Mercy Medical Center Community Health June 8 The Sisters of Mercy Needs Assessment & welcome all people of every Implementation 2016 creed, color, economic and Strategy social condition.

Community health needs assessments (CHNA) and implementation strategies are required of tax- exempt hospitals as a result of the Patient Protection and Affordable Care Act. The CHNA and implementation strategies create an important opportunity to improve the health of communities by ensuring that hospitals have the information they need to provide community benefits that meet the needs of their communities. They also provide an opportunity to improve coordination of hospital community benefits with other efforts to improve community health. On December 31, 2014, the Internal Revenue Service (IRS) published final rules implementing the “Additional

Requirements for Charitable Hospitals” section of the Affordable Care Act (ACA). The hospital facility must "conduct" a community health needs assessment ("CHNA") during the current taxable year or in either of the two taxable years immediately preceding such taxable year and an "authorized body of the hospital facility" must adopt an "implementation strategy" to meet the community health needs identified through the CHNA. Included in this document is Mercy Medical Center’s CHNA and Implementation Strategy as approved by the Mercy Health Services Mission & Corporate Ethics Committee on June 8, 2016.

Mercy Medical Center 345 Saint Paul Place Baltimore, Maryland 21201 www.mdmercy.com

TABLE OF CONTENTS

EXECUTIVE SUMMARY ...... 2

GENERAL BACKGROUND ...... 3 Mercy Health Services & Mercy Medical Center ...... 3 History ...... 3 Mission & Values ...... 3 Vision ...... 4 Mercy Medical Center Service Area ...... 4

BALTIMORE’S CHALLENGES ...... 4

MERCY COMMUNITY BENEFIT SERVICE AREA...... 6

COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS & METHODS ...... 7

Quantitative Data ...... 7 Key Findings ...... 8 Demographics: Income, Unemployment, & Poverty ...... 8 Demographics: Race & Ethnicity ...... 10 Demographics: Age & Gender ...... 11 Education ...... 12 Physical, Built, and Social Environment ...... 13 Community Health Indicators ...... 15 Top Causes of Premature Death ...... 18 Maternal and Child Health Indicators ...... 15 Qualitative Data ...... 22 Input from Community Representatives...... 22 Community Stakeholders ...... 23 Stakeholder Interview Process ...... 24 Summary of Feedback ...... 24

PRIORITIZATION OF NEEDS ...... 26

COMMUNITY HEALTH NEEDS ASSESSMENT IMPLEMENTATION STRATEGY ...... 27 Summary ...... 27 Aligned Population Health Initiatives ...... 27 Community Partnerships ...... 28 Improving access to care for homeless neighbors ...... 29 Improving birth outcomes and prenatal care ...... 30 Facilitating care coordination with Federally Qualified Health Centers ...... 31 Providing support to victims of violence and addition ...... 32 Providing health education to the population ...... 33 Successful Initiatives ...... 34

EXISTING HEALTH CARE FACILITIES & RESOURCES ...... 35

DATA SOURCES & TECHNICAL NOTES ...... 36

ACKNOWLEDGEMENTS ...... 41

DISCLAIMER ...... 42

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EXECUTIVE SUMMARY

Mercy Health Services is an independent, not-for-profit, mission-driven health system serving Baltimore since 1874. At its center is a general acute-care teaching hospital affiliated with the University of Maryland School of Medicine located in the heart of downtown Baltimore. The Sisters of Mercy have sponsored Mercy since its healthcare operations began and Mercy has maintained a special, commitment to poor and underserved persons consistent with the mission of the Sisters of Mercy.

Mercy Medical Center is one of 13 hospitals in Baltimore City and one of 5 hospitals within the defined Community Benefit Service Area (CBSA). It serves a unique role as a high-quality community hospital, providing a broad range of primary and secondary acute-care services, as well as a preferred tertiary referral center providing services to patients from a broad geographic area. Mercy generates most of its total revenue from regionally oriented, surgically focused specialty programs from patients from nearly every ZIP code across Maryland. However, when it comes to Community Health Needs and Community Benefit activities, Mercy has focused its resources on a smaller geographic area that represents downtown and inner-city neighborhoods in order to include medically underserved, low income, and minority populations. Mercy provides an array of specialized citywide support programs for targeted populations including: lower-income pregnant women, individuals experiencing homelessness, substance abusers, and support and coordination with Federally Qualified Health Centers to meet community health needs. Mercy also houses a citywide forensic examination program for victims of sexual assault and a family violence program.

Baltimore City faces numerous social and economic challenges that negatively impact the overall health status of the population. Nearly 1-in-4 or roughly 145,000 persons in Baltimore live below the federal poverty line. Baltimore’s economic challenges also translate to significant social challenges including high rates of violent crime and drug addiction. As result, Baltimore City, especially Mercy’s defined CBSA, suffers from higher rates of mortality and lower life expectancy. The top four causes of premature death in the CBSA are heart disease, cancer, homicides, and HIV/AIDS. In addition, Baltimore City has higher rates of infant mortality and low birth weight births. Significantly more people die prematurely from all causes in the defined CNHA Service Area than in the City as a whole. Further, significant populations of individuals experiencing homelessness are found in Mercy’s CBSA. The estimated life expectancy for individuals experiencing homelessness is only 48 years.

Mercy’s location in the middle of a disproportionately poor city presents challenges and health disparities that are not evident in other parts of Maryland. Mercy has identified areas of opportunity where the mission and strengths of the institution intersect with the unmet public health needs that merit attention. Consistent with feedback received from community representatives, Mercy intends to focus its resources specifically on interventions, programs, and initiatives to: Improve access to care and the frequency of care for our homeless neighbors; Improve birth outcomes and pre-natal care for expectant mothers; Improve care coordination with the City’s Federally Qualified Health Centers; and Support to victims of violence and addiction. Finally, Mercy has been successful in improving quality, lowering costs and responding to population/community needs by increasingly focusing on high-utilizer patients within the CBSA and beyond.

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GENERAL BACKGROUND

Mercy Health Services, Inc. ("MHS"), a Maryland nonstock corporation that has been determined by the Internal Revenue Service to be a tax-exempt organization described in Section 501(c)(3) of the United States Internal Revenue Code, owns and operates a health care delivery system in Maryland (the "Health System"). The Health System is a patient-centered, integrated system delivering high-quality, high-value health care services in various locations throughout the Baltimore metropolitan area and State of Maryland. MHS is the parent of Mercy Medical Center, Inc. ("Mercy" or "MMC"), a non-profit corporation, which owns and operates a 184-licensed bed general acute-care teaching hospital affiliated with the University of Maryland School of Medicine. The MMC campus is located in the heart of Downtown Baltimore, Maryland. MMC is both a prominent community hospital, providing a broad range of primary and secondary acute-care services, as well as a preferred tertiary referral center in certain select specialties. MMC is currently ranked the number three hospital in Maryland by U.S. News and World Report. MMC was also recently named a “high performing” hospital by U.S. News and World Report in five areas including: Geriatrics, Gynecology, Nephrology, Neurology & Neurosurgery, and Orthopedics.

History

The Sisters of Mercy have sponsored Mercy since its healthcare operations began in 1874 when six sisters of Mercy arrived in Baltimore to take charge of a health dispensary named Baltimore City Hospital. City Hospital. Established four years prior by the Washington University School of Medicine, the dispensary was located in a former schoolhouse at the corner of Calvert and Saratoga Streets. Mercy has had a continuing presence in downtown Baltimore since its founding. In 1999, the Sisters of Mercy and MHS entered into a formal Sponsorship Agreement. MHS is an independent health system governed by a 29 member self-perpetuating Board of Trustees comprised primarily of Baltimore area residents with deep roots in the local business, healthcare, and philanthropic communities.

Mission & Values

Like the Sisters of Mercy before us, we witness God’s healing love for all people by providing excellent clinical and residential services within a community of compassionate care.

 Justice—We base our relationships with all people on fairness, equality and integrity. We stand especially committed to persons who are poor or vulnerable.  Prayer—We believe that every moment in a person’s journey is holy. Prayer is our response to God’s faithful presence in suffering and in joy, in sickness and in health, in life and in death.  Dignity—We celebrate the inherent value of each person as created in the image of God. We respond to the needs of the whole person in health, sickness and dying.  Hospitality—From many religious traditions and walks of life, we welcome one another as children of the same God, whose mercy we know through the warmth, fidelity and generosity of others.  Excellence—We hold ourselves to the highest standards of care and to serving all with courtesy, respect and compassion. Maintaining our involvement in the education of physicians and other healthcare professionals is a priority.  Stewardship—We believe that our world and our lives are sacred gifts which God entrusts to us. We respond to that trust by constantly striving to balance the good of all with the good of each, and through creative and responsible use of all our resources.

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Vision As a highly integrated Catholic health system sponsored by the Sisters of Mercy, Mercy Health Services will offer to all those in greater Baltimore, with a special commitment to poor and underserved persons: o The hospital of choice in our market; o Seamless and cost‐effective care, rooted in our values, across the continuum for each person; o A comprehensive ambulatory network readily accessible to everyone; o Regionally recognized, patient‐focused Centers of Excellence; o A recognized leader in quality care and patient safety; and o Innovative senior care to meet evolving needs.

MMC Service Area

Mercy provides healthcare services to patients from a broad geographic area within the State of Maryland and beyond. Mercy's primary service area consists of the majority of Baltimore City and portions of Baltimore and Anne Arundel Counties. Mercy's secondary service area generally surrounds the Primary Service Area and includes the remaining portions of Baltimore City, portions of Baltimore County and a portion of Anne Arundel County. These service areas accounted for approximately 67% of Mercy's total discharges in the 12 months ended June 30, 2015. The remaining 33% of discharges originate from outside Mercy’s traditional service areas, including patients from outside of Maryland. Due to its downtown location near several other hospitals, including two large Academic Medical Centers and two other multi-hospital health systems, Mercy is not the dominant hospital provider in any of the ZIP codes comprising Mercy’s traditional service area. Further, Mercy Medical Center generates more than sixty percent (60%) of its total revenue from regionally oriented, surgically focused specialty programs (Centers of Excellence) drawing patients from nearly every ZIP code across Maryland.

While patients throughout Maryland seek-out Mercy’s high-quality health services, it has traditionally focused its numerous community benefit programs and services specifically on economically disadvantaged neighborhoods within Baltimore City, consistent with its long-standing special commitment to poor and underserved persons. This includes an array of specialized citywide support programs for lower-income pregnant women, individuals and families experiencing homelessness, substance abusers, and support and coordination with Federally Qualified Health Centers to meet the community health needs. Mercy also houses a citywide Sexual Assault Forensic Examination program (SAFE) for victims of sexual assault and a Family Violence Response Program. In FY2015, Mercy provided $59.3 million in Community Benefits representing 13.5% of total hospital operating expenses, including $17.9 million in Charity Care. According to the most recently available data (FY2014) Mercy ranks as the 9th highest hospital in percentage of operating expenses dedicated to Community Benefit among 52 Maryland hospitals reporting. Mercy ranks 4th among 13 hospitals located in Baltimore City.

BALTIMORE’S CHALLENGES

Baltimore City faces numerous social and economic challenges that negatively impact the overall health status of the population. The City has suffered a dramatic decline in population, employment and wealth since the 1950s. Following the post-war industrial era, Baltimore City’s population declined from 949,708 (1950) to 621,849 (2015 estimate), a 36% decrease. Likewise, its population rank among U.S.

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cities declined from 6th largest to 26th largest. Meanwhile, Maryland’s total population grew from 2,343,001 to 6,006,410 during the same period, a 156% increase. As population, jobs and wealth migrated out to the suburbs and exurbs of the broader metropolitan area; Baltimore’s poor remained, making the City a concentrated "poorhouse for the region's minority poor,” according to one urban scholar. Indeed, Baltimore’s current unemployment rate stands at 7.4% (April 2016), well above Maryland’s rate of 5.3% and the national rate of 5.5%. The City’s Median Household Income is $41,819 (2014 dollars) compared to $74,149 for Maryland. Perhaps most poignantly, nearly 1-in-4 (23.3%) or roughly 145,000 persons in Baltimore live below the federal poverty line, more than double Maryland’s poverty rate of 10.1% (including Baltimore City) and significantly higher than the national poverty rate of 14.8%.

Not surprisingly, these economic factors; high unemployment, low income, and extraordinary levels of poverty often result in reduced access to health care, especially preventative treatment that could improve population health and limit potentially avoidable hospital utilization. While the Affordable Care Act has greatly expanded health insurance to the poor, an estimated 8.9% of individuals in Baltimore under age 65 lack health insurance coverage, according to the most recent available data from the U.S. Census Bureau’s Small Area Health Insurance Estimates.

Linked to Baltimore’s economic challenges are significant social challenges impacting community health, including high rates of violent crime and drug addiction. Baltimore has the one of the highest violent crime rates among major U.S. Cities with a rate of 1417 per 100,000 residents. The Baltimore City Health Department estimates that roughly 60,000 Baltimore residents are suffering from drug addiction. The U.S. Drug Enforcement Agency reports Baltimore has the highest per capita heroin addiction rate in the country. Baltimore recorded a total of 304 alcohol and drug intoxication deaths in 2014, representing nearly a third of all intoxication deaths in the state.

Against this backdrop, Mercy has remained in Baltimore as a prominent community hospital for more than 142 years, serving the health care needs of Baltimore City’s residents regardless of creed, color, economic or social condition. In 2010, Mercy rededicated its commitment to serving Baltimore City with the completion of a new, state-of-the-art replacement hospital, the Mary Catherine Bunting Center, representing a $400+ million investment in its downtown medical campus in the heart of Baltimore City.

As Baltimore economic disparities and social challenges manifested during the historic April 2015 unrest, Mercy Medical Center continued 24-7 operations uninterrupted, serving the City as a beacon of health, healing and calm. Mercy was proud to care for more than 45 injured Baltimore police officers and firefighters during the period—continuing a century-long tradition that began with the Great Baltimore Fire of 1904. Since the events of April 2015, Mercy has joined with other Baltimore hospital partners in successfully advocating for $15 million in new hospital funding to create a Population Health Work Force Program to train and hire workers from geographic areas of high economic disparities and unemployment to improve population health. Mercy Medical Center is also a signatory of the American Hospital Association’s “Equity Pledge to Act” to address health care disparities by measuring disparities in health care quality, addressing gaps, providing cultural competency training for all staff, and by promoting dialogue with board leadership around increasing diversity.

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MERCY COMMUNITY BENEFIT SERVICE AREA

The Sisters of Mercy were originally founded in Dublin, Ireland to care for homeless, abused and neglected women and children. This timeless legacy influences Mercy’s approach to focus special attention on certain target populations, such as infants, women, and the impoverished. Mercy defined its Community Benefit Service Area as part of its CHNA process for the 2013 tax year. During a series of meetings as part of the CHNA process for 2013, Mercy’s Community Benefits Committee discussed the socioeconomic and health parameters that define Mercy’s “community”. Following a data driven process (See: Mercy Medical Center 2013 CHNA), the committee appropriately decided that Mercy should focus its limited resources on Community Benefit activities to improve population health within 18 Community Statistical Areas (CSAs) that represent downtown and the inner-city neighborhoods east, west, and south of the city center. The Committee believes that this definition of Mercy’s community, which represents a smaller geographic area than the CBSA previously utilized by Mercy, will foster greater coordination, better strategic partnerships and improved measurement of outcomes, in particular with respect to the targeted populations including lower-income mothers and their babies and individuals experiencing homelessness. In addition, as part of the CHNA process for 2013 and 2016, Mercy representatives sought input regarding its proposed Community Benefit Service Area from community leaders, public health experts, and representatives of minority, low income, and medically

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underserved populations. The consensus feedback from these discussions validated and confirmed Mercy’s Community Benefit Service Area Definition. In accordance with IRS regulations governing CHNAs, Mercy has defined its CHNA community to in order to include “medically underserved, low income or minority populations”. Prior to 2013, Mercy’s community benefit outreach was focused on a large geographic area within Baltimore City (15 ZIP codes) that as previously selected as Mercy’s Community Benefit Service Area (“CBSA”) based on the prevalence and concentration of emergency room visits.

CHNA PROCESS AND METHODS

Quantitative and qualitative data was gathered by Mercy in order to undertake the 2016 CHNA. The process for gathering this data is described below.

Quantitative Data

As part of the quantitative data gathering process for the 2016 CHNA, Mercy’s Community Benefit Committee members worked collaboratively with The Baltimore Neighborhood Indicators Alliance-Jacob France Institute at the University of Baltimore (BNIA-JFI). BNIA-JFI is a nonprofit organization whose core mission is to provide open access to meaningful, reliable, and actionable data about, and for, the City of Baltimore and its communities. BNIA-JFI builds on and coordinates the related work of citywide nonprofit organizations, city and state government agencies, neighborhoods, foundations, businesses, and universities to support and strengthen the principle and practice of well informed decision making for change toward strong neighborhoods, improved quality of life, and a thriving city. BNIA-JFI is also a partner member of the National Neighborhood Indicators Partnership of the Urban Institute (NNIP). NNIP is a collaborative effort by the Urban Institute and nearly 40 local partners to further the development and use of neighborhood-level information systems in local policymaking and community building. BNIA-JFI provided to Mercy’ Community Benefit Committee a broad array of neighborhood data indicators that provide all of the facts and circumstances present in Mercy’s Community Benefit Service Area including barriers to accessing care, to prevent illness, to ensure adequate nutrition, or to address social, behavioral and environmental factors that influence health in the community.

Incorporated into BNIA-JFI’s neighborhood-level socioeconomic datasets are individual Neighborhood Health Profiles completed by the Baltimore City Health Department and updated in March 2012. The Neighborhood Health Profiles examine at the underlying factors that affect health in each neighborhood—the social determinants of health. The social determinants of health are the conditions in which residents live, learn, work, and play, and include factors like access to healthy food, healthy housing, quality schools, and safe places to be active. The Neighborhood Health Profiles present health outcome information at the Community Statistical Area (CSA) level in Baltimore City in order to support community-level health improvement efforts to achieve the Healthy Baltimore 2015 plan, the City’s comprehensive public health agenda to improve health outcomes in Baltimore. The Baltimore City’s Office of Epidemiology utilized rigorous research methods and survey analysis techniques to aggregate all the data to the Community Statistical Area (CSA) level. The use of the most recently available Neighborhood Health Profile information from the Baltimore City Health Department ensures that the

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community health priorities of Mercy Medical Center remain aligned with the current health priorities of the City. Data sources include a variety of public and private sources such as: The U.S. Census, The American Community Survey, The Vital Statistics Administration at the Maryland Department of Health and Mental Hygiene, The National Center for Health Statistics, The Baltimore City Public Schools System, The Mayor’s Office of Information Technology, The Baltimore City Housing Department, The Baltimore City Comptroller’s Office, The Baltimore City Planning Department, The Baltimore City Real Property Management Database, The Baltimore City Liquor Board, The Baltimore City Health Department, Center for a Livable Future, and the Maryland Department of the Environment.

Key Findings

Demographics: Income, Unemployment & Poverty

The chart below details the Household Income, Unemployment & Poverty makeup of Mercy’s CNHA Service Area. The percentage of Households earning less than $25,000 is dramatically higher than the citywide percentage. Conversely, there are far fewer Households earning more than $75,000 within Mercy’s CNHA Service Area than Citywide. In certain neighborhoods including Greenmount East, Oldtown/Middle East, Poppleton/Hollins Market and Upton/Druid Heights, more than half of all

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Households earn less than $25,000. Similarly, the percentage of families earning below the poverty level is significantly higher within Mercy’s CNHA Service Area than the City as a whole, which is already among the poorest jurisdictions in the State of Maryland. Unemployment within Mercy’s CNHA Service Area is slightly higher than Citywide. Perhaps more than any other dataset included in this report, the chart below demonstrates Mercy’s long-standing special commitment to serve the poor and underserved.

% of Percentage of Population by Household Income families % of earning population below 16+ that is poverty <$25,000 $25-40,000 $40-60,000 $60-75,000 $75,000+ unemployed level Canton 9.3 7.8 13.0 12.0 57.9 4.0 3.1 Clifton-Berea 48.0 22.0 14.7 7.6 7.7 10.0 21.5 Downtown/Seton Hill 42.6 14.9 17.4 9.0 16.1 3.1 15.1 Fells Point 17.3 8.9 11.8 11.8 50.2 4.3 6.9 Greater Rosemont 46.8 18.2 15.5 8.1 11.4 15.5 25.2 Greenmount East 54.1 20.6 10.8 4.9 9.6 15.7 25.3 Harbor East/Little Italy 42.2 16.8 8.0 4.3 28.7 11.1 41.2 Inner Harbor/Federal Hill 20.0 4.1 14.0 7.1 54.7 4.2 7.7 Madison/East End 46.8 15.9 16.4 7.6 13.3 15.6 31.5 Midtown 38.2 14.8 16.2 9.0 21.7 6.6 10.8 Oldtown/Middle East 63.1 14.5 10.5 3.6 8.3 14.8 50.5 Patterson Park North and East 26.7 10.2 17.2 8.2 37.7 9.3 25.9 Poppleton/Hollins Market 62.4 12.5 10.1 5.0 10.0 11.4 44.8 Sandtown-Winchester/Harlem Park 48.9 18.3 16.3 9.2 7.4 14.0 31.6 South Baltimore 15.9 5.9 13.3 9.4 55.4 6.3 5.1 Southwest Baltimore 49.6 18.0 13.9 7.4 11.1 15.7 33.0 Upton/Druid Heights 65.6 10.5 10.8 7.4 5.7 14.6 50.6 Washington Village/Pigtown 30.6 12.7 21.2 10.5 25.1 9.4 24.4 Mercy Community Benefit Service Area Estimate 41.0 14.1 14.3 8.0 22.7 10.3 23.3 Baltimore City 33.2 15.4 16.6 5.4 25.5 9.9 19.1

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Demographics: Race & Ethnicity

The chart below details the population and racial/ethnic makeup of Mercy’s CNHA Service Area. Mercy’s CNHA Service Area population (186,653) represents approximately 30% of Baltimore City’s total population. The mix of white and black population in CNHA Service Area is roughly equivalent the citywide mix. Mercy’s CNHA Service Area also includes two neighborhoods (Patterson Park North and East, Fells Point) with disproportionately high numbers of Hispanic/Latino residents compared to the City as a whole. Mercy’s CNHA Service Area includes one neighborhood (Downtown/Seton Hill) with a significantly greater share of Asian residents. Access to government sponsored health insurance (Medicaid and subsidized private qualified health plans on Maryland’s Health Exchange) and limited English proficiency may present barriers to some Hispanic/Latino residents within Mercy’s CNHA Service Area seeking health care services.

Percent of Population by Race/Ethnicity

Population Hispanic/ CSA 2010 Black White Asian Other Two or More Latino Canton 8100 4.0 86.0 3.4 0.4 1.3 5.0 Clifton-Berea 9874 96.3 1.1 0.3 0.3 1.1 1.0 Downtown/Seton Hill 6446 37.0 39.2 15.9 0.6 2.8 4.5 Fells Point 9039 7.8 69.8 4.6 0.7 2.0 15.1 Greater Rosemont 19259 96.6 0.7 0.2 0.3 1.3 1.0 Greenmount East 8184 95.8 1.6 0.2 0.3 1.1 0.9 Harbor East/Little Italy 5407 57.9 28.5 4.6 0.6 1.6 6.8 Inner Harbor/Federal Hill 12855 11.5 79.5 3.9 0.4 1.6 3.2 Madison/East End 7781 90.3 3.1 0.8 0.6 1.2 4.0 Midtown 15020 32.1 52.7 7.8 0.5 2.9 3.9 Oldtown/Middle East 10021 89.5 5.4 2.0 0.3 1.0 1.7 Patterson Park North and East 14549 38.0 36.0 1.9 1.2 1.8 21.1 Poppleton/The Terraces/Hollins Market 5086 82.9 12.7 1.0 0.4 1.4 1.7 Sandtown-Winchester/Harlem Park 14896 96.6 1.1 0.3 0.2 1.0 0.7 South Baltimore 6406 2.7 90.3 2.7 0.3 1.5 2.6 Southwest Baltimore 17885 75.8 16.8 1.1 0.6 2.1 3.6 Upton/Druid Heights 10342 92.4 3.9 0.6 0.4 1.4 1.4 Washington Village/Pigtown 5503 49.0 39.1 5.3 0.7 2.5 3.4 Mercy Community Benefit Service Area Estimate 186653 61.6 28.9 2.7 0.5 1.6 4.6 Baltimore City 620961 63.8 28.3 2.3 0.5 1.7 4.2

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Demographics: Age & Gender:

The chart below details the Age & Gender makeup of Mercy’s CNHA Service Area. In terms of both Age and Gender, there is little difference between Mercy’s CNHA Service Area and Baltimore City as a whole. However, several neighborhoods within Mercy’s CNHA Service Area included higher percentages of persons under age 18 than the Baltimore City as whole. Mercy’s CNHA Service Area does not have a disproportionate share of residents over age 65 compared to Baltimore City more broadly.

Percentage of Population by Age (years) Percentage of Population by Gender CSA Under 18 18-24 25-44 45-64 65 and up Male Female Canton 7.1 10.5 53.0 18.5 10.9 49.5 50.5 Clifton-Berea 25.5 10.5 22.5 26.1 15.5 45.3 54.7 Downtown/Seton Hill 8.0 20.6 50.7 16.9 3.8 49.1 50.9 Fells Point 9.7 11.3 51.7 19.5 7.7 51.0 49.0 Greater Rosemont 26.1 11.0 22.3 27.6 12.9 45.6 54.4 Greenmount East 25.4 10.8 21.7 29.9 12.3 45.7 54.3 Harbor East/Little Italy 24.0 9.8 37.0 22.6 6.6 48.6 51.4 Inner Harbor/Federal Hill 9.5 13.3 47.2 19.4 10.6 50.8 49.2 Madison/East End 32.8 13.1 24.9 22.6 6.6 46.1 53.9 Midtown 6.0 22.6 39.3 19.4 12.7 48.6 51.4 Oldtown/Middle East 25.0 12.3 27.0 23.9 11.9 45.3 54.7 Patterson Park North and East 22.2 11.6 41.2 18.7 6.2 50.1 49.9 Poppleton/The Terraces/Hollins Market 25.5 10.5 28.7 25.9 9.3 47.2 52.8 Sandtown-Winchester/Harlem Park 25.8 11.5 23.9 26.9 11.8 45.7 54.3 South Baltimore 10.6 10.4 51.3 19.6 8.1 50.9 49.1 Southwest Baltimore 27.1 11.0 25.3 26.6 10.0 48.6 51.4 Upton/Druid Heights 29.1 12.1 24.3 24.3 10.1 44.7 55.3 Washington Village/Pigtown 21.0 11.3 37.6 22.0 8.1 49.8 50.2 Mercy Community Benefit Service Area Estimate 20.4 12.6 33.5 23.2 10.2 47.8 52.2 Baltimore City 21.5 12.6 29.0 25.2 11.7 47.1 52.9

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Education:

The chart below details several key indicators related to education attainment, literacy, and truancy within Mercy’s CNHA Service Area. Most indicators are consistent with the City as a whole. However, truancy levels worsen within Mercy’s CNHA Service Area as students reach high school age. Like the rest of the City, there are large disparities in educational achievement within Mercy’s CNHA Service Area from neighborhood to neighborhood. Areas with higher rates of poverty and minority population are less likely to enter kindergarten “ready to learn”, achieve lower proficiency scores in reading and math, miss more days of school, and achieve fewer high school diplomas and college degrees.

% of students % of adults 25+ attaining % of % of students missing 20 or reading at educational levels* Kindergarten more days of school Students "proficient" or "Fully Ready "advanced" levels Some HS or to Learn" 3rd 8th HS or Assoc. BS/BA or CSA Grade Grade Elementary Middle High less Degree more Canton 96.0 80.0 80.0 6.0 12.8 34.5 7.4 29.0 63.7 Clifton-Berea 79.0 54.7 47.4 16.2 16.4 43.4 27.4 65.4 7.2 Downtown/Seton Hill 75.0 55.6 57.9 14.0 14.9 40.8 8.8 27.4 63.8 Fells Point 88.7 77.5 81.0 6.8 8.7 27.4 11.0 25.6 63.4 Greater Rosemont 77.5 53.5 58.2 12.8 11.8 38.2 28.3 63.9 7.9 Greenmount East 80.3 60.4 51.4 14.5 14.6 44.3 24.6 69.7 5.7 Harbor East/Little Italy 40.3 71.7 64.6 20.6 14.0 36.2 27.0 41.5 31.5 Inner Harbor/Federal Hill 90.0 94.3 60.0 7.5 15.8 34.8 10.5 23.4 66.1 Madison/East End 61.0 59.9 47.7 16.3 17.1 50.4 39.7 55.1 5.2 Midtown 72.5 73.3 75.0 11.2 10.9 32.6 12.9 28.9 58.2 Oldtown/Middle East 77.2 57.8 57.0 16.4 15.7 46.0 36.1 51.5 12.4 Patterson Park North and East 66.3 65.0 64.7 10.4 15.0 41.5 25.5 40.3 34.2 Poppleton/The Terraces/Hollins 84.2 58.3 52.8 21.5 23.4 39.9 31.0 52.6 16.4 Sandtown-Winchester/Harlem Park 83.6 50.9 49.4 13.0 14.7 43.4 30.1 64.5 5.5 South Baltimore 90.5 86.2 82.4 11.3 16.4 27.3 12.2 29.9 58.0 Southwest Baltimore 69.1 49.2 54.7 16.7 17.4 44.3 31.4 59.1 9.5 Upton/Druid Heights 74.0 51.1 39.4 19.5 21.0 41.9 33.2 55.5 11.2 Washington Village/Pigtown 94.0 59.3 55.1 13.2 28.9 35.3 20.9 45.1 33.9 Mercy Community Benefit Service Area Estimate 77.4 63.2 59.5 13.3 15.4 39.4 23.9 47.6 28.6 Baltimore City 77.6 64.9 62.0 13.1 13.3 35.6 19.8 53.4 26.8

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Physical, Built, and Social Environment:

The Baltimore City Health Department compiled data on the built and social environment affecting residents in the City in order to identify and track environmental factors that directly contribute to the health and well-being of residents. Scholarly research like the CDC’s Adverse Childhood Experiences (ACE) study highlights the link between childhood trauma and later-life health. The CDC’s ACE study found a strong correlation between adverse childhood experiences and poor health outcomes. The ACE Study suggests that children exposed to the “toxic stress” of violence, homelessness, abuse, and neglect are at a greater risk for illness and premature death as well as a lower quality of life. The chart below reveals that residents in Mercy’s CNHA Service Area are disproportionately exposed to alcohol and liquor stores, juvenile arrests, domestic violence and gun violence. In addition to these adverse social conditions, the built environment presents similar challenges within our community.

Alcohol Tobacco Domestic Store Store Violence Non-Fatal Density per Density per Juvenile Arrests Incidents Shootings per 1,000 1,000 per 1,000 10-17 Reported per 10,000 CSA Residents Residents Year Olds 1,000 Res. Residents Canton 4.3 23.5 81.5 39.6 0.0 Clifton-Berea 1.9 49.6 144.9 63.5 72.9 Downtown/Seton Hill 7.9 130.3 1005.6 76.8 90.0 Fells Point 4.1 50.9 27.5 39.9 5.5 Greater Rosemont 0.9 36.9 107.9 62.6 42.1 Greenmount East 1.6 49.7 116.6 72.9 68.4 Harbor East/Little Italy 2.8 - 116.9 75.5 22.2 Inner Harbor/Federal Hill 3.3 25.8 359.0 39.1 3.1 Madison/East End 1.7 50.1 108.3 75.4 50.1 Midtown 1.9 28.7 198.0 24.1 14.0 Oldtown/Middle East 0.8 - 145.6 65.7 42.9 Patterson Park North and East 1.2 50.1 72.8 60.2 18.6 Poppleton/The Terraces/Hollins Market 2.0 43.3 111.9 68.6 27.5 Sandtown-Winchester/Harlem Park 1.3 56.1 211.6 67.9 64.4 South Baltimore 2.0 18.7 69.9 38.2 3.1 Southwest Baltimore 2.2 51.4 132.7 77.2 41.4 Upton/Druid Heights 0.7 39.0 250.2 72.6 42.5 Washington Village/Pigtown 2.4 50.9 91.7 80.1 38.2 Mercy Community Benefit Service Area Estimate 2.1 45.9 151.1 59.9 35.8 Baltimore City 11.5 21.8 79.2 54.2 2.3 -data not available due to CSA shift

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In addition, as shown in the charts below, Mercy’s CNHA Service Area has more than twice the rate of vacant homes and lead paint violations as the rest of the City. Furthermore, an oversupply and over- reliance on carry out restaurants and corner stores for food supply also highlights the existence of food deserts within our community.

Lead Paint Violations per 1,000 Energy Cutoffs per Vacant Buildings Vacant Lots per households 1,000 households per 1,000 housing 1,000 Housing CSA (annually) (annually) units Units Canton 1.3 7.2 5.7 11.1 Clifton-Berea 63.6 61.2 250.7 129.7 Downtown/Seton Hill 0.9 4.1 99.3 46 Fells Point 3.3 5.7 12.3 21 Greater Rosemont 24.7 77 156.9 50.9 Greenmount East 64.6 59.9 326.9 272.1 Harbor East/Little Italy - - 20.6 - Inner Harbor/Federal Hill 1.1 11.9 4.7 67.7 Madison/East End 90.3 89.8 206.6 46 Midtown 1.5 7.4 36.0 16.6 Oldtown/Middle East - - 346.7 - Patterson Park North and East 24.9 32.2 37.9 216.6 Poppleton/The Terraces/Hollins Market 8.7 31.3 154.9 226.6 Sandtown-Winchester/Harlem Park 39.8 86.9 343.3 150.7 South Baltimore 1.4 8 3.9 49.4 Southwest Baltimore 43.5 79.6 270.8 109.1 Upton/Druid Heights 21.6 45.2 336.7 155.1 Washington Village/Pigtown 13.7 45.8 75.0 79.3 Mercy Community Benefit Service Area Estimate 24.5 39.3 153.1 94.4 Baltimore City 11.8 39.1 80.3 59.3 -data not available due to CSA shift

Fast Food Restaurants Carry-out Restaurants Corner Stores per per 1,000 per 1,000 Residents 1,000 Residents

Mercy Community Benefit Service Area Estimate 3.1 22.1 15.2

Baltimore City 1.5 12.7 9.0

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Key Community Health Indicators

Life Expectancy, Premature Mortality, and Years of Potential Life Lost (YPLL):

In the citywide health profile, the Baltimore City Health Department used life expectancy estimates that reflected the mortality rates in Baltimore City: Life expectancy is a measure that summarizes health over the entire lifespan. Life expectancy at birth is the average number of years a newborn can expect to live, assuming she or he experiences the currently prevailing rates of death throughout her or his lifespan. The estimated citywide life expectancy at birth in Baltimore was 71.8 years. The mortality rate is the rate at which individuals in a population die, expressed in terms of deaths per 10,000 residents per year, and is age adjusted. Age-adjusted mortality reflects all deaths from all causes, taking into account differences in population size and age distribution. Years of potential life lost (YPLL) is a measure of the impact of premature mortality on a population. Premature mortality is death before the age of 75. YPLL is calculated by adding together the years of life that were not lived because people died before age 75. Both life expectancy and YPLL are heavily influenced by deaths in the first few decades of life. Infant deaths and juvenile deaths can heavily impact a community’s life expectancy data and YPLL.

As show in the map above, 7 of the 11 Community Statistical Areas within Baltimore City that are in the lowest quintile for Life Expectancy at Birth are located with the Mercy Community Benefit Service Area.

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The following chart below reveals that significantly more people die prematurely from all causes in Mercy’s CNHA Service Area than in the City as a whole. The Health Department calculated that 36.2% of all deaths in the City are avertable. Avertable deaths are defined as being deaths that could have been avoided if all Baltimore communities had the same opportunities for health. Specifically, the Health Department created a baseline by calculating the death rate in the five communities with the highest income in the City. The assumption is that the death rate in the five highest-income neighborhoods can be achieved by every other community. In the chart below, a positive percentage in the column labeled “% of deaths potentially avertable” reflects the percentage of deaths that could have been avoided if a particular CSA had the same death rate as the baseline rate from the five highest-income communities.

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Age-adjusted Deaths % of Deaths per 10,000 Total Annual YPLL Potentially CSA Residents, All Causes per 10,000 Residents Avertable Canton 86.7 506.7 15.9 Clifton-Berea 141.9 2423.5 45.8 Downtown/Seton Hill 238.2 1511.9 69.9 Fells Point 110.6 806.9 35.0 Greater Rosemont 140.0 1902.1 46.7 Greenmount East 144.9 2241.6 54.1 Harbor East/Little Italy - - - Inner Harbor/Federal Hill 113.2 1431.0 42.9 Madison/East End 157.9 2264.0 64.0 Midtown 90.6 875.0 18.2 Oldtown/Middle East - - - Patterson Park North and East 128.9 1852.6 48.5 Poppleton/The Terraces/Hollins Market 171.7 2366.5 64.0 Sandtown-Winchester/Harlem Park 144.5 2323.1 50.8 South Baltimore 122.3 782.4 40.6 Southwest Baltimore 157.8 2250.4 57.3 Upton/Druid Heights 175.8 2494.5 63.2 Washington Village/Pigtown 145.9 1482.8 55.3 Mercy Community Benefit Service Area Estimate 128.0 1636.3 46.6 Baltimore City 110.8 1377.4 36.2 -Data not available due to CSA shift

While the overall death rates in Mercy’s CNHA Service Area area higher than the city average, the data for the Downtown/Seton Hill community, Madison/East End, Poppleton, and Upton/Druid Heights merits further examination. The data indicates that residents in these areas dying far earlier than residents in higher income neighborhoods. One likely factor in the Downtown/Seton Hill data point (approx 70% avertable death) could be the disproportionate concentration of homeless persons in the downtown area. Healthcare for the Homeless estimates that life expectancy for an individual experiencing homelessness at any point is only 48 years.

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Top causes of premature deaths:

Adult Deaths per 10,000 Residents, by Cause of Death

CSA Heart Disease Cancer (All) Lung Cancer Stroke HIV/AIDS Canton 22.8 25.1 6.5 3.5 + Clifton-Berea 30.7 31.3 7.9 7.3 7.2 Downtown/Seton Hill 71.0 47.2 16.1 11.7 10.4 Fells Point 28.3 25.9 9.8 4.9 + Greater Rosemont 35.8 28.8 7.4 6.9 6.5 Greenmount East 37.4 26.3 7.7 6.9 8.2 Harbor East/Little Italy - - - - - Inner Harbor/Federal Hill 28.5 24.3 7.7 5.1 5.6 Madison/East End 35.2 28.6 9.3 8.4 5.9 Midtown 26.7 18.6 5.8 3.9 6.7 Oldtown/Middle East - - - - - Patterson Park North and East 32.2 22.9 5.8 4.3 9.3 Poppleton/The Terraces/Hollins Market 32.6 27.4 10.2 8.2 11.8 Sandtown-Winchester/Harlem Park 36.4 28.0 7.7 6.2 6.8 South Baltimore 35.0 33.3 12.1 2.9 + Southwest Baltimore 42.3 32.7 11.5 5.9 5.8 Upton/Druid Heights 47.9 30.3 9.1 6.9 12.4 Washington Village/Pigtown 42.5 32.5 11.6 4.9 3.7 Mercy Community Benefit Service Area Estimate 33.6 26.6 8.2 5.6 5.2 Baltimore City 28.5 23.1 6.9 5.2 3.9 -Data not available due to CSA shift

+Rate not calculated, fewer than five deaths

Consistent with Mercy’s 2013 CHNA, A significant output of Mercy’s community health profile is the identification of the top causes of premature death within our specific community. The top four causes of premature death in our 18 priority communities are heart disease, cancer, homicides, and HIV/AIDS. These four categories contribute greatly to the years of potential life lost in each neighborhood. Of note, these four conditions are not necessarily the top causes of death in our community. For example, there are 5.2 strokes deaths per 10,000 residents in the City and 3.5 homicide deaths per 10,000 residents in the City. However, when calculating the years of potential life lost, the younger age of homicide victims prioritizes the impact of their premature death in our health profile.

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Age-adjusted Deaths per 10,000 Residents by Cause of Death

Chronic Lower Respiratory Drug-Induced CSA Disease Homicide Deaths Diabetes Septicemia Canton 4.5 + + 3.2 2.2 Clifton-Berea 2.3 8.5 6.5 3.7 4.4 Downtown/Seton Hill 8.2 3.4 4.0 5.5 6.2 Fells Point 6.7 1.4 4.0 2.7 3.5 Greater Rosemont 4.3 8.2 5.4 3.2 4.5 Greenmount East 3.7 6.7 6.7 5.9 4.0 Harbor East/Little Italy - - - - - Inner Harbor/Federal Hill 5.1 3.7 3.1 3.4 2.0 Madison/East End 6.2 10.6 6.3 5.1 4.7 Midtown 2.0 1.2 2.0 3.7 1.3 Oldtown/Middle East - - - - - Patterson Park North and East 3.0 6.1 3.9 4.1 4.8 Poppleton/The Terraces/Hollins Market 8.4 6.3 10.0 5.5 7.3 Sandtown-Winchester/Harlem Park 3.4 8.6 7.6 4.3 5.0 South Baltimore 8.3 + 2.6 3.9 2.1 Southwest Baltimore 4.5 6.3 7.8 5.3 5.0 Upton/Druid Heights 2.3 7.5 8.5 7.7 6.4 Washington Village/Pigtown 9.3 2.4 3.4 5.3 6.9 Mercy Community Benefit Service Area Estimate 4.4 4.4 4.3 4.2 3.8 Baltimore City 3.9 3.5 3.7 3.5 3.5 -Data not available due to CSA shift +Rate not calculated, fewer than five deaths

% of All Deaths, by Cause of Death

CSA Heart Disease Cancer (All) Lung Cancer Stroke HIV/AIDS Canton 27.0 27.0 7.2 4.5 + Clifton-Berea 22.6 23.2 6.0 5.3 4.2 Downtown/Seton Hill 24.4 21.4 6.2 2.6 8.8 Fells Point 24.2 22.8 8.3 4.6 + Greater Rosemont 26.6 20.4 5.3 5.1 4.3 Greenmount East 25.3 18.6 5.9 4.8 6.6 Harbor East/Little Italy - - - - - Inner Harbor/Federal Hill 23.7 20.6 6.3 4.1 6.5 Madison/East End 20.4 17.5 5.6 4.1 4.9 Midtown 30.3 20.7 6.5 4.4 6.5 Oldtown/Middle East - - - - - Patterson Park North and East 24.5 18.1 5.0 3.5 7.1 Poppleton/The Terraces/Hollins Market 17.4 16.0 6.4 4.7 8.0 Sandtown-Winchester/Harlem Park 25.5 19.6 5.4 4.3 4.4 South Baltimore 27.7 26.3 9.7 2.2 + Southwest Baltimore 26.4 20.2 7.0 3.6 4.0 Upton/Druid Heights 26.5 17.4 5.5 3.6 7.4 Washington Village/Pigtown 26.6 21.8 8.9 3.8 3.4 Mercy Community Benefit Service Area Estimate 25.1 20.7 6.5 4.1 4.7 Baltimore City 25.8 20.8 6.3 4.7 3.5 -Data not available due to CSA shift +Rate not calculated, fewer than five deaths

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Maternal and Child Health Indicators:

As noted earlier, The Sisters of Mercy were originally founded in Dublin, Ireland to care for homeless, abused and neglected women and children. This influences Mercy’s special attention to mothers and infants. Mercy is the largest birthing hospital in Baltimore delivering roughly 1-in-5 of all children born in Baltimore City each year. Mercy is the second largest hospital provider to low-income mothers insured by Medicaid in the state with nearly 2,000 Medicaid births annually (72% of mothers delivering at Mercy are Medicaid-insured). Additionally, Mercy has a long-standing practice partnering with Federally Qualified Health Centers to improve community health and to help manage high risk populations, including pregnant women. Mercy currently provides on-site Obstetric services and delivers babies for three FQHC’s. Despite strong efforts among hospital and community providers as well as the successes of the City’s B‘more for Healthy Babies campaign, more must be done to improve the health outcomes for mothers, infants, and children in our City. Baltimore’s City’s rates of infant mortality, especially in poor neighborhoods, including those within Mercy’s Community Benefit Service Area remain unacceptably high.

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Despite reductions in the citywide teen birth rate in recent years, the rate of births to persons 15-19 years old remains 51% higher in Mercy’s Community Benefit Service Area. With respect to the percentage of women receiving prenatal care in the first trimester, Mercy’s Community Benefit Service Area is on par with the citywide average. However, the disparity within Mercy’s community merits further attention. Only 50.2% of women in Madison/East End received prenatal care in the first trimester compared to 75% in both Canton and South Baltimore, even as the neighborhoods are in close proximity to each other. Furthermore, the data suggests that several areas within Mercy’s Community Benefit Service Area are unfortunately confronted by high rates of smoking during pregnancy, pre-term births, low birth weights, and infant deaths.

% of Live Births % of Women Teen Birth Rate with Receiving per 1,000 Inadequate Prenatal Care in Live Births per Persons 15-19 Birth Spacing the 1st CSA 1,000 Persons Years Old (<12 months) Trimester Canton 12.0 51.2 2.3 75.0 Clifton-Berea 18.1 123.9 5.5 51.2 Downtown/Seton Hill 9.8 58.7 2.2 63.8 Fells Point 15.4 168.9 2.2 61.3 Greater Rosemont 18.1 113.9 6.3 54.9 Greenmount East 17.9 114.7 6.5 56.2 Harbor East/Little Italy - - - - Inner Harbor/Federal Hill 16.6 89.6 5.7 54.7 Madison/East End 24.6 128.1 5.9 50.2 Midtown 6.7 10.7 2.1 66.1 Oldtown/Middle East - - - - Patterson Park North and East 19.9 142.5 4.6 52.4 Poppleton/The Terraces/Hollins Market 18.1 94.0 7.4 58.0 Sandtown-Winchester/Harlem Park 18.5 116.0 5.2 52.8 South Baltimore 14.2 55.4 2.6 75.0 Southwest Baltimore 20.6 117.9 7.2 57.4 Upton/Druid Heights 21.9 116.9 5.1 55.3 Washington Village/Pigtown 14.5 82.6 4.3 65.3 Mercy Community Benefit Service Area Estimate 16.6 98.7 4.7 59.8 Baltimore City 15.5 65.4 4.7 59.5 -Data not available due to CSA shift

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% of Births to Mothers who % of Live % of Births Reported Births Classified as Infant Smoking Occurring Low Birth Mortality Rate During Preterm (<37 Weight (<5 lb. per 1,000 Live CSA Pregnancy weeks) 8 oz.) Births Canton 3.1 10.3 6.6 + Clifton-Berea 15.2 19.3 15.3 16.8 Downtown/Seton Hill 6.0 13.0 10.2 + Fells Point 3.9 13.5 7.9 7.1 Greater Rosemont 12.2 16.4 14.8 13.8 Greenmount East 13.4 18.7 18.6 15.7 Harbor East/Little Italy - - - - Inner Harbor/Federal Hill 10.5 17.0 12.4 12.1 Madison/East End 13.5 19.3 16.3 16.7 Midtown 7.1 12.1 12.5 11.5 Oldtown/Middle East - - - - Patterson Park North and East 11.6 19.1 14.3 + Poppleton/The Terraces/Hollins Market 10.7 19.1 15.4 13.0 Sandtown-Winchester/Harlem Park 14.8 17.9 16.0 21.2 South Baltimore 7.7 10.5 6.1 8.8 Southwest Baltimore 17.3 18.3 15.2 13.6 Upton/Druid Heights 12.3 19.0 15.2 15.0 Washington Village/Pigtown 19.8 17.1 14.1 12.6 Mercy Community Benefit Service Area Estimate 10.7 15.9 12.7 12.0 Baltimore City 10.2 16.0 13.0 12.1 -Data not available due to CSA shift +Rate not calculated, fewer than five deaths

Qualitative Data – Input from Community Representatives

In addition to gathering quantitative data, Mercy obtained input from important community stakeholders regarding the health needs of the community. Mercy’s Community Benefit Committee received input from a diverse group of leaders that represent broad interests in our community, including: leaders of medically underserved and low-income populations, persons with expertise or special knowledge in public health, and persons who lead local health agencies. A designee of the Community Benefit Committee conducted in-person interviews with leaders of neighborhood associations, elected officials, chief executives of community health clinics, foundation executives, advocates for the homeless and elderly, and public health experts (among others). A list of the interviewees along with a description of their special knowledge or expertise is provided in the following chart:

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Community Stakeholders Name Title Organization Background Interview The Sharp Leadenhall Planning Committee is a Sharp Leadenhall Andrew Gervase President community organization representing the historic 2/26/2016 Planning Committee Sharp Leadenhall neighborhood in South Baltimore.

Baltimore City Elected official representing a substantial portion of Hon. Eric Costello Councilman 2/8/2016 Council Mercy's Community Benefit Service Area.

The Baltimore City Health Department is the oldest, continuously-operating health department in the United States, BHCD has a wide-ranging area of Olivia D. Farrow, Deputy Baltimore City responsibility, including acute communicable diseases, 2/5/2016 Esq. Commissioner Health Department chronic disease prevention, emergency preparedness, HIV/STD, maternal-child health, school health, senior services and youth violence issues.

Total Health Care is one of Maryland’s largest minority- Faye Royale-Larkins, Chief Executive Total Health Care, run, nonprofit, federally qualified community health 2/16/2016 RN, MPH Officer Inc. centers. For more than 45 years, Total Health Care has provided medical care in Baltimore. Health Care for the Homeless is an FQCA-deemed, free- standing 330(h) federally qualified health center President and Healthcare for the Kevin Lindamood accredited by the Joint Commission for both 1/29/2016 CEO Homeless ambulatory and behavioral health care and certified as a Primary Care Medical Home (PCMH).

As the region’s premier resource on philanthropy dedicated to informing grantmakers and improving the Consultant, Association of community, The Association of Baltimore Area James Macgill, Jr. Health Affinity Baltimore Area 2/16/2016 Grantmakers' membership includes more than 140 Group Grantmakers private and community foundations, corporations, donor advised funds, giving circles and public charities.

The Baltimore City Department of Social Services Baltimore City Molly McGrath assists people in need by administering a wide range of Director Department of 2/17/2016 Tierney public assistance programs. Primarily, BCDSS helps low- Social Services income people as well as families and children in crises.

The Annie E. Casey Foundation is devoted to developing a brighter future for millions of children at B'More for Healthy Senior Associate risk of poor educational, economic, social and health Babies Initative & Gena O'Keefe, M.D. with The Annie E. outcomes. The foundation makes grants that help cities 2/10/2016 The Annie E. Casey Casey Foundation and neighborhoods create more innovative, cost- Foundation effective responses to the issues that negatively affect children.

Christ Lutheran Church is a metropolitan congregation of the Evangelical Lutheran Church in America. The Rev. Susan Christ Lutheran congregation also offers extensive programs in Senior Pastor 2/3/2016 Tjornehoy Church education for persons of all ages; a nursery school and a year-round homeless shelter for forty women and children.

HealthCare Access Maryland is a nonprofit agency that connects residents to public health care coverage and helps them navigate services effectively. HCAM connects uninsured and underinsured clients to health HealthCare Access insurance, health care, and vital community resources. Traci Kodeck Interim CEO 2/5/2016 Maryland HCAM programs and services are designed to bridge gaps in services to pregnant and postpartum women, immigrants, people experiencing homelessness, youth in foster care, people with substance use disorders, individuals recently released from jail, and others.

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Stakeholder Interview Process:

A designee employed by Mercy Medical Center conducted the interviews with individual community members. Interviews typically lasted one-hour each. Each community member was provided with Mercy’s previous 2013 CHNA & Implementation Strategy and the most recently available quantitative data for the Community Benefit Service Area. Mercy’s representative provided a detailed description of the proposed 2016 Mercy Community Benefit Service Area. Mercy’s representative sought input and feedback on a number of key issues and questions. Specifically, Mercy sought feedback on: Whether the Mercy Community Benefit Service Area for 2013 was appropriate to continue for the 2016 CHNA; Mercy’s proposed focus areas to be included in the 2016 CHNA Implementation Strategy; Key social, economic and health outcomes data about the residents within Mercy’s Community Benefit Service Area; Ideas for increased community partnerships; and What other health issues impact the quality of life of residents.

Summary of Feedback:

In summary, Mercy received positive feedback regarding Mercy’s leadership among Baltimore City hospitals, its lasting commitment, and ongoing actions related to specific populations, especially individuals experiencing homelessness, pregnant women, and infants.

. Stakeholders responded that the proposed 2016 Mercy Community Benefit Service Area and the proposed focus areas of the 2016 CHNA Implementation Strategy were very well crafted and appropriate given Mercy’s existing areas of strength, range of services, and strong community benefit activities. . Stakeholders were generally not surprised about some of the poor health outcomes compared to the City as a whole given the significant economic and social challenges present in many of the neighborhoods within Mercy’s Community Benefit Service Area. . Stakeholders appreciated that Mercy focuses its limited community benefit resources specifically to assist medically underserved, low income, and minority populations given its size compared to other larger hospitals in Baltimore City. . Several Stakeholders remarked about Mercy’s continued investments in its downtown facilities as a strong statement about Mercy’s commitment to Baltimore City.

The theme that emerged from all stakeholders was that Mercy exceeds expectations in its commitment to the community and is a willing and critical partner to organizations seeking to improve the quality of life of area residents. Most importantly, stakeholders believed that Mercy should continue to build upon its current CHNA Implementation Strategies in order to improve community health recognizing that the challenges within Mercy’s Community Benefit Service Area will require steady, focused interventions over the long-term. Several stakeholders discussed the importance of all City hospitals and community health organizations working more collaboratively with each other to improve community health, recognizing that Mercy alone would not able to make dramatic improvements in the overall health status of the population within the Community Benefit Service Area.

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Further, Stakeholders also highlighted a number of global issues and needs that ultimately impact the health status of the population, including:

. The need for major, sustained investments from federal, state, local government and philanthropy for effective job training, education, and other policies that support long-term job growth and economic prosperity in Baltimore City. Stakeholders almost uniformly stated that poverty and lack of economic opportunity are root causes of health disparities. While stakeholders believed that health systems and community-based providers should play a central, leading role in better managing the health of the population, some questioned whether it was appropriate to hold these entities solely accountable for major societal challenges, such as poverty, that impact community health. . The critical need for increased investment from federal, state, local government and philanthropy to expand access to mental health services and substance abuse treatment for Baltimore City residents. The rise of opioid addiction, while not a new epidemic to Baltimore, was a familiar refrain from many stakeholders. . The need for increased investment in stable, affordable housing options for individuals and families experiencing chronic homelessness as well as for families that are routinely displaced as a result of economic challenges. And, that the nexus between supportive housing and population health needs greater understanding and measurement in order to justify funding from the health care system. One stakeholder put it this way: “Homelessness makes you sick. Being very sick can make you homeless. And, if you’re sick, homelessness makes you sicker.” In short, if policy makers and health systems want to see gains in population health, housing supports must be a consideration for investment to improve population health.

Finally, Stakeholders made specific recommendations, including:

. Build stronger connections to senior housing facilities in order to better manage patients outside the hospital. Mercy’s care model at Basilica Place (a 200 unit HUD Section 8 senior housing apartment building) should be measured for outcomes as it may warrant replication to other sites. . Support efforts to move the B’More for Healthy Babies initiative towards a long-term, sustainable financial model. . Continue to strengthen Child Fatality Review processes by better connecting care across multiple providers. . Strengthen the continuum of care to outpatient and supportive services for individuals admitted and discharged from inpatient detoxification units. . Support efforts to increase access to adult outpatient dental care for Medicaid insured populations. . Provide targeted health education/literacy materials at Department of Social Services Resource Centers located within the CHNA Service Area. . Evaluate grant opportunities to partner with Federally Qualified Health Centers and Department of Social Services to expand nurse home visits to new/expectant mothers.

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PRIORITIZATION OF NEEDS

Mercy’s location in the middle of a disproportionately poor, urban City presents challenges and health disparities that are not evident in other parts of Maryland. The health needs and societal needs identified in our Community Health Profile and interviews are staggering; simply put, a hospital like Mercy cannot single-handedly move the needle on many of these key community metrics. Therefore, Mercy intends to focus its limited resources on a defined number of health needs within the community, while putting tremendous thought and effort into executing our mission “to witness God’s healing love for all people by providing excellent clinical and residential services within a community of compassionate care”.

In order to prioritize the multitude of health needs and disparities identified by the CHNA, the Community Benefits Committee has identified areas of opportunity where the mission and strengths of our institution intersect with the unmet public health needs that merit immediate attention and feedback from community health leaders. We are seeking to identify opportunities to align Mercy’s strengths with the needs identified by the Baltimore City Health Department’s Healthy Baltimore 2015 plan, the needs identified through our interview process. In determining those health needs that Mercy will not attempt to meet pursuant to this CHNA, focus will be placed on whether other organizations or governmental entities are better placed to respond to such health needs than Mercy.

As stated earlier, Mercy intends to continue its focus on the specific needs indentified in its 2013 CHNA. The desire to continue with these focus areas is validated by the feedback from community stakeholders to build upon existing successful efforts, as well the recognition that these needs require focused intervention over the long term. They are:

. Improving access to care and the frequency of care for our homeless neighbors. . Identifying tactics and strategies to improve birth outcomes and pre-natal care for expectant mothers. . Facilitating better care coordination with the City’s Federally Qualified Health Centers. . Providing support to victims of violence and addiction. . Providing narrowly tailored health education to micro-targeted segments of the population within our community.

In contrast, at this time Mercy does not intend to create a new community-based program focused solely on heart disease and cancer. Considerable local and state resources are currently invested in these key causes of premature death. Furthermore, two large, high-quality academic medical centers exist within walking distance of our downtown hospital and provide significant cardiology and cancer programs to the community. While Mercy does not plan to create new stand alone programs in these two high priority fields, we do plan to continue our efforts to reduce these top causes of premature death through our existing clinical programs and by improving care coordination and health education in the community setting.

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CHNA IMPLEMENTATION STRATEGY

Based on CHNA data and community stakeholder interviews, Mercy Medical Center’s CHNA Implementation Strategy remains focused on the following needs in our community:

. Improving access to care and the frequency of care for our homeless neighbors. . Identifying tactics and strategies to improve birth outcomes and pre-natal care for expectant mothers. . Facilitating better care coordination with the City’s Federally Qualified Health Centers. . Providing support to victims of violence and addiction. . Providing narrowly tailored health education to micro-targeted segments of the population within our community.

Detailed explanations of the strategic goals and objectives for each of these five focus areas are contained on the following pages.

Aligned Population Health Initiatives

In addition, since the 2014 implementation of the new Maryland all-payer model which followed the completion of Mercy’s 2013 CHNA and Implementation Plan, Mercy is increasingly focused on high- utilizer patients, including those within our defined Community Benefit Service Area. Under the new All Payer Model Mercy Health Services continues improving quality, lowering costs and responding to population/community needs. Through Global Budget Revenue (GBR) incentives, Mercy has broadened its focus and reached further into the community to work towards Maryland’s statewide population health goals. Mercy has reduced its population of high utilizers through highly effective readmission reduction and extended care activities. Mercy knows its high risk population including individuals experiencing homeless (proximity driven), end stage liver disease (program driven) and high risk mothers. Mercy has tailored specific interventions for these target populations. Mercy will continue to build on its successful 2014-15 population health strategies. A hospital stay provides a critical opportunity to identify and interact with high-risk/high need patients to prevent future hospitalizations. Central to Mercy’s success in managing complex patients and reducing potentially avoidable utilization is a centralized care management infrastructure. Mercy will continue to build its core care management capabilities in and pursue additional strategies alone and/or in collaboration with other hospitals, FQHCs or payer partners. Mercy’s complex care coordination and improvement activities include:

. Risk stratification of the population with a focus on patients with a high risk diagnosis . A bedside medication delivery at discharge program . Intensive education for patients and families through the Get Well Network . Timely communication with primary care providers (PCP) and connecting patients without primary care physicians to PCP’s in the community (including Obstetricians) . Extended care activities by a physician-led population health team including a post acute clinic for post-discharge needs, scheduling or checking on follow-up appointments. . Expedited charity care policy to speed transitions home or to lower cost settings. . Care coordination across settings

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As expected, there is significant geographic overlap of high utilizer patient origin and Mercy’s Community Benefit Service Area, especially in the immediate areas where the most vulnerable populations reside (map below). The similarity of geography presents an ongoing opportunity to increase alignment between Mercy’s Community Benefit activities and Mercy’s focused population health interventions to reduce potentially avoidable utilization as identified in Mercy’s 2016 Strategic Hospital Transformation Plan provided to the

Maryland Health Services Cost Review SOURCE: Berkeley Research Group Analysis for Mercy Medical Center Data period: Fiscal Year 2015 High Utilizer: > 2 Commission. Inpatient or Observation encounters (Bedded Care) in the year Exclusions: Age 0-17; Mortalities

Community Partnerships

Mercy has long-standing, and strong, community partnerships with Federally Qualified Health Centers (FQHC’s). FQHC’s fill a vital role in the community and our partnerships emphasize cooperation in caring for patients rather than competition. Mercy specifically maintains active partnerships with Health Care for the Homeless, Family Health Centers of Baltimore, Total Health Care and Park West Medical Center to help manage high risk populations including pregnant women. Ms. Faye Royale-Larkins, Chief Executive Officer, Total Health Care serves on the MHS Board of Trustees. MHS executives or physician leaders serve on the Boards of Total Health Care, Family Health Centers of Baltimore, Health Care for the Homeless and Park West Medical Systems.

Implementation Strategy Detail

The following charts reflect the actions identified for measurement and tracking for the Mercy Implementation Strategy. The charts describe the actions the Mercy intends to take to address health needs, describes the anticipated impact of the actions, identifies resources committed and highlights key partnerships and collaborations. The Implementation Strategy is not intended to be a comprehensive catalog of the many ways the health needs of the community are addressed by Mercy Medical Center but rather a representation of specific actions that the hospital commits to undertaking and monitoring as they relate to each identified need. Key partners have been included in the line item entries on the Implementation Strategy charts; however, many Mercy clinical departments will be partnering in the collaborative efforts and specific actions that address the goals of “meeting the health needs of the community” whether that entails involvement in a clinical program or protocol or if it is an individual or group sharing knowledge in an educational outreach opportunity.

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2016 CHNA IMPLEMENTATION STRATEGY

Improving access to care and the frequency of care for our homeless neighbors.

 Maintain support for Healthcare for the Homeless (HCH): Mercy provides primary medical and pediatric physicians, nurse practitioners, PA and social work providers to support the mission of primary care, preventative medicine and support services at the HCH site. The initiative supports a continuum of care for patients utilizing HCH and Mercy services. Effective preventative care for this high risk population reduces avoidable utilization.

 Maintain Supportive Housing Program: Mercy’s Supportive Housing Program (MSHP) coordinates services to homeless families, families in shelters and families at risk of homelessness. The goal of MSHP is to house homeless families, prevent homelessness for families at risk of eviction and to provide support services such as counseling and advocacy.

 Maintain Emergency Department Social Work: An emergency department visit provides a critical opportunity to identify and interact with high‐risk patients and Hospital prevent future visits. Mercy provides case management/Social Worker (LCSW) capacity Initiatives & in the Emergency Department for homeless, substance abuse and psychiatric patient Objectives populations in need of primary care and social support referrals.

 Bi-Directional Patient Navigator: Maintain patient navigator position for Healthcare for the Homeless (HCH) that will be primarily responsible for facilitating and ensuring that HCH patients keep their appointments and ensure that these patients arrive on time at the site of service. In addition, this position will identify patients in Mercy’s Emergency Department who are in need of the client services provided by HCH.

 Maintain/Expand Mobile Clinic Services: Partner with HCH to improve access to primary care, by supporting HCH’s efforts to maintain and expand mobile clinic services for homeless clients along the Fallsway and specifically at the Weinberg Housing Resource Center.

 Maintain Emergency Dental Care & Charity Dental Clinic Care.

Key Partners & Healthcare for the Homeless, Catholic Charities, Mercy Emergency Department, Mercy Resources Social Work Department.

Mercy Medical Center is a founding partner of Health Care for the Homeless which works to prevent and end homelessness for vulnerable individuals and families. HCH offers quality, integrated health care and promotes access to affordable housing and sustainable incomes through direct service, advocacy and community engagement. Mercy Medical Center Comments physicians, nurses, social workers, supportive housing personnel and pastoral care staff support the health care needs of clients served by HCH. In partnership with Baltimore City shelters, the HCH Convalescent Care Program provides 24-hour shelter, recuperative care, case management and nursing assistance for individuals with medical conditions not appropriate for hospitalization.

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2016 CHNA IMPLEMENTATION STRATEGY

Identifying tactics and strategies to improve birth outcomes and pre-natal care for expectant mothers.

 Support Baby Basics Prenatal Health Literacy Program: The Baby Basics Prenatal Health Literacy Program provides health education to expectant mothers at Federally Qualified Health Centers, read, understand, and act upon pregnancy information. The program empowers underserved populations to be active participants and to effectively navigate the healthcare system.

 Provide HCAM/ED Linkage & Referral Initiative for Pregnant Women: Pregnant mothers presenting to the Mercy ED are provided resources and referrals for insurance coverage.

 Host & Support Child Fatality Review Committee: Mercy hosts and participates in the multi-stakeholder Baltimore City Child Fatality Review Committee. The committee is provided notice of unexpected resident child deaths each month by the Office of the Chief Medical Examiner, reviews the circumstances of each incident, and then Hospital recommends and works to implement local level systems changes to prevent future Initiatives & deaths. Objectives  Increase completion of pre-natal records: Collaborate with FQHCs to make pre-natal records available for every mother delivering at Mercy.

 B’More for Healthy Babies: Provide executive support to move the B’More for Healthy Babies initiative towards a long-term, sustainable financial model.

 Explore Nurse Home Visits: Seek and evaluate grant opportunities to partner with Federally Qualified Health Centers and the Department of Social Services to expand nurse home visits to new/expectant mothers.

 Maintain Access to OB and NICU services: Mercy provides support to physician practices through subsidies for PA and NP physician extenders in order to provide OB and NICU health care Services regardless of insurance status.

Key Partners & B’More for Healthy Babies, Baltimore City Health Department, Metropolitan OBGYN, Total Resources Healthcare, Family Health Centers of Baltimore, Park West Health System.

As the largest Birthing hospital in Baltimore City and as the second largest hospital provider of obstetrical services in Maryland for the Medicaid-insured population, Mercy is deeply Comments committed to working with community stakeholders, local and state government and other providers to lower instances of infant mortality and premature births.

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2016 CHNA IMPLEMENTATION STRATEGY

Facilitating better care coordination with the City’s Federally Qualified Health Centers.

 Participate in collaborative efforts to improve FQHC sustainability: Mercy views Federally Qualified Health Centers as the backbone of population health for poor, minority populations in Baltimore City and the State of Maryland. It is critical that FQHCs work collaboratively to improve the long-term sustainability of their business models given current market dynamics since the implementation of the Affordable Care Act. Mercy will partner with collaborative initiatives to improve FQHC sustainability.

 Participate on FQHC Boards: Similarly, senior Mercy Executives volunteer to serve on the boards of several Baltimore City Federally Quality Health Centers to promote collaboration and FQHC stewardship and sustainability.

 Maintain support of Family Health Centers of Baltimore: Mercy provides subsidized support to Adult and Pediatric physician offices through the Family Health Centers of Baltimore (an FQHC). This helps to provide cost‐efficient and accessible health care regardless of insurance status and arranges for sliding scale fees to assist the uninsured Hospital with physician and other expenses. Initiatives & Objectives  Continue Family Violence Training: Mercy’s Family Violence Program develops training curriculums and provides training sessions for Baltimore City Federally Qualified Health Centers.

 Electronic Health Record / Health Information Exchange: Mercy makes continual investment in EHR technology which facilitates the sharing of patient data amongst both internal and external providers. Mercy regularly contributes clinical and demographic data to CRISP, which is Maryland’s Health Information Exchange (HIE). FQHCs are then able to access that data through CRISP’s provider portal to incorporate relevant information for patient care coordination. Mercy’s Epic system also allows providers to send and receive transitions of care electronically through direct messaging functionality.

Key Partners & Total Health Care, HealthCare for the Homeless, Family Health Centers of Baltimore, Park Resources West Health System

As noted earlier, Mercy has long-standing, and strong, community partnerships with Federally Qualified Health Centers (FQHC’s). FQHC’s fill a vital role in the community and our partnerships emphasize cooperation in caring for patients rather than competition. We are Comments focused on collective learning, leveraging our respective strengths, and specific initiatives to improve community health. Mercy specifically maintains active partnerships with Health Care for the Homeless, Family Health Centers of Baltimore, Total Health Care and Park West Medical Center to help manage high risk populations including pregnant women.

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2016 CHNA IMPLEMENTATION STRATEGY

Providing support to victims of violence and addiction.

 Maintain Forensic Nurse Examiner Program: The Forensic Nurse Examiner (FNE) Program (formerly the SAFE Program) provides care to victims of sexual, domestic, child, elder and institutional violence. The centerpiece of Mercy’s program is a skilled team of Forensic Nurse Examiners (FNEs) who document the details of the assault, collect crucial time-sensitive evidence and perform medical exams, tests and treatments. In order to raise awareness and reduce violence, the program's leadership and certified nursing staff provide community education about domestic violence and sexual assault to law enforcement and the community. The FNE Program is the designated site for forensic patients in Baltimore City and the only comprehensive program of its kind in Maryland.

 Maintain Inpatient Substance Abuse and Medical Detoxification Services: Mercy offers one of two inpatient detoxification units in Baltimore City and provides physician subsidies for the professional component of these inpatient services. Of note, a number of diseases and medical conditions are over-represented in patients with substance abuse. Consultative and follow up care with appropriate specialists also are supported.

Hospital  Maintain Family Violence Response Program: The Mercy Family Violence Response Initiatives & Program provides confidential services to patients and employees who are victims of Objectives violence, abuse and neglect, including domestic violence, sexual assault and vulnerable adult abuse. The program offers counseling, crisis intervention, safety planning, danger assessment, counseling/legal resource linkage, advocacy, documentation and free short-term individual follow-up counseling regarding domestic violence.

 Maintain Screening, Brief Intervention and Referral to Treatment (SBIRT) services: Mercy is one of three Hospital-based SBIRT sites in Baltimore City. SBIRT is a proven- effective public health approach to identifying and providing early intervention among individuals at risk for developing substance use and other behavioral health disorders.

 Stabilization Center: Mercy and several other partners, including the Baltimore City Health Department and Behavioral Health System Baltimore, are supporting efforts to establish a Baltimore City Stabilization Center to better meet the needs of people in Baltimore who are intoxicated in public and pose a risk to themselves or people around them. The planned center will provide an array of support services to help clients stabilize their physical condition and take steps to improve their lives.

Key Partners & Baltimore City Health Department, Behavioral Health System Baltimore, Baltimore City Resources Sexual Assault Response Team (SART), Mercy Emergency Department.

As noted earlier, Baltimore has the one of the highest violent crime rates among major U.S. Cities with a rate of 1417 per 100,000 residents. The U.S. Drug Enforcement Agency reports Comments Baltimore has the highest per capita heroin addiction rate in the country. Therefore, hospitals alone cannot significantly reduce violent crime or addiction in Baltimore. However, the programs described here are incredibly important pieces to a network of services provided to victims in Baltimore. Mercy will seek to enhance and continue these existing community resources.

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2016 CHNA IMPLEMENTATION STRATEGY

Providing narrowly tailored health education to micro-targeted segments of the population within our community.

 Community Seminars: Mercy provides a series of topical community health seminars that are free and open-to-the public at Mercy’s downtown campus and throughout the broader region. The health seminars include expert presentations by Mercy primary care and specialist physicians on a variety of key health issues effecting community members.

 Personalized Health Education: Mercy provides disease specific, patient education through its Get Well Network to reduce readmissions and improve population health. The program leverages the patient’s in-room television to engage patients and families in the care process for improved outcomes. The Get Well Network delivers personalized patient education, medication information and chronic condition management tools. Hospital Initiatives &  Health Web Videos: Mercy maintains a large catalogue of more than 1000 high- Objectives quality, professionally produced web videos featuring Mercy primary care and specialist physicians on a variety of key health topics that are accessible on Mercy’s website and YouTube Channel.

 Nutritional counseling and weight loss counseling sessions: Mercy offers periodic nutritional and weight loss counseling sessions to employees, patients and the broader public in order to support a culture of fitness and wellness within our community.

 Health literacy for those in need: Evaluate opportunities to provide targeted health education/literacy materials at Department of Social Services Resource Centers located within the CNHA Service Area.

Key Partners & Mercy’s Nursing Division, Mercy Marketing Department, Mercy HR Department, Mercy’s Resources Center for Endocrinology

There is a dearth of updated, high quality health education materials in our community. Significant thought went into identifying the most effective means of communicating public health messages to such a diverse community. Mercy already generates a large volume of Comments health information via newsletters, the Mercy website, our YouTube channel and other media and Mercy continues to explore new opportunities to make this valuable health information available to the public.

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Successful Initiatives

Below is a review of key successful actions that were taken since Mercy finished conducting its immediately preceding CHNA:

1. Access to care for our homeless neighbors a. Maintained partnership with Health Care for the Homeless (HCH). Mercy is a founding partner of HCH, which was established in 1985. HCH provided 101,588 encounters to 9,830 unique clients in 2015. Encounters have increased by 49% and unique clients by 60% in the past three years. b. Established navigator position to decrease the wait time for HCH clients seeking specialty care to Mercy. c. Launched the Emergency Room (ER) Diversion Project targeted at the 25 individuals visiting the ER the most each month. Provided special care to these patients in coordination with HCH. d. In partnership with HCH, launched a mobile clinic that provided 2,029 encounters during 2015.

2. Improved birth outcomes and prenatal care a. 2,271 Baby Basics books provided to Federally Qualified Health Centers (FQHC) with 1,008 of these books given to patients. 967 (96%) patients demonstrated use of the Baby Basics book. b. 276 patients participated in Mom’s Club activities at FQHCs c. Mercy provided Baby Basic education to 159 staff at 12 FQHC sites and trained 34 facilitators for Mom’s Clubs at FQHCs. d. Increased exclusive breastfeeding rate to 21.8 percent (baseline of 18.5% in FY13). e. Mercy executives provide strategic assistance to B’More for Health Babies. f. Maintained community teaching hospital partnership with the University of Maryland School of Medicine.

3. Support for victims of violence and addiction a. Initiated Screening, Brief Intervention, and Referral to Treatment Program (SBIRT) in the Emergency Department; 98,065 patients screened. b. Provided 3,090 inpatient detoxification care admissions. c. Provided domestic violence intervention for 2,150 patients and Mercy employees through the Mercy Family Violence Response Program. d. Provided support to 2,317 victims of sexual assault through the Forensic Nurse Examiner Program and 344 community education programs. e. Developed a domestic violence screening tool for FQHCs modeled after the HARK Screening Instrument f. Developed training curricula with specialized modules to address challenges specific to the FQHCs patient population: i. Chase Brexton Health System – LGBT, and ii. Health Care for the Homeless – Homeless. g. Conducted training for 268 FQHC staff from 12 sites.

4. Care coordination with Federally Qualified Health Centers (FQHCs) a. Mercy President and CEO hosted four meetings with FQHC CEOs and Chief Medical Officers

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b. Mercy executives and physicians serve on Board of Directors of four FQHCs c. See 2b, 2c, and 2d above d. See 3c, 3d, and 3e above

5. Health education to the community a. Produced 156 segments of the weekly television series “The Woman’s Doctor.” b. 122 videos available on Mercy’s YouTube channel. c. Created a roster of health opportunities for Mercy Nursing Councils. d. Provided monthly blood pressure screenings, stroke education, diabetes support, and mindfulness program at Mercy.

EXISTING HEALTH CARE FACILITIES & OTHER COMMUNITY RESOURCES

Five of the sixteen acute care hospitals in Baltimore City are located within Mercy’s Community Benefit Service Area. As noted earlier due to Mercy Medical Center’s downtown location between other larger hospitals, Mercy is not the dominant hospital provider in any Baltimore City ZIP codes. The map below demonstrates which hospital providers represent the dominant number (>40%) of hospital charges in various Baltimore area ZIP codes. However, Mercy maintains an array of specialized citywide support programs for pregnant women, homelessness, substance abusers (Inpatient Medical Detoxification Unit), and Federally Qualified Health Centers) supported, in part, by our community benefits program.

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Baltimore City Hospitals: Johns Hopkins Hospital, LifeBridge Sinai Hospital, University of Maryland Medical Center, St. Agnes Hospital, John Hopkins Bayview Medical Center, Medstar Good Samaritan Hospital, MedStar Union Memorial Hospital, MedStar Harbor Hospital Center, University of Maryland Midtown Campus.

Federally Qualified Health Centers: In addition to hospitals, seven different federally qualified health centers (FQHCs) operate 15 different community health clinics inside or within walking distance of our community. A map of Federally Qualified Health Centers can be found at: http://phpa.dhmh.maryland.gov/opca/docs/Maryla nd%20MUAP_FQHC%208-4-14.pdf

SBIRT Sites: To address addiction and substance abuse, multiple providers have treatment centers and sites inside Mercy’s community. This map gives a sense for the location of treatment centers and SBIRT sites (Screening, Brief Advice, Brief Intervention, Referral to Treatment, Brief Treatment) in the City. A concentration of these facilities is housed within our community: http://www.marylandsbirt.org/about/maryland-sbirt-sites/

Data Sources & Technical Notes

Community Statistical Area updates

Since the 2013 Mercy Medical Center Community Health Needs Assessment, two of the Community Statistical Areas have shifted. These two CSAs are Jonestown/Oldtown and Perkins/Middle East. However, this shift only affects boundaries in that the same exact geographical areas are encompassed. The two new CSAs are Harbor East/Little Italy and Oldtown/Middle East.

Demographics and socioeconomics

The total population of the city does not include the incarcerated population. The analysis was done excluding the incarcerated population. Data for the Community Statistical Areas and the city as a whole are from the 2010 Census and the American Community Survey (2009-2013), via Baltimore

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Neighborhood Indicators Alliance (www.bniajfi.org). The American Community Survey (ACS), administered to a representative sample by the U.S. Census Bureau, replaced the long form of the decennial census. Annual data is updated through monthly samples across the United States. Five years of samples are required for small-area data (e.g. census tracts); one year and three year estimates are available for larger areas (e.g. county-level). The 2010 Census was the short form and for this report provided the information for the neighborhood population, age, gender, race and ethnicity, family poverty rate, and single-parent household. The definition of Unemployment from the U.S. Census is as follows: all civilians 16 years old and over are classified as unemployed if they were neither “at work” nor “with a job but not at work” during the reference week (the calendar week preceding the data on which the respondents completed their questionnaires or were interviewed), were actively looking for work during the last 4 weeks, and were available to start a job. Also included as unemployed are civilians who did not work during the last 4 weeks, and were available to start a job. Also included as unemployed are civilians who did not work at all during the reference wee, were waiting to be called back to a job from which they had not been laid off, and were available for work except for temporary illness.

Education

Kindergarten readiness data are from Baltimore City Public Schools for school years 2012-2013. School readiness was computed based on the Maryland Model for School Readiness Working Sampling System (WSS). Each year, teachers use seven domains of learning to assess students’ readiness. The seven domains include language and literacy, physical development, social studies, scientific thinking, mathematical thinking, the Arts, and social/personal development. Student reading level data are also from Baltimore City Public Schools, 2013. Maryland School Assessments are scored using a three level system. “Proficient” is a realistic and rigorous level of achievement indicating proficiency in meeting the needs of students. “Advanced” is a highly challenging and exemplary level of achievement indicating outstanding accomplishments in meeting the needs of students. The reading levels of the students are based on where the students live, not the CSA where the students go to school. School absenteeism and reading level data are from Baltimore City Public Schools, 2012-2013, via Baltimore Neighborhood Indicators Alliance. Adult education attainment data are from the American Community Survey. For this current update, the two categories were expanded into three categories to update a change in how BNIA categorizes education levels (High School or less; Some High School or Associates Degree; BS/BA or more).

Built and social environment

Alcohol Store density data are from Baltimore City Health and Human Welfare via the Baltimore City Liquor License Board, 2013. This data include only Class “A” licenses. Tobacco store density data were not available for this update, so data was used from the 2011 report, which were from the City Comptroller in April 2009. The Comptroller maintains data on tax revenue, licensure, regulation, and other-related items related to tobacco outlets. The data were geocoded by BCHD and used to calculate CSA-level densities. Juvenile arrest, domestic violence, and non-fatal shootings data are from the

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Baltimore City Police Department, 2013. Rates and percentages were calculated using the 2010 Census Bureau data as the denominator. The juvenile arrest rate reflects the number of individuals who were arrested (e.g. apprehended, taken into custody or detention, held for investigation, arrested, charged with, indicted or tried for any offense). The arrest rate differs from the rate of conviction (not included here), which would reflect the number of persons found guilty and convicted of an offense.

Housing

Lead paint violation data were not available for this update, therefore data from the 2011 report was used. This data came from the Mayor’s Office of Information Technology, updated December 2009. Only lead paint violations for years 2000-2008 were used to calculate rates for the 2011 report. The Mayor’s Office of Information Technology obtained the information from the Baltimore City Real Property Systems (BITs). Energy cutoff data also were not available for this update, and so data from the 2011 report were used. Data for the 2011 report were from Baltimore Gas and Electricity, as provided to BCHD from 9/1/2010 through 8/31/2010. Cutoffs were geocoded by BCHD and used to calculate CSA- level rates. These data include only unduplicated complaints made to or fulfilled by Baltimore Housing and Community Development and grouped under “Housing Code Enforcement,” regardless of the outcome of the complaint (e.g. violation, citation, no action, etc.). Vacant building data was taken from Baltimore City Department of Housing, 2013. This measures the percentage of residential properties that have been classified as being vacant and abandoned by the Baltimore City Department of Housing out of all properties. Properties are classified as being vacant and abandoned if: the property is not habitable and appears boarded up or open to the elements; the property was designated as being vacant prior to the current year and still remains vacant; and the property is a multi-family structure where all units are considered to be vacant. Vacant lot data were not available for this update, therefore data from the 2011 report was used. Data from the 2011 report came from the Mayor’s Office of Information Technology, which obtained it Real Property Management Database.

Food Environment

Fast-food restaurant data are from the Center for a Livable Future (CLF) at Johns Hopkins University, 2011. CLF obtained the food permit list from the Baltimore City Health Department in August 2011, which includes all sites that sell food, such as stores, restaurants and temporary locations such as farmers’ market stands and street carts. The restaurants were grouped into three categories, including full service restaurants, fast food chains and carryouts. Carryout and fast food chain restaurants were extracted from the restaurant layer and spatially joined with the 2010 Community Statistical Area (CSA) data layer, provided by BNIA-JFI. The prepared foods density, per 1,000 people, was calculated for each CSA using the CSA’s population and the total number of carryout and fast food restaurants, including vendors selling prepared foods in public markets, in each CSA. Carryout data was not available, and so data from the 2011 report were used. These came from the BCHD open food facilities permit/license database, updated June 2009. These data were geocoded and used to calculate CSA-level densities. The Baltimore City Health Department identifies the establishments as a carryout and then separates the carryouts into chain fast food restaurants and carryouts. Carryout data in this report reflect

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establishment coded as “carryout” either, 1) in their restaurant name, or 2) on their restraint signage (verified via Google Street View). Corner store data were not available for this update, and so data from the 2011 report were used. This data came from CLF at JHU, and include corner stores, convenience stores, dollar stores, and gas stations with minimarts. These data were updated January 2011 and used as provided. The travel time to the nearest supermarket was calculated by Nicole Robinson. To calculate this time, the center of the population was calculated for each CSA by identifying the Census Block Group with the highest population. The geographic center of the most highly populated Census Block Group (i.e. the center of the population) was used as the starting point for each CSA. ArcMap was sued to identify the closest supermarket to the center of the population. Google Maps was then used to determine the time it takes to arrive at the nearest grocery store from the center of the population. Google Maps estimates travel time for multiple modes of transportation including walking, driving, and using public transportation (based on public transportation schedule). A food desert is an area that lacks access to healthy and affordable foods.

Estimated life expectancy at birth

Defined as the average number of years a person born today would live if he/she experienced the mortality rates observed in this report over the course of his/her life. The life expectancy estimate in this report reflects the mortality rates among people living in Midtown from 2005 to 2009. Babies born today in Midtown would only experience this life expectancy only if the current age-specific mortality rates remained constant over the course of their lives. Life expectancy was calculated using a life table calculator for small area estimates developed by the South East Public Health Observatory in England (http://www.sepho.org.uk/viewResource.aspx?id=8943). The calculator uses an abridged life table methodology, with five-year age groups (except for under 5 and above 85 which were treated as under 1, 1-4 and above 85) and combines the Chiang and Silcocks methodologies. Some inaccuracy will result due to the use of age groups rather than single year age categories, as well as due to small numbers of deaths in certain age groups. For more information on this methodology, please refer to: Williams E, Dinsdale H, Eayres D, and Tahzib F. Technical Report – Calculating Life Expectancy in Small Areas. Oxford, England: Southeast England Public Health Observatory, 2005 (available at http://www.sepho.org.uk/Download/Public/9847/1/Life%20Expectancy%20Nov%2005.pdf).

Avertable deaths

Avertable deaths are deaths that could have been avoided if all neighborhoods in Baltimore had the same opportunities at health. Data presented here are based on the assumption that the death rates experienced in the five communities with the highest median incomes are achievable in every community. Age-sex-specific mortality rates were calculated for ten-year age groups (except for under 5 and above 85 which were treated as under 1, 1-4 and above 85) for the five CSA’s with the highest median household incomes. These age-sex-specific reference mortality rates were then applied to the populations of all 55 CSA’s and Baltimore City as a whole to generate a projected number of deaths for each area. The avertable deaths thus represents an estimate of the percent of area deaths that would have been avoided if they had experienced the same mortality rates as the highest income communities

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for years 2005-2009. A negative percentage means that the area experienced a lower mortality rate than the top 5 neighborhoods.

Age-adjusted mortality

This represents the number of deaths per 10,000 people per year assuming that each neighborhood had the same age structure (number of people in each age group). Age adjustment is done so that a neighborhood with a proportionally large number of elderly people (who are more likely to die because of their age) does not show a higher mortality rate simply because of the older age of its inhabitants. Ageadjustment was based on 10-year age groups and the 2000 projected US population distribution #1 (from: Klein RJ, Schoenborn CA. Age-adjustment using the 2000 projected US population. Healthy People Statistical Notes, no. 20. Hyattsville, Maryland: National Center for Health Statistics. January 2001). Breast and prostate cancer mortality rates used the sex-specific 2000 projected US Population with the same age groups (from: Day, Jennifer Cheeseman, Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050, US Bureau of the Census, Current Population Reports, P25- 1130, US Government Printing Office, Washington, DC, 1996).

Years of potential life lost (YPLL)

The number of years of life lost due to death before age 75. For example, a person dying at age 74 accrues 1 YPLL, while a person dying at age 30 accrues 45 YPLL. YPLL provide a measure of the impact of premature mortality on a population. Deaths that occur earlier in life contribute more years of life lost than deaths later in life, capturing the value society places on young lives. At the neighborhood level, the YPLL was based on the sum of years of life lost for all the Residents of that neighborhood who died in 2005-2009.

Maternal and child health

Lead poisoning: Lead poisoning is when a person has elevated lead in his/her body. This can be determined based on the amount of lead in the blood. The lead poisoning percentages represent the percentage of Baltimore City children age 0-6 years who had an elevated blood-lead level ( 10 g/dL) in 2008 out of all children who were tested. The elevated blood level was based on the highest venous or, in the absence of a venous test, the highest capillary test. Venous tests, which require a blood draw, are considered more reliable; however, in their absence, a capillary test (based on a finger stick) can indicate the presence of lead poisoning. In Baltimore City, children are required to receive a blood test for lead at 12 and 24 months of age, but, not all children present for testing.

Birth Outcomes: The birth rate is defined as the number of live births per 1,000 persons. The teen birth rate is the number of live births to females between 15-19 years of age per 1,000 females in the population in that age range. Adequate birth spacing is defined as spacing of births of greater than 27 months for women. Smoking during pregnancy was reported on the birth certificate. Preterm births are live births occurring before 37 weeks gestation. Low birth weight is defined as live births weighing less than 2500g (5 lbs 8oz) at delivery. Infant mortality rate: Number of infant deaths (babies less than 1 year of age) per 1,000 live births in a given year. Aggregation to the Community Statistical Areas (CSAs): all

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data were aggregated first to the Census tract of residence. Since CSAs are groupings of census tracts, CSA data were obtained by aggregating Census tract-level data.

Aggregation to the Community Statistical Areas (CSAs)

All data were aggregated first to the Census tract of residence. Since CSAs are groupings of census tracts, CSA data were obtained by aggregating Census tract-level data.

Limitations

Small numbers: Because neighborhoods can have small population sizes in certain age groups, there is the possibility that small differences could produce large differences in rates. We addressed this potential issue by grouping years together and thereby estimating rates using larger numbers. Despite this, there is some uncertainty associated with these estimates due to the small population sizes involved. Data availability: These reports only contain data on a select set of indicators of health and the social determinants of health among many other possible indicators. Data were not included for smoking and healthcare-seeking behaviors, diet, exercise, the prevalence of chronic diseases, disability, drug addiction, and mental illness, air quality measures, stress, and a range of other individual- and community-level social determinants such as language ability, health literacy, social support, social capital, and social cohesion.

Mercy Community Benefits Steering Committee

The following individuals devoted numerous hours on the Community Benefits Committee by helping develop Mercy Medical Center’s Community Health Needs Assessment:

Name Title Kathryn Ault Director of Pastoral Care Dashaira Bennett Outreach Social Worker Nicholas J. Koas Senior Vice President Reverend Thomas R. Malia Assistant to the President for Mission Ryan C. O’Doherty Director of External Affairs Dianna O’Neil, MS Director of Finance, Patient Care Services Terri Palazzo, MS, RN, FACHE Senior Director, Emergency Department Kathryn Pilkenton Senior Director, Financial Planning Mary Louise Preis, Esquire Chair, Mission and Corporate Ethics Committee of the MHS Board of Trustees; Retired banking and insurance executive Sally B. Ratcliffe, LGSW Director of Social Work Leslie Sporn Director of Corporate and Foundation Relations Christopher G. Thomaskutty Senior Vice President, Chief of Staff Mary Catherine Webb, LCSW Retired Director of Social Work and Pastoral Care

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ACKNOWLEDGEMENTS: On behalf of the Sisters of Mercy and the entire Mercy team, we wish to offer our gratitude and special recognition to the following organizations for their invaluable contributions and support of our Community Health Needs Assessment and Implementation Strategy:

. Baltimore Neighborhood Indicators Alliance-Jacob France Institute at the University of Baltimore . Baltimore City Health Department . Healthcare for the Homeless . Baltimore City Department of Social Services . The Annie E. Casey Foundation . Total Health Care, Inc. . HealthCare Access Maryland . Association of Baltimore Area Grantmakers . Sharp Leadenhall Planning Committee . Christ Lutheran Church . B'More for Healthy Babies Initiative . Baltimore City Council

DISCLAIMER:

This Implementation Strategy addresses the community health needs described in Mercy Medical Center’s Community Health Needs Assessment that Mercy plans to address in whole or in part and that are consistent with its mission. Mercy 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. Alternatively, other organizations in the community may decide to address certain needs, indicating that Mercy then should refocus its limited resources to best serve the community. Beyond the initiatives and programs described herein, Mercy is addressing some of these needs simply by providing health care to the community, regardless of ability to pay.

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