and parents on drugs and alcohol, including vaping, or e-cigarette use. Activity #2: Participate in local youth mental health coalition and support related activities. Outcome: Hospital representatives from the Community and Behavioral Health departments participated on school district wellness committees, as requested, to address mental health issues among youth. Activity #3: Increase capacity to provide outpatient services to youth and adults. Outcome: Measured by patient volume in outpatient BHS in Chelsea and Dexter. Activity #4: Provide opportunities for mindfulness and wellness. Outcome: In partnership with the Cancer Center, and Therapy Departments, SJMC provided free yoga classes designed specifically for cancer patients, survivors and families in the community. Goal #2: Reduce Substance Use Disorders to protect the health, safety, and quality of life for all, especially children. Activity #1: Support local community coalitions in addressing the risk and protective factors that lead to youth substance abuse. Outcome: SJMC facilitated the SRSLY coalitions in Chelsea, Dexter, Manchester and Stockbridge, which work to prevent youth substance abuse. These communities have seen youth substance use rates drop in recent years, as measured by the Michigan Profile for Healthy Youth survey. Less than 15% of high school students reported regular marijuana use in these four communities, and this rate was lower than it was when SRSLY started; regular marijuana use has increased in other communities in Washtenaw County during the same time period. Lifetime and regular alcohol use and binge drinking were also down across these four towns during this time period; Binge drinking among Chelsea teens is down by 52% compared to 2007. (Source: MiPHY)

Activity #3: Build skills and provide support to prevent the onset or complications of diabetes and other weight-related illnesses. Outcome #1: SJMC began offering the Diabetes Prevention Program in 2016 through Faith Community Nursing, and expanded the program under Diabetes Education in 2017. Program participants have reported an average weight loss of 10 pounds, or 5.74% of starting body weight. The most recent cohort to complete the program in Chelsea enjoyed the peer support aspect of the program so much, they decided to form an ongoing monthly share group, so they could continue to meet after the initial 12-month program ended. Outcome #2: The SJMC Diabetes Share Group met monthly to provide education and support to residents living with diabetes. The group heard presentations from medical professionals and community partners, including the local wellness center and farmers markets. Outcome #3: Hungerwise is a mindfulness program to support healthy eating, created by SJMC in partnership with the Center for Eating Disorders in Ann Arbor. SJMC subsidized the program to make it more accessible to area residents. Hungerwise is not a weight loss or dieting program. Participant feedback has been very positive. Activity #4: Participate in local wellness coalitions’ and support activities related to social support as needed. Outcome #1 : 80% of wellness coalition meetings include a representative from SJMC, totaling more than 250 hours per year donated in-kind to support the coalitions. Goal #2: Improve social determinants of health for the poor and vulnerable living in the SJMC service area. Activity #1: Provide support to partner organizations working to address social determinants of health for poor and vulnerable populations living in the SJMC service area. Outcome: From 2016 to 2018, SJMC donated $627,084 to non-profit organizations in the communities to address social determinants of health, including housing, food access, social isolation, education and transportation. Activity #2: Increase rates of low-income residents with health insurance. Outcome: Two SJMC staff members were trained to help people enroll in health insurance through the marketplace exchanges, or Medicaid expansion. More than 100 local residents were able to enroll in health insurance through Medicare, Medicaid, the Health Insurance Exchange, or McAuley Support with the help of these hospital staff. Activity #3: Increase access to transportation for low-income residents. Outcome: SJMC provided vouchers to patients who cannot afford transportation to and from healthcare appointments. The hospital also provided in-kind an financial assistance to the Washtenaw Area Value Express bus, which services Chelsea and the surrounding communities.

Michigan Medicine (UMHS)

Priority 1: Mental Health and Substance Use Disorders Goal #1: Improve mental health through prevention and by ensuring access to appropriate quality mental health services and supports. Activity #1: UMHS Depression Center has continued its depression and suicide awareness campaigns in numerous schools throughout Washtenaw County. Also, the Depression Center continued to build community awareness through its Bright Nights Forum at local libraries. Outcome: Depression Center data available regarding awareness activities. Bright Nights Forum served approximately 125 persons per forum. Activity #2: UMHS continued to provide a regularly occurring Speaker series for the Deaf, Deaf/ Blind, and Hard of Hearing population using American Sign Language and providing free parking and food. Outcome: Attendance data and topics can be obtained from UMHS Interpreter Services or from UMHS Deaf Health Clinic. Activity #3: Michigan Medicine Population Health Office and Community Health Services worked collaboratively to develop a Social Determinants of Health screening to first pilot test and then implement across all Patient Centered Medical Homes within the system. This tool has helped screen and identify patient needs. The two departments are working on how to effectively enact change for all those who desire assistance. Outcome: Patient Centered Medical Homes data report Activity #4: Train providers to increase capability towards addressing needs of LGBTQ+ population, youth in schools, and Limited English Proficient (LEP) population through UMHS Interpreter Services. Outcome: Michigan Medicine Adolescent Health Initiative has developed four Spark training modules to improve quality of care for LGBTQ+ youth. Activity #5: Continued collaboration with Michigan Islamic Academy to coordinate the Health Sparks school based health program. Outcome: Program serves approximately 160-200 students on a yearly basis and their school staff. Program has developed a peer to peer support network to help students learn how to identify depression in classmates and friends. Activity #6: Provide health safety net services to uninsured and underinsured through health clinics, health fairs, and screenings in the community. Outcome #1: Annually, Community Health Services provided free immunizations at local area churches and other community venues. Also, UMHS donated physician labor to the Hope Clinic from various departments. Outcome #2: UMHS Emergency Department provided Emergency ride home services for patients who need transportation. This served approximately 1000-1100 patients each year.

Activity #4: Michigan Medicine’s Regional Alliance for Healthy Schools (RAHS) served students and youth through visits with a Registered Dietitian. Outcome: RAHS, in partnership with the Washtenaw County Health Department and Saint Joseph Mercy Health System, provides a Prescription of Health program to help support the increase of fresh vegetables and fruit by providing tokens to redeem at local farmer markets. In FY18 they enrolled a total of 63 patients. RAHS also partnered with Food Gatherers to distribute food boxes to students and families in need throughout their schools within Washtenaw County. They distributed between 5 to almost 50 boxes at each of the six schools they serve. Activity #5: The Program for Multicultural Health in partnership with the UM-School of Public Health Dietetic Interns and School of Public Health Future Public Health Interns provide nutrition education to both youth and seniors. Outcome: Data available upon request. Activity #6: Participate and support local wellness activities, such as coalitions, walks, runs, and other wellness events. Outcome: Data available on monies to support, volunteers, and number of participants. Activity #7: UMHS Patient Food and Nutrition Services (PFANS) has partnered with Ypsilanti Meals on Wheels to provide tailored meals to fragile and homebound seniors that support their chronic disease conditions. Outcome: UMHS-PFANS has become the supplier of balanced and nutritious meals to Ypsilanti Meals on Wheels (YMOW). This partnership has allowed YMOW to increase the number of meals from 5 to 6-7 meals per week per person. Priority 3: Preconceptual and Perinatal Health Goal: Increase positive outcomes for preconceptual and perinatal health. Improve the health and well-being of women, infants, children, and families. Activity #1: U of M Psychiatry continues to provide a regular cycle of MOM Power programming out in the community for qualifying low-income residents. Outcome: Data available in MiChart. Activity #2: Provide positive parenting resources and empowerment workshops in public and low income housing communities. Outcome #1: Michigan Medicine Program for Multicultural Health has developed a partnership with Family Empowerment Program and the Nursing sorority (Chi Eta Phi) to host health cafes that help with empowerment of families and individuals towards better health. Outcome #2: Program for Multicultural Health staff devoted time to service to promote breastfeeding among Black Mothers through staff support of Black Mothers Breastfeeding Association (BMBFA), at the Ypsilanti Heritage Festival (YpsiFest) offering a safe, secure, and comfortable place for mothers to feed their infants. Also, providing trainings to groups within UMHS regarding supporting mothers when they go back to work. Activity #3: UMHS Maternal Infant Health Program has continued to serve Mothers and Infants within Washtenaw County. Outcome: MIHP Has served 787 women between FY16 & FY17.

Activity #4: UMHS Women’s Health Program provides a variety of classes to help educate women on birth, infant care, and other pre-conceptual and perinatal health topics. Outcome: Women’s Health Program has hosted a total of 42 events from FY16 - FY18. Activity #5: Develop data collection strategy for use in community to identify supports and programming needed. Outcome #1: Conducted a series five (5) focus groups (1 focus group in Spanish) with a total of 25 participants. Groups were hosted at community organizations, housing communities, and health centers in Ypsilanti, MI. Outcome #2: One-on-one interviews were conducted with mothers within the Deaf/Hard-of- Hearing community. Focus on Health Equity, the Social Determinants of Health and Community Accountability Within each of the three priority areas described above, the University of Michigan Health System (UMHS) worked to address the social determinants of health and to improve health equity. With funding approved by UMHS executive leaders, Michigan Medicine Community Health Services conducted two RFP processes from 2018-19, requesting proposals from both community-based organizations and University of Michigan internal departments. Ultimately, UMHS funded a total of 26 community-based projects in the following categories. Below is a breakout of dollars granted per CHNA health priority. For more information on the funding opportunity please visit: http://www.uofmhealth.org/news/ar- chive/201810/michigan-medicine-commits-72m-addressing-health-inequities or http://www.med. umich.edu/chs/.

Washtenaw County residents are 77.8 percent white, 14.2 percent Black or African American, 10. percent Asian, 4.5 percent Hispanic or Latino, and 0.2 percent Native Hawaiian or Pacific Islander. Percentages do not total because more than one race/ethnicity could be selected. RACE Percentage of County Population White 77.8% Black / African American 14.2% Asian 10.2% Native Hawaiian / other Pacific Islander 0.2% Other 1.0% Hispanic or Latino (of any race) 4.5% The additional villages of Greater Washtenaw County served are more rural, and less racially diverse.

Of the 3,941 in Stockbridge Township, for example, 98.7 percent are white and the population is older, on average, with 22.1 percent age 19 or under, 28.1% age 20 to 44, 31.2 percent age 45 to 64, and 18.7 percent 65 or older.^3 Stockbridge Township, Ingham Co. MI https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF Total Population: 3, GENDER Percentage of Stockbridge Township Population Percentage of Grass Lake Charter Township Population Male 49.54% 53.4% Female 50.6% 46.6% Age 19 years old & Under 22.1% 25.0% 20 - 44 years old 28.1% 27.6% 45 - 64 years old 31.2% 34.2% 65 & older 18.7% 13.2% RACE White 98.7% 95.4% Black / African American 0.2% 1.9% Asian 1.4% 2.0% Native Hawaiian / other Pacific Islander 1.6% 0.0% Other 0.0% 0.9% Hispanic or Latino (of any race) 4.2% 1.7% 3 Stockbridge Township, Ingham Co. MI https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF (Washtenaw County Population (2013-2017 ACS 5-Year Estimates) *race alone or in combination with other races)

III. 2019 CHNA PROCESS AND METHODS USED

Process and methods The purpose of the 2019 CHNA was to:

• Evaluate current health needs of the community and discern whether previously identified needs continue to be priority areas
• Identify resources available to meet both the priorities as well as the opportunities identified through the CHNA
• Inform the development of an Implementation Plan to address the health priorities
• Build capacity to address the opportunities within the context of the existing health system pro- grams, resources, priorities, and partnerships Infrastructure The infrastructure designed to successfully complete this CHNA required the full collaboration and participation of all three health systems and their partners.^4 Representatives from Saint Joseph Mercy Ann Arbor, Saint Joseph Mercy Chelsea, the University of Michigan Health System, the Washtenaw County Public Health Department and the Washtenaw Health Initiative (WHI) met regularly to develop the CHNA. Within each organization there was an internal structure for CHNA development. This infrastructure was based on existing partnerships within each health system, in addition to the establishment of new partnerships. No third parties were contracted to conduct this CHNA. Saint Joseph Mercy Ann Arbor -- The CHNA and Implementation Strategy work at SJMAA was guided by the Community Benefit Ministry Council (CBMC), a leadership council comprised of SJMAA clinicians, department directors, and administrators with background, knowledge, and interest in health promotion and disease prevention. This group met monthly to review and analyze data, identify community partners, set priorities, and make decisions about the hospital’s community health improvement initiatives. CBMC is responsible for conducting the Community Health Needs Assessment and developing the Implementation Strategy. Saint Joseph Mercy Chelsea -- The CHNA and Implementation Strategy work at SJMC was guided by the Community Health Improvement Council (CHIC), a leadership council comprised of SJMC board members, clinicians, department directors, and administrators with background, knowledge, and interest in health promotion and disease prevention. This group met monthly to review and analyze data, identify community partners, set priorities and make decisions about the hospital’s community health improvement initiatives. CHIC is responsible for conducting the Community Health Needs Assessment and developing the Implementation Strategy. University of Michigan Health System -- The CHNA and Implementation Strategy work at UMHS was guided by the UMHS Community Health Coordinating Committee (CHCC). CHCC includes a wide range of leaders from the University of Michigan Medical School, the Office of Health Equity and Inclusion, the Department of Family Medicine, the Population Health Department, the Cardiovascular Center, the Children’s and Women’s Hospital, and the Obstetrics/Gynecology Department at UMHS, as well representatives from the Michigan Institute for Clinical and Health Research, the UM School of Public Health’s Office of Public Health Practice, the UM Law School, the UM Ford School of Public Policy, and several community members.

The Washtenaw County Health Department (WCHD) actively participated in the UNITE process as a collaborator, a subject matter expert, and a connector to community resources and representatives. WCHD worked to align the Washtenaw County Community Health Improvement Plan (CHIP) priority health issues with those of UNITE. The Washtenaw Health Initiative continued to support and assist the UNITE group in the 2018- CHNA cycle. This support was given through the dedication of in-kind staffing (0.25 full-time equivalent in-kind staffing) for managing the project, securing logistics, gathering and analyzing data, and facilitating the group. Data sources Secondary data analysis In order to build on the wealth of information and data analysis that had already been conducted by social service agencies, local government entities, county public health departments, and community-based organizations, the UNITE collaborative reviewed and analyzed 40 community assessments relating to health outcomes and the social determinants of health, including reports on housing and homelessness, food security, poverty, transportation, health literacy, and economic equity. Each team member was allotted a certain number of reports to analyze and summarized key data points as they related to health inequities. These content and data summaries formed the basis for a deeper discussion at a UNITE data retreat that was convened in November 2018. Primary data collection In addition to the secondary data analyzed, UNITE members conducted primary data collection in areas where it was felt there were gaps in existing data. Specifically, Michigan Medicine conducted five focus groups to understand the needs of pregnant women and mothers of young children, as these groups were underrepresented in the secondary data. Four English and one Spanish focus group were facilitated in the community, with a focus on low-income and under-served groups. UNITE sought to better understand their specific needs, especially in light of the fact that pre-conceptual and perinatal health had previously emerged as one of the community’s top health needs. Another mode of primary data collection was through the Michigan State Innovation Model (SIM), which required hundreds of primary care providers across the state to screen their patients for social determinants of health needs. Michigan Medicine and Saint Joseph Mercy Health System clinical partners through IHA medical group deployed this SDOH survey across a variety of clinical service providers. Through December 2018, 72,430 patients were screened across three health systems and 5 percent reported at least one of the nine social needs on the screening tool.^5 Community engagement and prioritization of needs Throughout the months of September and October 2018, UNITE members sought qualitative input from community members and key stakeholders on what the top community health needs were, as well as broader community needs. UNITE members collected this data in person at meetings of wellness coalitions, safety-net organizations, food pantries, civic clubs, ministerial associations, and Washtenaw Health Initiative stakeholders. UNITE also collected this data electronically, via a survey link sent to community partners (including healthcare providers as well as social service providers and community-based organizations). Summaries of all of their input were discussed at the UNITE November 2018 retreat.