Sutter Health Sutter Amador Hospital

1. 2013 – 2015 Implementation Strategy Responding to the 2013 Community Health Needs Assessment

Sutter Amador Hospital 200 Mission Blvd. Jackson, CA 95642 http://www.sutteramador.org/

1 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 Table of Contents

2 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 This implementation strategy describes how Sutter Amador Hospital, a Sutter Health affiliate, plans to address significant needs identified in the Community Health Needs Assessment (CHNA) published by the hospital on October 5, 2013. The document describes how the hospital plans to address identified needs in calendar (tax) years 2013 through 2015.

The 2013 CHNA and this implementation strategy were undertaken by the hospital to understand and address community health needs, and in accordance with proposed Internal Revenue Service (IRS) regulations pursuant to the Patient Protection and Affordable Care Act of 2010.

This implementation strategy addresses the significant community health needs described in the CHNA that the hospital plans to address in whole or in part. The hospital reserves the right to amend this implementation strategy as circumstances warrant. For example, certain needs may become more pronounced and merit enhancements to the described strategic initiatives. Alternately, other organizations in the community may decide to address certain community health needs, and the hospital may amend its strategies and refocus on other identified significant health needs. Beyond the initiatives and programs described herein, the hospital is addressing some of these needs simply by providing health care to the community, regardless of ability to pay.

About Sutter Health

Sutter Amador Hospital is affiliated with Sutter Health, a not-for-profit network of hospitals, physicians, employees and volunteers who care for more than 100 Northern California towns and cities. Together, we’re creating a more integrated, seamless and affordable approach to caring for patients.

The hospital’s mission is to enhance the health and well-being of people in the communities we serve, through a not-for-profit commitment to compassion and excellence in health care services.

Vision Sutter Health leads the transformation of health care to achieve the highest levels of quality, access and affordability.

Values Excellence and Quality Caring and Compassion Honesty and Integrity Teamwork Community At Sutter Health, we believe there should be no barriers to receiving top-quality medical care. We strive to provide access to excellent health care services for Northern Californians, regardless of ability to pay. As part of our not-for-profit mission, Sutter Health invests millions of dollars back into the communities we serve – and beyond. Through these investments and community partnerships, we’re providing and preserving vital programs and services, thereby improving the health and well-being of the communities we serve.

In 2012, our network of physician organizations, hospitals and other health care providers invested $795 million (compared to $756 million in 2011) in health care services for low-income people, community health improvement services, and other community benefits.

For more facts and information about Sutter Amador Hospital, please visit http://www.sutteramador.org/

3 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 2013 Community Health Needs Assessment Summary

Every three years nonprofit hospitals are required to conduct community health needs assessments (CHNA) and use the results of these to develop community health improvement implementation plans. These assessments are required of virtually all nonprofit hospitals by both state and federal laws.

Between early 2012 and February 2013, Valley Vision, Inc., conducted an assessment of the health needs of residents living in the Sutter Amador Hospital service area (HSA). For the purposes of the assessment, a health need was defined as: “a poor health outcome and its associated driver.” A health driver was defined as: “a behavioral, environmental, and/or clinical factor, as well as more upstream social economic factors, that impact health.”

The objective of the CHNA was to provide necessary information for Sutter Amador Hospital’s community health improvement plan, identify communities and specific groups within these communities which are 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 full 2013 Community Health Needs Assessment report conducted by Sutter Amador Hospital is available at http://www.sutterhealth.org/communitybenefit/community-needs-assessment.html

Definition of Community A community-based participatory research orientation was used to Served by the Hospital conduct the assessment, which included both primary and secondary data. Primary data collection included input from more than 50 members of the HSA, expert interviews with 14 key informants, focus group interviews with 39 community members, and input gathered at meetings of the Sutter Amador Hospital community advisory board. In addition, a community health assessment collected data on more than 40 assets in the greater Amador County area. Secondary data included health outcome data, socio-demographic data, and behavioral and environmental data at the ZIP code or census tract level. Health outcome data included Emergency Department (ED) visits, hospitalization, and mortality rates related to heart disease, diabetes, stroke, hypertension, COPD, asthma, and safety and mental health conditions. Socio- demographic data included data on race and ethnicity, poverty (female- headed households, families with children, people over 65 years of age), educational attainment, health insurance status, and housing arrangement (own or rent). Further, behavioral and environmental data helped describe general living conditions of the HSA such as crime rates, access to parks, availability of healthy food, and leading causes of death.

The study area of the assessment included the greater Amador County region. A key focus was to show specific communities (defined geographically) experiencing disparities as they relate 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.

HSAs were determined by analyzing patient discharge data. The primary geographic area served by the hospital was identified

4 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 through the collection and analysis of ZIP codes associated with patients discharged from the hospital over a six-month period.

Analysis of both primary and secondary data revealed five specific Communities of Concern living with a high burden of disease in Amador County. These five Communities of Concern had consistently high rates of negative health outcomes that frequently exceeded county, state, and Healthy People 2020 benchmarks, and were confirmed by experts as areas prone to experiencing poorer health outcomes relative to other communities in the HSA.

The Sutter Amador HSA five Communities of Concern are home to nearly 20,000 county residents. The areas consist of ZIP code communities occupying the north, central, and western portions of the Amador County area. Ione and Jackson are the most densely populated ZIP codes and include both urban and rural areas. The rural communities of Fiddletown, River Pines, and Amador City have significantly lower populations.

Jackson (95642) is the largest city in Amador County and the location of the majority of the region’s retail centers, government and social service agencies, and health care providers. Sutter Amador Hospital is located in Jackson.

Amador City (95601) is a small, rural community in the central part of Amador County, 6.5 miles north of Jackson (95642). This community is approximately eight miles or 15 minutes away from Sutter Amador Hospital.

Fiddletown (95629) and River Pines (95675) are rural communities located in the northeastern part of Amador County. Sutter Plymouth Health Center is approximately eight miles from Fiddletown and 12 miles from River Pines. Drive time to Sutter Amador Hospital from Fiddletown is approximately 30 minutes.

Ione (95640) is located in a large ZIP code in western Amador County. The ZIP code includes the town of Ione and adjacent rural areas. This community is approximately 11 miles or 20 minutes away from Sutter Amador Hospital.

Significant Health Needs The following significant health needs were identified by the 2013 CHNA. Identified

5 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 Intends to Significant Community Health Need Address Lack of or limited access to primary and preventative services Cost of co-pays is prohibitive; Lack of providers who accept Medi-Cal patients; Clinics struggle to meet demand for services; Clinics located mainly in population Yes centers, creating challenges for rural populations; Long wait times to secure appointments or inability to be seen; People only seek treatment for acute conditions or serious injuries; and Rural areas do not have urgent care facilities Lack of or limited access to specialty care Extreme difficulty getting referrals for specialty care; Specialists not located in rural areas; Many travel out of area to Stockton, Sacramento, Lodi; Conditions requiring No specialty services (i.e. dialysis) may not be properly managed; and Lack of chronic disease management support Limited transportation options Public transit routes not linked to healthcare or social service delivery points; Reaching services may require all day travel, especially on public transit; Rural No areas may not have any public transit; cost of gas prohibitive to accessing services; Elderly population becomes isolated when they can no longer drive; and Roads can be unsafe due to weather conditions Limited mental health services; lack of access to mental health services Lack of available services in Amador County, especially in rural areas and for uninsured; No services available for children and adolescents; Many programs Yes and services have been cut due to lack of funding; Many travel out of area to Stockton, Sacramento, Lodi; and Prisoners leaving Mule Creek State prison lack transitional support Lack of substance abuse treatment and rehabilitation, both inpatient and outpatient Lack of available services; Behavioral health issues exacerbated by lack of residential treatment options in Amador County; Youth and adults in residential No substance abuse programs are far from family; Prisoners leaving Mule Creek State prison lack transitional support; and Homeless population cannot access services if not sober Limited access to dental care No Medi-Cal coverage for adults, extraction often the only option; Long wait times Yes or travel out of area for pediatric dentists; Lack of providers in rural area; and Demand exceeds number of providers Limited access to prescription medications and medical equipment Prohibitive cost of prescription medication and equipment to manage chronic No conditions; Individuals forced to choose between food, rent, or medication; and Prescription costs are especially difficult for seniors on fixed incomes Lack of or limited access to health education Need for more education about maintaining health and/or managing chronic Yes health conditions; and Need for education around healthy lifestyle choices Lack of opportunities for physical activity Classes, gyms, and youth sports are too expensive; Community facilities limited Yes or have restricted hours due to budget cuts; and Cost of driving to activities is prohibitive, especially in rural areas Lack of or limited access to healthy food Abundance of fast food in urban areas; Produce is often expensive or of poor No quality in rural areas; People in rural areas must travel several miles to grocery stores; and Healthy foods are not always the most economical choice

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:

1. All data were to be sourced from credible and reputable sources 2. Data must be consistently collected and organized to allow for future trending 6 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 3. Data must be available at the ZIP code level or smaller

All indicators listed below were examined at the ZIP code level unless noted otherwise. County, state, and Healthy People 2020 targets (when available) were used as benchmarks to determine severity. All rates are reported as per 10,000 of population unless noted otherwise. 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 hospitalizations for heart disease, diabetes, hypertension, and stroke were adjusted to reduce the influence of age. Appendix I contains a detailed methodology of all data processing and data sources.

Secondary quantitative data used in the assessment include those listed in Tables 1 (Health outcome data used in the CHNA reported as ED visits, hospitalization, and mortality) and Table 1 (Socio- demographic, behavioral, and environmental data profiles used in the CHNA) contained in the full CHNA report.

Data on socio-demographics of residents of these communities, which included socio-economic status, race and ethnicity, educational attainment, status as home owner or renter, 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 exceeding established quantitative benchmarks or was consistently mentioned in the qualitative data.

The health needs identified through analysis of both quantitative and qualitative data are listed above. These were prioritized according to the degree of support in the findings. Each need is noted as a “health driver,” or a condition or situation that contributed to a poor health outcome. Health outcome results follow the list below.

7 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 2013 – 2015 Implementation Strategy

This implementation strategy describes how Sutter Amador Hospital plans to address significant health needs identified in its 2013 Community Health Needs Assessment and consistent with its charitable mission. The strategy describes:

 Actions the hospital intends to take, including programs and resources it plans to commit;  Anticipated impacts of these actions and a plan to evaluate impact; and  Any planned collaboration between the hospital and other organizations.

8 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 Lack of or limited access to primary and preventative services

Name of Program, Initiative Free Mammogram Screening Program or Activity

Description Throughout the month of October, Sutter Diagnostic Imaging centers across the SHSSR Region provide free digital screening mammograms to uninsured women in honor of National Breast Cancer Awareness Month. The goal of this outreach effort was to not only provide free screenings to underinsured women in our communities, but it also serves as an opportunity to provide women with information on health and insurance resources. Free mammograms are offered in various locations, at various times, including in Amador County, to ensure as many women as possible were able to take advantage of this effort. In addition, a packet of follow up resources was created in the event that a participant had an abnormal screening, as well as insurance enrollment services. Sutter Diagnostic staff was also given resources to provide to women who needed diagnostic follow up and/or treatment. In 2012, as a result of all of the crucial Breast Cancer Awareness efforts, SHSSR provided a total of 670 free and low-cost mammograms.

Our goal is not only to screen uninsured women, but we also use these events as a connection point for the underserved members of our community, to link them with a primary care provider and follow up resources if needed, as well as insurance enrollment information. We will have to examine the current model of this program in 2014, as under the Affordable Care Act, all women (with the exception of undocumented immigrants) will have insurance; therefore, we will reassess our process moving forward, as these events have typically targeted the uninsured only.

Anticipated Impact and Plan SAH will continue evaluate the impact of our Free Mammography to Evaluate Screenings on an annual basis, by tracking the number of people served and by assessing the community’s access to care needs in its next Community Health Needs Assessment. We will also reexamine this program with a critical eye in 2014, to ensure it evolves with the needs of the community after the implementation of the ACA.

Name of Program, Initiative Insurance Outreach, Education and Enrollment or Activity

Description Sutter Amador Hospital is working with the Amador-Tuolumne Community Action Agency (ATCCA) to provide insurance outreach and education to the underserved population in Amador County. With the support of Sutter Amador Hospital and the help of a small federal grant, the ATCCA will be doing major outreach to connect with the underserved population in Amador County to educate them about insurance coverage through Covered California. This effort by ATCAA and other community

9 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 partners throughout SHSSR program is vitally important, as Covered California, the new health insurance exchange and a critical piece of the Affordable Care Act, will launch October 1, 2013. As a result, enrolling the un- and underinsured population will be a major component of our CHNA implementation planning, as this is the first step to connecting patients with primary care and medical homes. In addition to providing funding to ATCAA, we will look for opportunities to link ATCAA with SAH efforts and other community initiatives to reach as many underserved residents as possible.

Anticipated Impact and Plan SAH will evaluate the impact the Amador-Tuolumne Community Action to Evaluate Agency’s insurance education and enrollment efforts, by tracking the number of un- and under-insured people the ATCAA is able to reach, and by assessing the community’s access to care needs in its next Community Health Needs Assessment.

Name of Program, Initiative Expanded Partnerships with Rural Health Clinics/FQHCs or Activity

Description Over the long-term, SAH plans to explore the possibility of expanding partnerships with rural health clinics and FQHCs. We would look at creative ways to strengthen the relationship between SAH and FQHC’s like WellSpace Health, as building both the capacity and sustainability of FQHC’s continues to be of critical importance not only to Sutter, but is vital to the overall health and wellbeing of the community.

Our 2013 CHNA reports show that lack of access to care is one of the most dire health related challenges facing our region. If we don’t make strategic investments in our rural health clinics and FQHC's, we are going to be left with thousands of newly insured Medi-Cal patients in 2014, with no medical home. Therefore, it is our goal to tighten the partnership with these important health clinics, to provide a linkage to primary and mental health services to those who need it the most.

In addition to addressing the lack of access to primary and preventative services, expanded partnerships with rural health clinics and FQHCs would also tackle lack of access to mental health services.

Anticipated Impact and Plan SMF will continue along the path of recruiting more physicians for the to Evaluate rural health clinics in Amador and will review the impact (number of patients seen, etc) on a yearly basis. We predict this effort will help increase access to primary and mental health services for the underinsured residents in the SAH HSA. If we need to move into phase two down the line, where we look at partnership with an FQHC, we would project the number of patients that could be served each year and determine the impact on the community’s access to care needs in its

10 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 next CHNA, to measure effectiveness.

Name of Program, Initiative Other investments or Activity

Description SAH will continue to invest in many of the organizations and events it’s historically supported, and recommend expanding the scope of the key community benefits initiatives that have become so important to the underserved community and directly address the top health needs identified by the CHNA in the Sutter Amador Hospital HSA.

We recognize that we can’t address all of the health needs in our community alone, we also provide funding and support to various organizations throughout the community to help us meet the needs of patients as it relates to all of the priority needs outlined in the full CHNA. We will continue to explore new partners, examine existing programs and look for ways to form innovative partnerships, to collaboratively meet the needs of the underserved in Amador County, especially around issues like access to care, dental and other priority needs that have been identified.

Anticipated Impact and Plan We will review these investments on a yearly basis and evaluate their to Evaluate impact on the needs identified in the CHNA and measurable outcomes.

11 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 Lack of or limited access to health education

Name of Program, Initiative Diabetes Education or Activity

Description Led by a nationally recognized diabetes educator and specially trained staff of nutritionists, Sutter Amador Hospital's (SAH) Outpatient Diabetes Education and Clinical Nutrition Center helps people with diabetes and their families understand and manage this life-threatening disease. Services include training in the use of blood sugar testing equipment, diet and exercise, food shopping and symptom control. The program also offers Sweet Success, a program with special education and counseling for pregnant women.

The Outpatient Diabetes Education and Clinical Nutrition Center also hosts a Diabetes Fair that offers free blood-glucose and hemoglobin AIC testing for more than 200 participants each year. The fair provides an opportunity for local residents to talk to vendors about personal blood sugar testing equipment, insulin pumps, dietary supplements and other products.

In addition, the Diabetic Youth Summer Camp Program is funded by vendors of the Diabetes Fair and gifts from the community. This program pays for young people with diabetes to attend summer camps designed for their special needs and provides an opportunity for them to meet others dealing with the challenges of living with diabetes.

Anticipated Impact and Plan SAH will continue to evaluate the impact of the Diabetes Education to Evaluate program, by examining how many people we reach and if it has a positive effect on the overall health literacy in Amador County. We are also looking at other possible education classes that we can bring to SAH or provide funding to other organizations who are doing important health literacy work, within the SAH HSA.

12 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 Limited Access to Dental Care

Name of Program, Initiative Support of Dental Care in the SAH HSA or Activity

Description Sutter Amador Hospital partnered with the Amador Oral Health Task Force to help address one of the priority areas of focus in Amador: providing underinsured children with dental care. This partnership allowed the Oral Health Task Force to offer twice-yearly dental screenings, dental education and fluoride varnish to uninsured/underinsured children in Amador County. As a result of this effort, 260 underinsured and uninsured kindergarteners received dental screenings. Lack of adequate dental care was identified as a major need in Amador County; therefore, support of the Amador Oral Health Task Force and other dental related efforts, is vital in the quest to spread oral health throughout the community.

In addition to past efforts that address the lack of access to dental care, SAH will continue to look for new opportunities to engage various organizations throughout the SAH HSA to provide preventative dental care to the children and adults in the community.

Anticipated Impact and Plan Since the completion SAH will continue evaluate the impact of the to Evaluate Diabetes Education program, by examining how many people we reach and if it has a positive effect on the overall health literacy in Amador County. We are also looking at other possible education classes that we can bring to SAH or provide funding to other organizations who are doing important health literacy work, within the SAH HSA.

13 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 Lack of Opportunity for Physical Activity

Name of Program, Initiative Let’s Get Healthy Amador Campaign or Activity

Description In partnership with public health and other community organizations, Sutter Amador Health plans to take part in the “Let’s Get Healthy Amador” campaign. This important public/private partnership will actively work to encourage people throughout Amador County to exercise and stress the importance of healthy living. Additionally, walking groups and other group fitness activities will be created and promoted to the greater Amador community as a part of this effort.

In addition serving on the “Let’s Get Healthy Amador” board and providing other resources, Sutter Amador Hospital has a beautiful walking trail on the campus of the hospital, which is open to not only patients, but the entire community. Between the walking trail and expanded effort to promote exercise through the healthy living campaign, providing encouragement and opportunity for physical activity is going to be a major focus in 2014.

Anticipated Impact and Plan Once the “Let’s Get Healthy” campaign is underway, SAH will evaluate to Evaluate the impact of program by examining how many people are reached, the number of participants in walking groups and other group fitness opportunities, and if the overall effort has a positive effect in providing healthier options and physical activity in Amador County and the SAH HSA.

14 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 Needs Sutter Amador Hospital Plans Not to Address

No hospital can address all of the health needs present in its community. Sutter Amador Hospital is committed to serving the community by adhering to its mission, using its skills and capabilities, and remaining a strong organization so that it can continue to provide a wide range of community benefits. This implementation strategy does not include specific plans to address the following significant health needs that were identified in the 2013 Community Health Needs Assessment:

Lack of or limited access to specialty care: At this time, SAH does not have sufficient resources to address this need.

Limited transportation options: At this time, SAH does not have sufficient resources to address this need.

Limited mental health services; lack of access to mental health services: In this first phase of addressing priority needs; SAH is focusing on building capacity and connecting people with primary care. Hopefully once we’ve made a dent in that priority need, we can then shift our focus to mental health.

Lack of substance abuse treatment and rehabilitation, both inpatient and outpatient: While SAH plans to investigate bringing classes and other educational opportunities that address this need to Amador’s HSA, at this time, lack of access to care remains the top priority.

Lack of or limited access to healthy food: Not only is there a lack of effective interventions to address this need, this is not something that we are able to greatly affect through community benefit; therefore, we are focusing our resources elsewhere.

15 Sutter Amador Hospital, Implementation Strategy 2013 - 2015 Approval by Governing Board

This implementation strategy was approved by the Governing Board of Sutter Amador Hospital on November 11, 2013.

16 Sutter Amador Hospital, Implementation Strategy 2013 - 2015