Access to Healthcare Resources Needs Assessment 2013 - 2014

Table of Contents Acknowledgements ……………………………………………………… 2 Background………………………………………………………………. 3 Process Model……………………………………………………………. 3 Research………………………………………………………………….. 4-5 Survey …………………………………………………………………….. 5-12 Focus Groups……………………………………………………………… 13-17 Conclusion/Summary……………………………………………………….18 Recommendations for Action …………………………………………….. 18-19

2 Acknowledgements This report about the access to healthcare resources in Sussex County, is a final product of dedicated people coming together to obtain more information about the challenges our community faces when trying to obtain healthcare services. We hope that the information here can assist in future planning to enhance the services already available and to create new ones when opportunities arise. Special Thanks to the Zufall Health Center, a private, non-profit community health center that provides primary and preventive medical and dental care to residents of northwestern NJ and the Sussex County residents who participated in this health needs assessment. We appreciate their time and willingness to share their personal stories. Focus Groups Partners:

 Sussex County Public Library – Franklin Branch

 Brookside Terrace

 Center for Prevention and Counseling - Pathways to Prosperity

 Sussex County Department of Human Services

 United Way of Northern NJ

3 Background Through conversations with multiple Sussex County community organizations and the review of previous health needs assessments, the Zufall Health Center learned about the need for additional healthcare and dental resources in the county. The National Organization of State Offices of Rural Health (NOSORH) - Leadership Institute provided a grant to the Zufall Health Center that would allow it to explore this need further. At the same time, Suyen L. Segura, a Sussex County resident and Public Health Graduate student from Montclair State University, saw an opportunity to complete her community project requirement in her own community. The Zufall Health Center and Suyen decided to complement previous community health needs assessments (CHNAs) conducted by the Atlantic Health System, St. Clare’s Health System and the Sussex County Department of Human Services. All these assessments identified “access to care” as a priority health need. The information gathered through the community survey and focus groups provide valuable insight into the issues that affect the ability to access medical and dental care such as cost, transportation and other barriers. The goals of this project were to assess residents’ knowledge of existing health care resources, raise awareness of current resources, and identify the gaps that exist, all the while focusing on the strengths and assets of the community through the Appreciative Inquiry Model.

Process Model Several documents were developed for the planning, implementation and evaluation of this needs assessment.

 Focus Group Recruitment flier

 Survey (English and Spanish in hard copy and electronic formats)

 Focus group discussion guide

 PPT presentation for focus group

 Thank you letter

4 The process used for this Needs Assessment involved five phases.

Research Secondary Data Methodology The community health needs assessments conducted by the Atlantic Health System, St. Clare’s Health Systems and the County-Wide Human Services Needs Assessment identified “access to healthcare and dental services” as a priority. The assessments were reviewed in detail to:

1. Identify the data already gathered and avoid duplication of efforts

2. Learn about the participating populations Appreciative Inquiry Model – NOSORH Leadership Institute The “Appreciative Inquiry” model for community development is a concept from the National Organization of State Offices of Rural Health (NOSORH) and Heartland Center for Leadership Development Leadership Institute. “Appreciative Inquiry involves making very conscious and deliberate choices about the kinds of questions we ask when initiating change in communities. By focusing on people’s experiences of ‘the best’, Appreciative Inquiry brings life to our pursuit of positive change.”(Heartland Center for Leadership Development, 2011) The AI process consists of the following steps a) Discovery, b) Dream, c) Design and d) Deliver. These steps were integrated throughout the development of the survey and in more detail in the focus groups guide and PPT presentation. Appreciative Inquiry Model

Primary Data Survey Methodology The survey contained 22 multiple-choice and open-ended questions that were administered in person by our data collectors, distributed through the use of SurveyMonkey or provided to community residents that visited the different social service offices and local organizations in the county. The survey asked about the awareness of healthcare facilities in the community, their

5 access and usage and basic demographic information. Data collected from the survey was entered and analyzed using the Statistical Package for the Social Sciences (SPSS). Strategic Analysis The information requested in the survey sought to cover areas not previously discussed on previous needs assessments with the objective of complementing the activities conducted by other healthcare facilities. For instance, 79.4% of the survey respondents did not participate in the telephone interview administered by the organizations who conducted previous CHNAs. Therefore, we can conclude that the feedback obtained belongs to another set of the population and is not duplicative. Limitations Due to limited resources, not all surveys were administered to the participants in person, but instead handed to them to complete. As a result, several surveys were not answered in their entirety. In addition, several questions were created as open-ended questions creating a variety of responses which made their analysis challenging. Survey Findings Overall Health

Overall Health and Gender The distribution of overall health versus gender can be appreciated in the following table. As you can see, the majority of the survey respondents were female. Table 1 Overall Health Male Female Excellent 15 23 Very good 31 59 Good 39 115 Fair 35 55 Poor 18 38

Overall Health and Age

6 When analyzing the health status versus the age of the individuals, we observe that the majority of the respondents enjoy good health and within that range the largest group belongs to the 25-34 year old bracket. The same age group is also highest among those that responded “very good” to their health status. A smaller group across all ages enjoys excellent health, while the 45-54 year old bracket reported to be in poor or fair health. Resources can be targeted and marketed to this last group of the population in order to move their health up from poor or fair to good, very good and excellent.

Areas of Health Concerns Through our survey we sought to identify what areas of health (physical or mental) the residents were most concerned about. We found that out of 456 surveys, 303 people identified their physical health as a concern. 210 were females while 93 were males. In regards to mental health being a concern, 112 respondents were females while 53 were males totaling 165 respondents. Respondents noted that they wanted to address their health concerns by gaining access to a variety of resources. The top 4 resources are represented in the following chart. Other resources mentioned included having a procedure recommended by a provider, obtaining mental health services, access to physical activities, economic or financial assistance, and continued medical care.

Familiar Resources Respondents identified several familiar resources that help them satisfy some of their healthcare needs. Resource Name Number of Resource Name Number of respondents respondents PCP/Specialists 26 Public Health Dept 1 Capitol Care 2 Samaritan Inn 2 2-1-1 Hotline 2 YMCA 2 Project Self- 11 Senior Services 2 Sufficiency Pathways to 8 Ginny’s house 1 Prosperity Planned Parenthood 2 NAMI 1 Family Promise 1 New Bridge 3 Sparta Med Center 2 Behavioral Health 15 Churches 2 None 24

7 When survey participants were asked what kind of services they had received in the past 12 months, they shared that preventive services was at the top with 33.3%, next was lab services (25%), followed by women’s health (22.8%), dental (20.6%) and children’s health (14.9%). We did not obtain any information from the surveys on the reasons why 5 % did not receive any medical services; however, focus group participants shared that the main reasons why medical clinics were not visited in the past year include lack of health insurance and/or cost, availability of sick appointments or appointments in general due to the limited hours of operation, and limited transportation services to and from facilities.

Survey participants appreciate good customer service and knowledgeable staff when visiting healthcare facilities and accessibility to medication ranks next. On the other hand, poor medical and dental care, poor customer service, lack of specialists, cost and lengthy waiting times are some of the negative aspects people sometimes experience and may deter them from seeking medical care. Survey participants responded that they valued certain qualities when visiting healthcare facilities in the county (n=86).

Clinics Participants were aware of several clinics in the area. The top 6 clinics that were mentioned are Newton Medical Center - Adult Clinic (42.3%) followed by St. Clare’s Sussex Adult Medical Clinic (13.8%), Urgent Care in Vernon (13.4%), the Free Clinic in Newton (13.2%), Neighborhood Health Services Corp. (11.8%) and Zufall Health Centers (8.1%).

Even though respondents were familiar with these clinics, only a small number visited them in the past 12 months (n=144). For instance, 16% visited the Newton Medical Center – Adult Clinic. Each of the remaining clinics mentioned previously were visited by less than 5% of the survey respondents. Of the 456 surveys collected, 288 of the respondents were female. As a result, the Newton Medical Center Prenatal clinic and Mammogram center, accounted for 5.2% (n=24) of the visits in the past year referred to in this survey report. Not surprisingly, participants reported that location and distance of health care facilities are specific elements that help them decide where to obtain care. For instance, 32% of respondents stated that residing within close proximity to an office determines where they will go. “Close” was not defined. Furthermore, respondents mentioned that they feel current locations are too far (6.1%) and the lack of transportation (2.6%) is a barrier to seeking care.

8 102 survey participants chose the town where they would prefer to have a healthcare facility. At the top of the list, were the Franklin/Sussex area; Newton, Vernon, and Sparta followed. Other towns received less rating. For instance, the area of Hopatcong/Byram, Montague and Hamburg received 5 votes each while Andover, Hardyston, Branchville, Lafayette, and Stanhope had less than 5 votes each.

The top improvements that respondents mentioned were expansion of transportation services (29.4%) increase in medical center locations (22.4%) and expansion of hours of operation (17.3%). Other areas of improvement included communication in other languages, and affordability of healthcare insurance. Survey respondents also showed interest for additional services. These include:

o Additional dental and eye care 38 or 8.3%

o More behavioral and mental health resources 22 or 4.8%

o Housing and utility assistance 16 or 3.5%

o Other included 24 hr urgent care, PCPs familiar with disabilities, specialists on Medicaid, alternative medicine, social activities, home care for seniors and children, homeless shelters, employment and medical equipment Level of Education Most respondents were high school graduates (n=165) followed by having completed some college or a 2-year degree (n=132). Those that completed some high school but did not graduate were around the same (n=45) as those that graduated with a 4 year college degree (n=41). The number that completed more than 4 year college degree is 30 while those that completed 8th grade or less were 12. The following table displays the distribution of the respondents based on their education level Education Level Frequency Percent 8th Grade or less 12 2.6 Some high school, but did not graduate 45 9.9 High school graduate 165 36.2 Some college or 2 year degree 132 28.9 4 year college graduate 41 9.0 More than 4 year college degree 30 6.6 Missing 31 6.8

9 We did not identify any association between level of education and the health status of the respondent. Race Survey respondents represented different races. For instance, 46 or 10.1% of the respondents were of Hispanic origin. The remaining 410 respondents identified their race as follow: Race Frequency Percent White 376 82.5 Black 19 4.2 Asian 2 0.4 American Indian 6 1.3 Other 20 4.4 Missing 33 7.2

Medical and Dental Insurances Survey participants answered questions regarding their medical and dental insurances. The chart below shows that more participants had medical insurance than dental insurance. A 61% responded they did not have any type of dental insurance.

Focus Groups Methodology Between February and March of 2014, four focus groups were held. Participants represented the following towns: Newton, Stillwater, Sparta, Franklin, Vernon, Stanhope, Wantage and Hardyston. The populations represented were the elderly, English and Spanish speaking community residents and representatives from local community service organizations. Survey participants that answered “yes” to the last question on the survey, which inquired about their willingness to join a focus group, were contacted via phone and given further information about the focus groups. Upon their agreement to participate, individuals were invited to either a lunch or dinner, depending on their availability. In addition, the Sussex County Department of Human Services distributed the recruitment flyer to local community organizations representatives who in turn shared the information with their members.

10 The focus groups were approximately 2 hours long and the groups ranged in size from 5 to 15 participants. Basic demographic information was obtained from the participants before each session via informational sheets. Strategic Analysis The focus groups provided qualitative information about the challenges the residents face when trying to access healthcare and dental services in the county. Participants were very open and shared many personal stories. Limitations As a result of the Affordable Care Act (ACA), we anticipate that the percentage of uninsured county residents decreased after implementation of the law. However, we can also expect that some individuals may have opted not to obtain insurance. For instance, a focus group participant mentioned that since she was not going to obtain healthcare insurance (even though she was eligible), the health facility would charge full price for the doctor’s visit. Focus Groups Findings Using the Appreciative Inquiry Model, we discovered several services and resources that the residents find useful and are appreciative of them. We also identified areas of concern and improvement as well as new initiatives that can be created through grassroots efforts such as increasing advocacy efforts for the county to increase funding for transportation. Discover Knowledge of healthcare resources (local healthcare clinics hand-out): Overall, focus group participants displayed some knowledge of the resources listed on the handout provided. While some resources were well known, others were not.

11 Popular and helpful organizations: Participants were familiar with and demonstrated great satisfaction with the following organizations and/or individuals:

 Project Self-Sufficiency (PSS)

 Diana Morrison, Pathways to Prosperity (Center for Prevention and Counseling)

 Donna Green, SHIP Counselor

 Pam Madzy, The Migrant Ministry Healthcare service experience Medical Services Experience: One of the well-known health resources in the county is the Adult Medical Clinic at Newton Medical Center which is visited by residents who do not have health insurance. The costs of their visits are covered by the Newton Medical Center Charity Care benefits. Some participants mentioned that they were used to visiting the providers at this site, but since they had recently acquired Medicaid coverage, they could no longer see them. One participant explained her medical experience as comprehensive. The primary care doctor at the center referred her to other services such as a diabetes educator, nutritionist, podiatrist, and urologist and ordered a colonoscopy. This last referral was important to her as she considers it a “proactive” measure that helped her physician rule out cancer. Another participant showed her satisfaction with her doctor with these words: “I like my doctor. She gives me all the facts and allows me to talk. She also kindly nudges me about the preventive tests I should get done”- about her doctor in Sparta. When discussing what good customer service is, one of the participants mentioned that when she had a medical emergency and had to have surgery, the medical staff was “straightforward, but

12 gentle” amidst the sad and difficult news she received. They were all “pleasant” noting that customer service goes a long way. Participants also appreciate when providers are knowledgeable; have good bed-side manners and when consistency exists, meaning that they would like to see the same provider instead of seeing someone different at every visit. They also remember when providers go the extra mile. For instance, a nurse traveled with a patient from Vernon to Morristown Memorial Hospital and he felt safe. Another example is when a doctor gave his patient his personal phone number to call in case of emergency. Unfortunately, same day appointments at health clinics in the area are not easy to obtain. People tend to wait until their condition worsens and go to the emergency room. The fact that certain clinics have limited office hours such as two days a week adds up to the challenge of accessing care. A participant shared with us that there seems to be problems with communication at the doctor’s offices. Sometimes, staff makes assumptions instead of talking to the patient. This lack of communication can result in unnecessary expenses for the patient. For example, a specialist ordered lab tests that were sent to lab instead of the hospital. Since the patient had Charity care, lab tests would have been covered; instead, the patient ended up paying for the full amount out of her pocket. Financial difficulties as a result of medical bills is a deterrent for patients to seek further testing when needed and recommended by their doctors. In addition, individuals feel embarrassed and are afraid to go back to see their doctors when they have pending bills with them. On a positive note, several participants mentioned that doctors are willing to make payment arrangements by reducing the fee or establishing a payment plan. Some residents mentioned that they experienced a decrease in services at St. Clare’s medical center in Sussex. Services provided at this location are now more limited compared to the ones offered before, particularly the care a patient received from a psychologist. Furthermore, it seems like the eligibility requirements to obtain any type of mental health is now reduced to only those individuals who are in a crisis. In general, care from specialists is difficult to obtain in Sussex County. One example is a mother who cannot find an epilepsy specialist for her child. She is then forced to look for care outside of the county. Women in the community also explain that access to free mammograms is available and they make use of this service. However, they added that they would like to see more availability of pap smears as well or more comprehensive women’s care. Dental Services Experience: Dental care is very scarce in Sussex County and customer service could be improved as perceptions of the care being provided are not optimal. One patient explained that she waited 3 hours to receive care and the staff told her she had to wait because she was paying only $20 and she was not going to see a “regular doctor”. The patient felt that she was going to receive suboptimal care by a student doctor. Timing to get a first dental appointment was a little lengthy, but once one becomes an established patient, the wait is not too long. Another participant explained that her dental care visit “was not pleasant”. “They were very rough on my teeth”, she added. Others said that they have not received any type of dental care in quite some time because they do not have dental insurance.

13 Access : Participants associate insurance with quality of care. Many agree that people who do not have insurance cannot receive good care. In addition, lack of insurance equals costly medical visits. For those who have medical insurance, they face challenges when trying to access doctors within the insurance network. Many doctors, primarily specialists are very difficult to find in Sussex County. They end up driving large distances to find providers that would take Medicaid or people can choose to obtain another health plan and pay more. At the same time, families are put into a position to choose between putting food on the table or paying for health insurance as one participant explained. Another participant added that even with insurance, since some providers know that the options are limited, they give people poor service. He summed up his feeling by saying “they know you have no other place to go, so they take their time” In some instances, being a recipient of charity care, not having insurance or having Medicaid, takes an “emotional toll”. Charity care has a bad perception. People feel embarrassed and it makes them feel as if they are less of a person. It also shows that they are experiencing a bad financial situation in front of others like neighbors who they might run into at the local medical facilities. Transportation: Sometimes, neighbors help neighbors go to the doctors’ visits because the current perception is that public transportation is difficult to obtain. According to many participants, the current bus route runs in a loop from Newton to Sussex passing through the towns of Newton, Sparta, Ogdensburg, Franklin, Hamburg and Sussex. This route leaves many areas in the county without access to a bus. Many people agree that “you cannot live in Sussex County without a car”. Participants who own a car stated that it was acceptable for them to drive 30 minutes to the nearest healthcare facility. They are used to it because of the nature of the county. Transportation services are hard to come by, especially for residents that do not live on the bus route, and even more so for those that need services not offered within the county altogether, like some specialty care. Besides the bus, participants mentioned one taxi company in Newton, but the rates tend to be quite high. We have learned since the survey and focus groups were conducted that transportation services had been enhanced, but unfortunately, many are unaware of these enhancements. Dream Participants were asked about the type of healthcare services they would like to have in the county, how these services would be offered and what else they would like to have in a better Sussex County. Respondents opened up candidly and provided numerous ideas. Participants would like to see a healthcare system where there are “no stereotypes or stigma” and where people could go anywhere they want, whether they have insurance or not. They do not want to be limited to insurance-provider networks. For instance, if they want to continue to be seen at the Newton Medical adult clinic even if they have insurance they want to be able to. They do not want be judged by or treated differently because of their socio-economic status. Care should be the same, no matter where they go. Residents also would like to see more programs like Pathways to Prosperity where people receive the tools to come out of a bad situation, whether it is financial, physical or emotional.

14 This program helps people create goals and develop timelines and milestones to achieve those goals. Pathways to Prosperity led by Dianna Morrison “works with families as “Path Leaders” to become self-reliant by completing comprehensive education, developing an action plan that maps out their road to success , and working with mentors, to make real and positive changes in their lives.” Other services/programs recommended by the audience include:

o Information about legal advice, and employment opportunities

o Section 8 housing

o Better communication of services in the county (about health fairs, and other county events at the town hall, through the community navigator and at the libraries)

o Free tax services

o Free kids programs – there seems to be a good number of activities for small children, but not for older ones

o Access to exercise (gym), complete streets, funding for trail maintenance and fun classes

o Access to affordable fresh fruits and vegetables

o Affordable community gardens

o Boys and Girls programs

Design Participants expressed frustration because they feel that assistance is not available unless one has terribly low income levels. To this, they suggested that the limits for county assistance be raised so that people with decent incomes were still eligible for much needed help. Another idea the community had was to create a position within the Department of Human Services for a community navigator that can assist residents by connecting them with county services, agencies and other resources. For instance, one participant is on top of his health and spent two days making phone calls to find the right doctors. For those who work full-time, it is difficult to make those phone calls. Focus group participants would like to see more affordable eye and dental care clinics. They would also like to see more ob-gyn providers and an expanded network for basic medical care services. Deliver Focus group participants felt somewhat lost when discussing this topic about who in the community can be engaged and what they can do about it. They were relatively quiet and did not

15 know where to turn and what to say. They understand many of the problems in the community and they have great ideas about what they would like to see, but how to achieve that improvement is where the challenge lies.

Demographic information of the focus groups respondents (n=20) Age Gender Town of Residence Race Educational Level 18-24 = 1 White = 17 Newton, Stillwater, Sparta, White = 17 8th grade = 0 25- 34 = 2 Hispanic = 3 Franklin, Vernon, Hispanic = 3 Some h. school = 1 35-44 = 4 Stanhope, Wantage and H.S. graduate = 4 45-54 = 5 Hardyston Some college = 6 55-64 = 6 4-year college 65-74 = 1 graduate = 3 75 or older = 0 More than 4 years college graduate = 5

Conclusion/Summary Sussex County is a community that strives for collaboration. Its residents are familiar with the benefits and challenges a rural area brings, but they also seek to have better health and healthcare services just as any community in the country. A few ways the county could move towards the improvement of healthcare resources are by:

 Increasing the number of healthcare facilities and/or additional hours of operation for current facilities

 Increasing staff at healthcare facilities

 Reduction in the referral hurdles, insurance issues or paperwork requirements at the facilities

 Improving communication and awareness of available resources throughout the county by using all venues possible (i.e radio, newspaper, internet, community events, children’s sporting events)

 Creating agencies that advocate and support residents (i.e. Hispanic Affairs in Morris County) through the use of community navigators

 Enhancing transportation services

Recommendations Based on the information gathered through this assessment, we recommend the creation of grassroots organizations where residents can be united, and empowered to have a voice, a decision, and to act by playing a role on the issues affecting the county. Residents have proven to come up with great ideas about what the community needs. They now need help on how to turn those

16 ideas into actions and plans by engaging current leaders, assigning roles and responsibilities or having new leaders bloom within the community itself. Two examples of the type of organization that have been mentioned as having a great positive impact on many people’s lives are the Migrant Ministry and Pathways to Prosperity. The Migrant Ministry is run by the Diocese of Paterson through Saint Kateri Parish and Migrant Ministry. Juan Arias and Pamela Madzy, along with church leaders and volunteers, have been working with the migrant community for about 15 years. Ms. Madzy and a group of volunteers help members live healthy and advocate for them within the health system. The latter is Pathways to Prosperity led by Dianna Morrison. This group “works with families as “Path Leaders” to become self-reliant. They develop an action plan that maps out their road to success, and work toward real and positive changes in their lives.”

A big thank you to all community residents and organizations in Sussex County that contributed to this assessment