RHP 12 Needs Assessment Summary

Introduction RHP 12 contains some of the most rural and medically underserved areas in all of Texas. Some our counties are actually classified as “Frontier”. The only areas of sizable cities in RHP 12 are the Lubbock area (Lubbock County) and the Amarillo (Potter County and Randall County). Even though we considered these areas somewhat separately, the health care needs and problems have much overlap.

RHP 12 RHP 12 includes all the Texas Panhandle which includes the following 47 counties: Potter, Randall, Lubbock, Armstrong, Bailey, Borden, Briscoe, Carson, Castro, Childress, Cochran, Collingsworth, Cottle, Crosby, Dallam, Dawson, Deaf Smith, Dickens, Donley, Floyd, Gaines, Garza, Gray, Hale, Hall, Hansford, Hartley, Hemphill, Hockley, Hutchinson, Kent, King, Lamb, Lipscomb, Lynn, Moore, Motley, Ochiltree, Oldham, Parmer, Roberts, Scurry, Sherman, Swisher, Terry, Wheeler and Yoakum.

Methods Much of the information was obtained under the direction of the West Texas AHEC. The first step of the project consisted of focus group meetings in 11 counties within RHP-12 Rural. Focus groups were conducted to gain a better understanding of community health needs and available resources. Subjects were recruited by West Texas AHEC staff in collaboration with the community champion. Focus group participants consisted of local government officials, local health care providers, and other community members who had a stake in public health. The focus groups were conducted by a moderator from the Earl Research Survey Lab. Telephone Surveys - The next step of the project consisted of telephone surveys that were conducted by the Earl Research Survey Lab. The goal was to complete 100 random-digit telephone surveys, per 3 county, from residents living in RHP-12 Rural owning a land-line. In RHP-12 Rural 1023 telephone surveys were completed with a response rate of 11.29% and a cooperation rate of 40.67%. Surveys were conducted in Spanish and English. The survey instrument contained questions regarding basic demographics, health care access and various health and behavior indicators. Behavioral Risk Factor Surveillance Survey (BRFSS) data was obtained in Amarillo and Lubbock and information was also taken from Covenant Hospital’s Needs Assessment. Population County population estimates are updated periodically by the Texas State Data Center – Office of the State Demographer at the University of Texas at San Antonio. County estimates are primarily based on the 100 percent population counts from the latest April, 2010 decennial census and are calculated to reveal population change up to a current date, in this case April 2010. These estimation methodologies utilize information on births, deaths and elementary school enrollment to estimate population. In this method, migration of the school-age population is assumed to be indicative of migration in the total population (with adjustments being made for the historical differences between the school-age migration rate and the total population's rate of migration). Data on public school enrollment from the Texas Education Agency and data from the Texas State Data Center's survey of private schools in Texas are used to estimate change in the school-age population. Data on institutional populations were obtained from applicable institutions, while data on other special populations, such as the elderly population were obtained from the U.S. Bureau of the Census. According to the county-based population estimates from the United States Census Bureau, RHP-12 Rural changed in population from 369,552 in April, 2000 to an estimated 370,191 in April, 2010 by 639 residents. This reflects an increase of 0.2 percent in population. During the same time period, the state's population changed by 4,293,741 residents from 20,851,820 to an estimated 25,145,561 persons representing a comparative change of 20.6 percent. A variety of data topics for Texas and all the counties is available at: http://quickfacts.census.gov/qfd/states/48000.html.

Of RHP-12 Rural’s population, 190,759 were male which represents 51.5 percent and 179,432 were female which represents 48.5 percent. Of the RHP-12 Urban area's population, 258,442 were male which represents 49.6 percent and 262,187 were female which represents 50.4 percent. This compares to the statewide

1 percentage of 49.6 percent for male and 50.4 percent for female. Of both Rural and Urban districts combined the ethnic divisions were White – 700,390, Hispanic – 309,702, Black – 48,897 and Other-119,869.

Disability Status: From the 2000 Census, data on Disability Status were derived when respondents reported long- lasting conditions: (a) blindness, deafness, or a severe vision or hearing impairment, (sensory disability) and (b) a condition that substantially limits one or more basic physical activities such as walking, climbing stairs, reaching, lifting, or carrying (physical disability). Disability status was also derived if the individuals in the working age range of 21 to 64 years had a physical, mental, or emotional condition lasting 6 months or more that made it difficult to perform certain activities such as: (a) learning, remembering, or concentrating (mental disability); (b) dressing, bathing, or getting around inside the home (self-care disability); (c) going outside the home alone to shop or visit a doctor's office (going outside the home disability); and (d) working at a job or business (employment disability). It was reported in the 2000 Census that the RHP-12 Rural area had an estimated 94,840 persons residing there between the ages of 5 to 20 years of age with approximately 6,166 or 6.5 percent with a disability.

Ages 65 and Older: For the population who are considered to be at the age of retirement or older - 65 years and older, the total number of persons in Texas was 2,601,886 or 10.3 percent of the total population in 2010. This region had a total of 50,863 or 13.7 percent in this older age group. In the same age group of 65 years and over, males in Texas represented 1,135,664 or 4.5 percent of the total population and females totaled to 1,466,222 or 5.8 percent, while in this RHP-12 Rural study area, males totaled to 22,561 or 6.1 percent of all persons in this area and females represented 28,302 or 7.6 percent of all persons.

Population Projections The Office of the State Demographer for the State of Texas distributes the most widely used population projections for Texas. Projection estimates in these tables and the methodology for migration scenarios have been revised as of 2008 by the Texas State Data Center and Office of the State Demographer - now housed at University of Texas San Antonio. Using this projection scenario, the following table represents population projections for RHP-12 Rural as computed in 2008 by The Office of the State Demographer for the State of Texas:

2 Population Projections and Percent Change Since 2000*.

Population Projections and Percent Change Since 2000* Year Total Pct Anglo Pct Black Pct Hispan Pct Other Pct Chg Chg Chg ic Chg Chg 2000 20,851 --- 11,074 --- 2,421, --- 6,669, --- 685,78 --- ,820 ,716 653 666 5 2005 22,556 8.2 11,327 2.3 2,588, 6.9 7,820, 17.3 818,72 19.4 ,046 ,873 605 842 6 2010 24,330 16.7 11,533 4.1 2,754, 13.8 9,080, 36.1 961,46 40.2 ,646 ,976 751 459 0 2015 26,156 25.4 11,694 5.6 2,913, 20.3 10,436 56.5 1,112, 62.2 ,723 ,520 062 ,546 595

Income The IRS county migration data reports income by the number of returns and the number of exemptions. The number of returns - as a unit of analysis may be used as a proxy for household income and the number of exemptions may be used as a proxy for the number of individuals in a family. Using the number of returns for household income, the RHP-12 Rural overall has an average household earnings of $49,141. Of those households which remained in the same area, an average reported non-migrating household income of $50,325 during the period 2008 to 2009. Total income earned by 10,150 households leaving the region was $368,959,000 which represents an average income of $36,351. Per Capita Income: Total personal income is a widely used measure of regional economic health while per capita income is generally used to compare the relative well-being of residents across areas (not accounting for differences in area cost of living). The per capita personal income for 2005 was $27,023 in RHP-12 Rural while Texas statewide had a per capita income of $32,460. For more information on this data, please go to http://www.bea.gov/bea/regional/reis .

Average Weekly Wage: TWC reported an average weekly wage during 3rd quarter 2010 for all covered wages and salaried employment in the RHP-12 Rural region to be $705.20. Average weekly wages for 3rd quarter 2011 was $761.01, an increase of 7.9 percent. This is compared to an increase of 6.3 percent statewide for the same period of time. The Texas statewide average weekly wage in the 3rd quarter of 2010 was $931.50. These wage data are the result of the reported quarterly wages and salaries paid by employers divided by 13 weeks. For the most current information, link to: http://www.tracer2.com/cgi/dataanalysis/AreaSelection.asp?tableName=Industry .

Poverty Population: The U.S. Department of Census estimated a 2002 poverty population for the RHP-12 Rural region for people of all ages at 60,325 persons. That figure represents 16.6 percent of the non-institutional population compared to a Texas percentage of 16.8 percent for people of all ages. According to the 2000 Census, the number of families living below poverty status in 1999 were 13,745 which was 14.1 percent of all families in the RHP-12 Rural study area. This compared to 12.0 percent of all families statewide living in poverty status in 1999. The total number of individuals living below poverty status was 61,194 in 1999 which was 16.5 percent of all individuals in the RHP-12 Rural study area. This compared to 12.4 percent of all individuals living below poverty status statewide. For the most recent poverty information, see: http://www.census.gov/hhes/www/saipe/county.html.

In the Urban region of RHP-12 those living below the poverty level in Potter County during 2006 to 2010 were 22.7% and in Randall County were 9.4%. In Texas as a whole those living below the poverty level was 16.8 for 2006 to 2010. In 2010 those living at or below the poverty level was 20.8%.

Employment Occupations: The best source of occupational information at the county level is from the 2000 Census. The total number of persons 16 years of age or older who were employed in RHP-12 Rural during the 2000 Census was 147,748. The following presents a table of those employed by occupational categories for this region compared to statewide percentages: 3 The same information for the Amarillo and Lubbock areas is shown below:

Occupational Categories Count RHP-12 Urban Percent State Percent Mgmt., Professional Occs. 67,995 31.5 33.3 Service Occupations 37,137 17.2 14.6 Sales and Office Occupations 61,718 28.6 27.2 Farmin g/Fish/ 1.271 0.6 Forestr y

Top 10 Manufacturers for the RHP-12 Rural Region: City County American Cotton Growers Littlefield Lamb Azteca Milling Lp Plainview Hale Cargill Meat Solutions Plainview Hale Cargill Meat Solutions Friona Parmer Caviness Packing Hereford Deaf Smith Conoco Phillips Crude Borger Hutchinson Terminal Hereford Svc Hereford Deaf Smith Jbs Swift & Co Cactus Moore Valero Mc Kee Refinery Sunray Moore National Oilwell Varco West Texas -Varies

Top 10 Manufacturers for the Amarillo and Lubbock Areas of RHP 12 Region:

• Aramark • B&W Technical Svc Pantex • Beef Products • Bell Helicopter Textron • Industrial Molding Corp • Mrs. Baird's Bakeries • Owens Corning • Tyco Fire Products • Tyson Fresh Meats • X-fab Texas

According to the 2000 Census, the RHP-12 Rural area had 103,025 employees who were private wage and salary

4 workers representing 69.7 percent of all workers. The RHP-12 Rural region had another 26,543 persons who were government workers or 18.0 percent, 17,166 who were self-employed workers or 11.6 percent and 1,014 who were unpaid family workers representing 0.7 percent. This compares to the Texas statewide distribution of 78.0 percent for private wage and salary workers, 14.6 percent for government workers, 7.1 percent for self-employed and 0.3 percent for unpaid family workers. Unemployment: According to TWC unemployment figures for April 2012 RHP-12 Rural had an unemployment estimate of 9,157 persons which represents a rate of 4.9 compared to a Texas statewide unemployment rate of 6.5 for the same month. For the RHP-12 Rural study area these estimates represent a decrease from April 2011 unemployment rate of 5.7 percent. The Texas statewide unemployment rate was 7.6 % for April 2011. According to TWC unemployment figures for April 2012 RHP-12 Urban had an unemployment estimate of 13,195 persons which represents a rate of 4.7 compared to a Texas statewide unemployment rate of 6.5 for the same month. For the RHP-12 Urban study area these estimates represent a decrease from April 2011 unemployment rate of 5.4 percent. The Texas statewide unemployment rate was 7.6 for April 2011.

For the latest unemployment rates, see TWC's LMI website - Unemployment Rates (LAUS): http://www.tracer2.com/cgi/dataanalysis/AreaSelection.asp?table Name=Labforce and for a description of methodology link to: http://www.tracer2.com/article.asp?ARTICLE ID=148. Educational Attainment of Rural and Urban Districts compared (Urban in parenthesis) is shown below.

Educational Count RHP-12 Rural Statewide Attainment Percent Percent

Less than 9th 36,600 (21,356) 15.9 (7.7) 11.5 Grade 9th to 12th 36,761 (36,148) 16.0 (13.1) 12.9 grade, no diploma H.S. graduate 69,194 (71,397) 30.1 (25.8) 24.8 (inc. equiv.) Some college, no 47,852 (69,907) 20.8 (25.3) 22.4 degree Associate 9,472 (14,803) 4.1 (5.4) 5.2 Degree Bachelor's 21,176 (41,450) 9.2 (15) 15.6 Degree Graduate or 8,502 (21,257) 3.7 (7.7) 7.6 Prof. Degree

The percent of high school graduates or higher was 68.0 percent for RHP-12 Rural compared to 75.7 percent for Texas. Also, the percent with bachelor's degree or higher was 12.9 percent as compared to 23.2 percent for Texas. Health Health Facilities - The number of acute and psychiatric care hospitals in RHP-12 Rural as of October 2007 was 29, with an average total beds capacity of approximately 36.2 compared to a statewide ratio of 123.1 beds per hospital according to statistical reports from the Texas Department of State Health Services. Link to http://www.dshs.state.tx.us for more data reporting on health care facilities. The Texas State Board of Pharmacy data for October 2007 shows there are 122 licensed pharmacies in RHP-12 Rural. The total number of licensed pharmacies statewide is 5,919. Health Facilities and the number of acute and psychiatric care hospitals in RHP- 12 Urban (Amarillo and Lubbock) as of October 2007 was 19, with an average total beds capacity of approximately 168.8 compared to a statewide ratio of 123.1 beds per hospital according to statistical reports from the Texas Department of State Health Services. Link to http://www.dshs.state.tx.us for more data reporting on health care facilities. The Texas State Board of Pharmacy data for October 2007 shows there are 5 168 licensed pharmacies in the RHP-12 Amarillo and Lubbock study area. The total number of licensed pharmacies statewide is 5,919.

Health Practitioners - Texas Department of State Health Services from 2010 (www.dshs.state.tx.us/chs) or information from the Texas Tribune, September 13, 20012 based on Texas Academy of Physicians information – Interactive: Primary Care Workforce Shortages are represented in the tables shown at the end of the report. A federally designated primary care physician shortage area is primary care physician/population of 1/3500 or less or 28.6 or less primary care physicians per 100,000population. The national average of primary care physicians per 100,000 population is 81/100,000 and the Texas average is 68/100,000. Seventeen of the 43 Rural RHP 12 counties are federally designated shortage areas and 35 of 46 of the entire RHP 12 are below the Texas average and only 7 exceed the national average. The Texas Department of State Health Services information for October 2007 also reports that there were 71 dentists in the RHP-12 Rural study area, with a ratio of 5,388.2 persons for each dentist in the area. The ratio of dentists per 100,000 residents was 18.6. By comparison, there was a statewide ratio of 42.8 dentists per 100,000 residents, with a total of 10,151 dentists statewide. See http://www.dshs.state.tx.us for a wider variety of Health Professionals and related information.

Federally Designated Health Professional Shortage Area of RHP 12 as of March 25, 2011 are shown on the maps following the tables at the end of the report. The map was created by the Primary Care Office at DSHS. The white counties are counties that have no designation at all, and this is typically because they lack enough population to make the HRSA HPSA matrix work and usually no doctors at all. The blue counties are counties that have been designated as entire county HPSAs after going through the matrix mentioned above. The specific reasons why each blue county was designated as a geographic HPSA have to do with patient-provider ratios as well as distance to care factors. The red counties have census tracts that fall into the same criteria as the blue, but not all of the county’s census tracts are deemed underserved by the distance and ratio factors. The cream colored counties and the bright green counties are either entire (cream) county designated, or partial (green) county designated based on needs of special populations. 99.9% of the time that translates to the county having plenty of providers, but far too few or none that will accept Medicaid, Medicare, CHIP, etc. There is a primary care shortage, dental care shortage and a severe Mental Health Care Shortage.

RHP-12 Rural had a total of 1,264 registered nurses (RN) working in the study area, representing a ratio of 302.7 persons for each RN in the RHP-12 Rural area. The statewide ratio was 152.2 persons for each RN in the state. For the same time period, the ratio of RNs per 100,000 population was 330.4 compared to 657.0 per 100,000 statewide. Link to http://www.dshs.state.tx.us for more data. The number of licensed vocational nurses (LVN) who practiced in the RHP-12 Rural area was 1,458 representing a ratio of 262.4 persons per each LVN in the area. This compared to 363.8 persons per each LVN statewide. The ratio of LVNs per 100,000 population was 381.1 compared to 274.9 per 100,000 population statewide. See http://www.dshs.state.tx.us for a wider variety of Health Professionals and related information. The number of licensed vocational nurses (LVN) who practiced in the RHP-12 Rural area was 1,458 representing a ratio of 262.4 persons per each LVN in the area. This compared to 363.8 persons per each LVN statewide. The ratio of LVNs per 100,000 population was 381.1 compared to 274.9 per 100,000 population statewide. See http://www.dshs.state.tx.us for a wider variety of Health Professionals and related information. Health Statistics - Some of the leading causes of mortality in Texas include malignant neoplasms or cancer, heart disease, and chronic lower respiratory disease. From information gathered by Texas Department of State Health Services for 2004, the study area of RHP-12 Rural had a total of 655 reported deaths from malignant neoplasm cancer. On a statewide level, Texas had 33,836 reported deaths from malignant neoplasm cancer. Texas Department of State Health Services reports that for 2004 there were 925 deaths from heart disease, and 230 deaths from lower respiratory disease in RHP-12 Rural. By contrast, Texas statewide had 40,091 deaths from heart disease and 7,387 deaths from chronic lower respiratory disease. See http://www.dshs.state.tx.us for a 6 wider variety of Texas health, disease and related information. Several state agencies collect statistics on health status indicators that can be used to assess the strengths or weaknesses of public health in a local area or community. For RHP-12 Rural, the Texas Department of State Health Services reported for August 2004 there were 43 infant deaths, as compared with a statewide rate of 2,398. See http://www.dshs.state.tx.us for a wider variety of Texas health, disease and related information. The Texas Department of State Health Services reported that for August 2003 there were 410 total teen pregnancies in RHP-12 Rural. There were different teen pregnancy rates in RHP-12 Rural depending on race, with 13 for Black teens, 289 for Hispanic teens and 108 for White teens. Statewide rates for teenage pregnancy were 19,730 for total teenage pregnancies, with 3,003 for Black teens, 12,693 for Hispanic teens and 4,034 for White teens. See http://www.dshs.state.tx.us for a wider variety of Texas health, disease and related information. Health Insurance In the Health and Human Services 2003 Data Book, figures show that the number of children under 19 in RHP-12 Rural who were not covered by health insurance is 20,564, which is 5.2% of the reported population in that age group. The number of uninsured children statewide is 885,999, or 7.1% of the reported population for children under 19. For more information, or to view or download the entire data book, see http://www.hhsc.state.tx.us. With a 2010 phone survey when asked if anyone in their household had been without health insurance at any time during the past 12 months, 23% answered yes. When asked the reason why someone in their household did not have insurance, employers not offering insurance (10%) and when offered, was too expensive to purchase (10%), were two of the main reasons mentioned. 3% of respondents also reported a household member having been dropped due to a pre-existing condition. In the Amarillo area (Potter and Randall Counties) 81.1% had health insurance in 2010 compared to 78.6% in 2007. The highest at risk age groups were 18 to 24 years (38.5%) and 25 to 34 years at 30.2%. Those with incomes of less than $15,000 per year had 55.6% of the group without coverage. The type of primary health insurance is shown below. Of children 89.4% had health insurance in 2010 compared to 85.9% in 2007. BRFSS data indicate that 22.1 percent of adult patients did not have insurance.

Type of Primary Health Insurance Percentage responding 2007 2010 (n=465)

(n=483) Health insurance through 59.8 63.3 someone’s work or union (includes HMO) Medicare 19.2 22.5 Health insurance bought 13.4 6.0 directly by yourself or family Medicaid or public aid 4.0 3.1 Veteran’s 2.7 2.2 Administration/Military Insurance through JO 0.6 2.0 Wyatt or a District Clinic Other 0.3 1.0

In Amarillo 21.2% needed to see a doctor but could not due to the cost. In the rural area survey when asked if anyone in their household was currently having difficulty in getting medical care; cost of services was an issue for 19%. Twenty percent stated that while having some form of insurance, their deductible was too expensive. 18% lamented a lack of information around what services might be available. Coverage denial was mentioned by 9% of respondents; 17% said their insurance coverage was inadequate to their healthcare needs, and 18% cited a lack of insurance coverage overall. The high cost of prescription drugs was an issue to 22% of the persons queried. Lack of transportation was mentioned by 6%, and 5% reported a cultural and or language barrier to 7 their accessing medical care. Other issues are long wait 23%, unable to get an appointment 15.7% and lack of transportation 5.6%

Specific Health Issues Vaccinations – In Amarillo 93.4% got need vaccinations in 2010 compared to 89.2% in 2007. In the rural counties 5% of the phone survey said certain vaccinations were unavailable and 6% said their health coverage did not provide for vaccinations. Four percent of adults did not have access to vaccinations. Of those age 65 and older 30.3% have not had a pneumococcal vaccination and 36.7% no flu vaccination within 12 months. Of t hose between 18 and 65 years 67.5% have had flu vaccination within 12 months. Excess Body Weight – In Amarillo 61.1% were had excessive body weight (overweight 32%, obese 28.4%) compared to 54.4% in 2007. Increasing obesity mirrors nationwide trends. Physical inactivity and diet are the major contributing factors according to surveys in both the rural and urban areas. Nationwide show the incidence is increasing. Diabetes Mellitus – Patients on survey who were told they have diabetes in 2010 (9.1%) and 2007 (11.0%) are compared to nationwide in 2009 (8.3%) and Texas 2007 (9.3%). Statistically there are many more cases of undiagnosed diabetes. Survey respondents indicated that 8.7 were told they had borderline diabetes and 4.3% of women said diabetes was diagnosed when they were pregnant. All national surveys show the incidence of diabetes is increasing. Approximately 1.8 million adult Texans have Type 2 diabetes and 460,000 are undiagnosed. Diabetes related illness is the 6th leading cause of death in Texas and the 4th leading cause of death for African Americans and Hispanics. Approximately 21.9% of adults with diagnosed diabetes do not have health insurance. Lubbock BRFSS data indicate that 10.7 percent have diagnosed diabetes. T he death rate from diabetes in Lubbock is 38.6/100,000 and is higher that the Texas rate of 26.5/100,000. Heart Disease, High Blood Pressure and Stroke- 4.8% of Amarillo respondents in 2010s said they have had a heart attack or angina and a higher incidence in Lubbock of 7.1% with a nationwide at risk comparison of 4.0% in 2008. In the rural counties 25% reported a household member with some form of heart disease; 7% cited someone in their household having had a stroke; and high blood pressure was cited by 56% as being prevalent in their household. In Lubbock 2.8% reported they had had a stroke. In Amarillo the at risk rate for stroke was 3.2% in 2010 and 3.1% in 2009. The national at risk for stroke percentage is 2.4%. Asthma - Respondents were asked if a doctor, nurse, or other health professional had ever told them they had asthma. As shown in Figure 28, 19.6 percent of the respondents had been told they had asthma. When asked if they still had asthma, 77 (66.4 percent) of the 116 respondents who had ever been told they had asthma answered “yes.” This equals 12.9 percent (“at risk”) of all 598 respondents. This is higher than both the nationwide percentage (8.8 percent) and the Texas percentage (6.5 percent) in 2009. Asthma was higher among female respondents, Black/African American respondents, respondents with some college education, respondents with an income of $50,001 to $75,000, and respondents who completed the interview in English. Tobacco Use – Amarillo respondents were asked if they had smoked at least 100 cigarettes (5 packs) in their entire life. A total of 42.9 percent reported having smoked at least 100 cigarettes in their life. The percentage of respondents who had smoked at least 100 cigarettes in their entire life appears to have decreased from 48.1 percent in 1999 to 44.3 percent in 2007 to 42.9 percent in 2010. The percentage of Amarillo 2010 respondents is equal to that of Nationwide 2009 respondents and higher than that of Texas 2009 respondents. Smoking at least 100 cigarettes in their life (“at risk”) decreased as education and income increased and was higher among male respondents. Respondents who had smoked at least 100 cigarettes in their entire life were asked if they still smoked every day, some days or not at all. As shown in Figure 34, 32.0 percent still smoked every day while 11.6 percent smoked some days. Fifty-seven percent no longer smoked cigarettes. The percentage of those respondents who still smoke every day appears to have decreased from 44.2 percent in 1999 to 36.7 percent in 2007 to 32.0 percent in 2010. An “at risk” person is defined as one who has smoked at least 100 cigarettes in their entire life and still smokes every day or some days (111 respondents/598 total = 18.6 percent). In Lubbock current smokers were 20.9% and 43.6 smoked at sometime in their lifetime. In rural counties when surveyed about perceptions around tobacco use, 43% of respondents thought tobacco use was a problem, with 43% citing youth smoking as their basis, and 37% including use of smokeless tobacco and youth. Twenty-nine percent of respondents believed that the number of pregnant women who smoke is too 8 high. Forty-six percent of respondents believed that the number of adults who smoke is too high. Lack of local enforcement of smoking bans was considered to be a problem by 24% percent of respondents and 25% of respondents were concerned about enforcement of minors purchasing tobacco products. Alcohol Use – In Lubbock binge drinking was reported in 14% and 16% with 2020.8% being males and 11.4% being females. Heavy drinking in 4.4% of respondents. In Amarillo respondents were asked how many times they had driven when they had had perhaps too much to drink, during the past 30 days. Of the nine respondents who reported driving after drinking too much, the average number of times they drove was 2.45. Fifty-eight percent of respondents blame the perception of acceptability around the use of drugs and alcohol by adults and youth, and 40% cited the rural nature of the county as being a factor. In the rural counties survey forty-five percent of respondents thought that current drug laws were not being enforced, while 29% cited a lack of education as being a contributing factor to alcohol and drug use. Mammogram Screening - Female respondents were asked if they had ever had a mammogram, an x-ray of each breast to look for breast cancer. The Amarillo BRFSS data indicated 62.0 percent of the female respondents reported having had a mammogram. Of women age 45 to 64, 15.8% has never has a mammogram. In Lubbock women of all ages reported that 26.1 have never had a mammogram. The percentage of the female respondents who had ever had a mammogram increased as the age of the respondent increased, and was higher among Black/African American respondents, respondents with a college degree or more, and respondents with an income of $50,001 to $75,000. In the rural counties opportunities and education regarding the need mammograms are known to be low although no specific data is available. Pap Smear - Female respondents were asked if they had ever had a Pap test, a test for cancer of the cervix and 86.8 percent of those respondents answered “yes.” It appears that a smaller percentage of female respondents reported ever having a Pap test in 2010 (86.8 percent) than in 2007 (90.3 percent). The percentage of female respondents who reported ever having had a Pap test was higher among Black/African American respondents and respondents with an income of $50,001 to $75,000. In Lubbock 24.7% of women 18+ years have had no pap smear within 2 years. Female respondents who reported having had a Pap test were asked how long it had been since they got their last one. Survey information shows 73.7 percent of those respondents reported they had gotten their last Pap test within the past year (57.0 percent) or within the past 2 years (16.7 percent). An “at risk” person is defined as a woman age 18 or older who has not had a Pap test in the past three years. The percentage of at risk women is lower for Amarillo 2010 respondents than Nationwide 2008 (17.1% and Texas 2008 (18.5%) respondents). The percentage of female respondents over 18 years of age who were at risk because they had not had a Pap test in the past three years increased as the age of the respondent increased. Rectal Exam - Male respondents were asked if they had ever had a digital rectal exam and 42.7 percent of those respondents answered “yes.” It appears that the percentage of male respondents who had ever had a digital rectal exam had decreased to 42.7 percent in 2010 from 46.6 percent in 2007. Male respondents who reported having had a digital rectal exam were asked how long it had been since they had the examination. 65.3 percent of those respondents reported having had this exam either within the past year (48.6 percent) or within the past 2 years (16.7%). In Lubbock 45.9% of males surveyed stated t hey had a rectal exam performed in the past. Sigmoidoscopy or Colonoscopy - Survey results indicated 30.7 percent of the respondents indicated they had had one or the other of the exams. Thirty-eight percent of Amarillo 2010 respondents age 50 or older were at risk compared to 37.8 percent of Nationwide 2008 respondents and 43.8 percent of Texas 2008 respondents). The percentage appears to have increased when compared to Amarillo 2007. Results show 40.4 percent of those respondents reported having one of these exams within the past year (22.2 percent) or within the past 2 years (18.2 percent). A smaller percentage of 2010 respondents (40.4 percent) than 2007 respondents (49.6 percent) reported having had a sigmoidoscopy or a colonoscopy exam within the past 2 years. HIV Testing - The Survey indicated that 37.0 percent had been tested for HIV. The percentage of respondents who reported being tested for HIV generally decreased as the age of the respondent and income decreased and was greater among Black/African American respondents and respondents with children under 18 living in the household (see Table 83). Forty percent of those who had been tested for HIV were tested from between January, 2008 and August, 2010.

9 Mental Health - Mental disorders are present in 6% of the adult population. 20% of of children have at some point in their life a seriously debilitating mental disorder. Mental disorders account for 25% of years of life lost to disability and premature mortality. Access in all of Texas is difficult due to insufficient providers and low funding levels. Fewer than half of the eligible mental health population received services in Texas. Only 41.7 of children ages 2 to 17 received care they needed. In the Lubbock area 18.8 percent of the adult population experienced 5 or more days of poor mental health. The 2010 Amarillo BRFSS data indicate 15% of respondents sought mental health services in the last two years. The most common problem reported by respondents who sought mental health care was the inability to get an appointment (24.2 percent). Access in all of Texas is difficult due to insufficient providers and low funding levels. In the Lubbock Independent School District that 19% had felt sad or depressed most or all of the time in the last month and 18% reported attempting suicide at least once. 15% had engaged in bulimic or anorexic behavior. Lubbock County’s rate for family violence was 90% higher than the Texas average and child abuse was 120% higher than the Texas average. Counseling services are offered on only a limited basis to Medicaid patients and worse to uninsured patients. In the rural counties respondents were asked to report on mental health issues present in their households during the previous 5 year period. Twenty-two percent of respondents reported a household member affected by depression or anxiety. Almost 3% of respondents had a family member attempt suicide. Three percent of respondents also reported a household member who had been diagnosed with a mental illness other than depression/anxiety, and over 2% stated the condition was too severe for the member to maintain employment. Stress was a mental health issue reported by 25% of persons surveyed. Three percent of respondents also reported a household member dealing with some form of eating disorder. When asked about their ability to receive help and support for these mental health issues, only 7% stated they were completely lacking a resource that would meet their needs, but 3% cited a lack of quality, affordable, accessible, mental health services in their local community, with lack of transportation affecting 4% of respondents. Less than 2% of respondents reported concerns around the perception of accessing mental health services. Memory Loss – Amarillo BRFSS information indicated 9.6 % of families had a family caregiver for someone who is elderly (age 65 or older). In the survey 33.0 % of respondents indicated that the elderly person cared for had memory problems that caused concerns. Maternal Care Issues – Maternal health is a key determinant in long term health status. Fewer than one half of pregnancies are planned. In Lubbock County in 2007 only 58.1% of mothers received first trimester prenatal care. In Lubbock 41.7 percent of births are to unmarried mothers and 4.9% to mothers less than 18 years of age. Adolescent motherhood to Hispanics girls is 10.9%. For all groups low birth rate babies were 8.4% of the total births. Potter/ Randall county has a very high rate per population of sexually transmitted diseases in. Dental Care – DSHS data indicate a severe shortage of dental care as do hospital needs assessments.

Government Grants Texas Tech Health Sciences at Amarillo has one HRSA grant, for the Pediatric residency. Funding is $960,000 for resident salary over a 5 year period. The second year of the grant began on July 1, 2012. There are two salaries plus benefits from the grant.Texas Tech Health Sciences at Amarillo also has a State DSHS for Early Head Start Home Based Option (EHS), Home Instruction for Parents of Preschool Youngsters (HIPPY), Nurse Family Partnership. It cannot be used towards any matching funds. However, no reimbursement has been received and the state has finalization of the budget. South Plains Rural Health Services, Inc. in Levelland, Texas has a HRSA grant for $650,000. Bailey County is in the final stage of a HRSA grant that was designed expand the size of t heir Rural Health Clinic (brick and mortor). However, matching money was not raised and changed the scope of the grant changed to equipment only. It will be finished by 12/31/12. Nolan County reports the following grants; US Department of Health and Human Services Passed through the Texas Department of State Health Services: Mental Health Block Grant Title XX-Social Services Block Grant Temporary Assistance for Needy Families (TANF)

10 Passed through Texas Department of Assistive and Rehabilitatitive Services Temporary Assistance for Needy Families (TANF) Medical Assistance Program (Title XIX Medicaid) ARRA-Medical Assistance Program (Title XIX Medicaid)

Cogdell Memorial Hospital of Snyder, TX in Scurry County reports a SHIP grant (Small Rural Hospital Improvement Program) from the state for physician peer review and IT infrastructure. Community Needs Identification ID # Description of problem needing to be addressed Data Source CN.1 Severe primary care provider shortage, wait time, expense, BRFSS data, Focus groups, lack of insurance, access to care survey, DSHS CN.2 Lack of mental health services, inability to get an BRFSS data, survey, focus groups. appointment, lack of insurance, need to use ERs for DSHS data initial contact. CN.3 Poor insurance support or uninsured. BRFSS data and surveys CN.4 High incidence of obesity, diabetes mellitus and BRFSS data, survey heart disease. CN.5 Need for specialists to assist in the treatment of obesity, BRFSS Data diabetes mellitus, heart disease, asthma, chronic lung lung disease. Travel to Urban areas for care is difficult. CN.6 Need for cancer screening with mammograms, pap BRFSS data, survey, focus groups. smears, colonoscopy, sigmoidoscopy, rectal exam.

CN.7 Insufficient maternal and prenatal care, BRFSS data, survey, focus groups. especially the first trimester teen pregnancy, high percentage of unmarried mothers CN.8 Alcohol abuse and binge drinking, substance abuse BRFSS data, survey. CN.9 Tobacco use BRFSS data, survey. CN.10 High prevalence of asthma and care issues BRFSS data, survey CN.11 Inadequate vaccination of the population BRFSS data CN.12 High incidence of sexually transmitted disease BRFSS Data CN.13 There is a shortage of dental care. DSHS data, surveys,

Hospital Needs Assessment CN.14 HIV Screening BRFSS data

Legend – Critical Need, Urgent Need, Important Need But Less Urgent

Urban Primary Care Physicians/100, County Population Physicians 000 Residents Armstrong County 2,293 0 0 Bailey County 6,297 6 95.3 Borden County 770 0 0 11 Carson County 6,781 0 0 Castro County 7,292 3 41.1 Childress County 7,949 9 113.2 Cochran County 3,454 2 57.9 Collingsworth 3,141 2 63.7 County Cottle County 1,845 0 0 Crosby County 6,471 2 15.5 Dallam County 6,802 0 0 Dawson County 14,751 5 33.9 Deaf Smith 20,704 11 38.6 County Dickens County 2,786 0 0 Donley County 3,873 1 25.8 Floyd County 6,833 11 102.4 Gaines County 16,670 6 30 Garza County 5,280 1 18.9 Gray County 22,879 16 69.9 Hale County 37,136 20 53.9 Hall County 3,842 1 0 Hansford County 5,219 3 57.5 Hartley County 5,836 2 85.7 Hemphill County 3,616 4 110.6 Hockley County 23,917 12 50.2 Hutchinson 23, 474 15 46.9 County Kent County 857 0 0 King County 377 0 0 Lamb County 15,666 2 19.1 Lipscomb County 3,174 0 0 Lynn County 5,878 3 51 Moore County 21,176 12 47.2 Motley County 1,416 1 70.6 Ochiltree County 10,087 5 49.6 Oldham County 2,340 0 0 Parmer County 10,244 4 39 Roberts County 954 0 0 Scurry County 17,264 9 52.1 Sherman County 3,378 0 0 Swisher County 8,189 3 36.6 Terry County 11,400 6 52.6 Wheeler County 5,130 5 97.5 Yoakum County 8,362 5 47.8

TOTAL 352,329 187 38.9 RURAL

Primary Physicians/100,00 County Population Care 0 Residents Physicians Lubbock County 269,648 220 85.7 Potter County 127,716 208 108.1 Randall County 121,738 32 26.3

TOTAL 519,102 460 73.4

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