Lansdale Hospital Community Health Needs Assessment

Acknowledgements

Authors and originators:

Rickie Brawer, PhD, MPH, MCHES, Associate Director, Center for Urban Health, Thomas Jefferson University Hospital and Assistant Professor, Department of Family and Community Medicine, Jefferson University, Sidney Kimmel Medical College

Marianna Calabrese, MA, Manager, Community Benefit

Kathryn McCarter, RN, MSHA, CCP, Director of Community Health

Consultants:

Jane Elkis Berkowitz, MRP, MA

Karen Arnone, Financial and Market Planning

Community Benefit Acknowledgement:

Thank you to the key community stakeholders in the Abington and Lansdale communities who participated in the conversations, Community Health Need Assessment interviews, focus groups, and follow up meetings.

Thank you to the Abington - Jefferson Health administration, physicians, leaders, and employees who participated in interviews, focus groups, and follow up meetings.

We would like to acknowledge the time and continued support of the Abington Health Foundation Community Benefit Committee for their time, expertise, leadership, and support during the process.

Table of Contents

Executive Summary ii

Introduction 1

Purpose of the Community Health Needs Assessment 5

Community Health Needs Assessment Methods 8

Community Health Needs Assessment Findings 13

Bucks/Montgomery Counties and Abington-Lansdale Community Benefit Area Demographics 14

Social Determinants of Health 18

Health Care Access 36

Health Status

Mortality 46

Maternal and Child Health 52

Morbidity 57

Preventive Care and Early Detection of Disease 75

Health Behaviors 84

Special Populations

Older Adults 99

Immigrants and Refugees 130

Homeless 135

Recommendations 137

Appendices 140

References 168

Executive Summary

Abington - Jefferson Health (AJH) is a Pennsylvania nonprofit organization located in Montgomery County, Pennsylvania that considers its community benefit service area to include proximate portions of Montgomery and Bucks counties where almost 544,000 people live. This Community Health Needs Assessment (CHNA) utilizes information collected from the Public Health Management Corporation's household health survey, numerous secondary data and literature sources, and internal experts and external representatives of health care and community based organizations who have knowledge of the health and social conditions of these communities.

AJH's community benefit area is an area with relatively low underlying economic and structural barriers such as income, culture/language, education, insurance, and housing, that affect overall health. Most health status indicators are improving, and many are better than the Healthy People 2020 goal (note that there is not a Healthy People 2020 target for many of the health status measures described in this CHNA). Racial/ethnic and income disparities exist, and for most indicators, people of color and/or Hispanic origin fare worse than their white neighbors.

In addition to extensive information about the population residing in the community benefit areas, this CHNA includes focused sections on the following special populations: adults age 60+, immigrants/refugees, and the homeless.

While the majority of health status measures indicate minimal to moderate deficiencies or hardship, there is a portion of the population in serious need of support for a variety of issues. The following are health status measures related to the overall population that do not meet the Healthy People 2020 goal in Bucks/Montgomery Counties and/or the Abington-Lansdale CB service areas:

 Insured adults and children  Regular source of care (children, adults, age 60+)  First trimester prenatal care  Hypertension (adults, age 60+)  HIV testing (adults, age 60+)  PAP testing (adults, age 60+)  Mammography (age 60+)  Smokers who tried to quit (adults, age 60+)  Female breast cancer mortality  Stroke mortality

Although some of measures exceed the Healthy People 2020 goal, according to the Centers for Disease Control Community Health Status Indicators methodology, the following are in the least favorable quartile when compared to peer counties:

Bucks Montgomery Overall cancer deaths X Motor vehicle deaths X Stroke deaths X Unintentional injury (including motor vehicle) deaths X

Bucks Montgomery Older adult depression X X Alzheimers/Dementia X X Adult smoking X Cancer morbidity X Syphilis X Gonorrhea X Older adult preventable hospitalizations X Adult female routine PAP tests X Inadequate social support X Unemployment X

In addition, the Pennsylvania Department of Health 2015-2020 State Health Improvement Plan's top 5 priorities for Southeastern Pennsylvania are:

 integration of healthcare and behavioral/mental healthcare  preventive screenings  obesity  behavioral/mental health for adults  primary care

Using the quantitative and qualitative data presented in this CHNA and a prioritization process, AJH identified the following most important priority health needs for the population of the Abington- Lansdale CB areas:

Mental Health Services Social and Health Care Needs of Older Adults Obesity Alcohol/ Substance Abuse Women's Cancer Chronic Disease Management (diabetes, heart disease and hypertension, stroke, asthma) Health Education, Social Services and Regular Source of Care

The Community Health Department of Abington Jefferson Health, working under the guidance of the Abington Health Foundation Community Benefit Committee is responsible for developing implementation plans focusing on priority issues including the above listed most important health needs.

iii

Introduction

Over the past century the major causes of morbidity and mortality in the United States have shifted from those related to communicable diseases to those due to chronic diseases. Just as the major causes of morbidity and mortality have changed, so too has understanding of health and what makes people healthy or ill. Research has documented the importance of the social determinants of health (for example, socioeconomic status and education), which affect health directly as well as through their impact on other health determinants such as risk factors. Targeting interventions toward the conditions associated with today’s challenges to living a healthy life requires an increased emphasis on the factors that affect the current causes of morbidity and mortality, factors such as the social determinants of health. Many community-based prevention interventions target such conditions. Community-based prevention interventions offer three distinct strengths. First, because the intervention is implemented population-wide it is inclusive and not dependent on access to the health care system. Second, by directing strategies at an entire population an intervention can reach individuals at all levels of risk. And finally, some lifestyle and behavioral risk factors are shaped by conditions not under an individual’s control. For example, encouraging an individual to eat healthy food when none is accessible undermines the potential for successful behavioral change. Community- based prevention interventions can be designed to affect environmental and social conditions that are out of the reach of clinical services.1

Description of Abington Jefferson Health

Effective April 30, 2015 at 11:59 pm, Thomas Jefferson University (TJU), a Pennsylvania nonprofit organization that is exempt from federal income taxation pursuant to Section 501(c)(3) of the Internal Revenue Code, became the sole corporate member of Abington Health (AH). As a result of this transaction, AH and its subsidiaries, Abington Memorial Hospital, Lansdale Hospital, and Abington Health Foundation (collectively, the "Subsidiaries"), became subsidiaries of TJU, creating a university health system, known as Jefferson, that encompasses Thomas Jefferson University plus Jefferson Health, the new combined clinical brand for the five hospitals and physician networks within the system.

The newly named Abington – Jefferson Health (AJH) is the organization that encompasses its flagship hospital, Abington Hospital in Abington, PA (the largest community teaching hospital in Montgomery or Bucks counties) and Abington – Lansdale Hospital in Hatfield Township, PA, as well as a number of outpatient settings for obtaining expert medical care in Bucks, Montgomery, and Philadelphia counties.

Abington – Jefferson Health entities include the following:

 Two hospitals: Together, Abington – Lansdale Hospital and Abington Hospital have 800 licensed beds  Five outpatient campuses: Abington Health Center – Blue Bell, Abington Health Center – Lower Gwynedd, Abington Health Center – Montgomeryville, Abington Health Center – Warminster and Abington Health Center – Willow Grove  Two urgent care centers, one in Feasterville and one in Flourtown

 Abington Health Physicians – Physician practices located in Bucks, Montgomery, and Philadelphia counties with 65 locations

Abington Hospital, founded in 1914, is the largest community teaching hospital in Montgomery or Bucks counties. Staff members have the privilege of working with medical students, residents and fellows from various medical schools and training programs in the Philadelphia area. The hospital sponsors five residency programs: family medicine, internal medicine, obstetrics/gynecology, general surgery and dentistry. In addition, the hospital provides postgraduate medical education in affiliation with several area medical schools. Abington also operates the Dixon School of Nursing and supports a pharmacy residency program.

Each year, AJH treats 125,000 patients in its two Emergency Departments with Abington Hospital having the distinction as the only Level II trauma center in Montgomery County. Abington Hospital – Jefferson Health has a comprehensive stroke center and offers highly advanced programs in cancer, cardiac, and orthopaedic care.

AJH employs approximately 6,000 employees who work with 1,400 physicians and serve more than 34,000 inpatients and almost 665,000 outpatient visits annually.

As noted in its Strategic Plan, the mission of the Community Health Department at AJH is to develop targeted health outreach programs and screenings in response to the identified needs of its community in concert with the mission of Jefferson Health: Health is all we do. The vision aims to create the healthiest community by orchestrating targeted outreach for maximum community benefit while reducing health disparities.

Models

With the growing burden of chronic disease, the medical and public health communities including AJH are reexamining their roles and opportunities for more effective prevention and clinical interventions. The potential to significantly improve chronic disease prevention and impact morbidity and mortality from chronic conditions is enhanced by adopting strategies that incorporate a social ecology perspective, realigning the patient-physician relationship, integrating population health perspectives into the chronic care model, and effectively engaging communities.

Abington highly values the principles of community engagement articulated by the Centers for Disease Control and has built its community benefit efforts on a community engagement model.

Principles of Community Engagement2

Principle Key elements

Set Goals  Clarify the purposes/goals of the engagement effort  Specify populations and/or communities

Principle Key elements

Study community  Economic conditions  Political structures  Norms and values  Demographic trends  History  Experience with engagement efforts  Perceptions of those initiating the engagement activities Build trust  Establish relationships  Work with the formal and informal leadership  Seek commitment from community organizations and leaders  Create processes for mobilizing the community Encourage self-  Community self-determination is the responsibility and right determination of all people  No external entity should assume that it can bestow on a community the power to act in its own self-interest Establish partnerships  Equitable partnerships are necessary for success

Respect diversity  Utilize multiple engagement strategies  Explicitly recognize cultural influences Identify community assets  View community structures as resources for change and and develop capacity action  Provide experts and resources to assist with analysis, decision-making, and action  Provide support to develop leadership training, meeting facilitation, skill building

Release control to the  Include as many elements of a community as possible community  Adapt to meet changing needs and growth

Make a long-term  Recognize different stages of development and provide commitment ongoing technical assistance

AJH also recognizes the value of an Expanded Chronic Care Model3 as a framework for addressing chronic disease in a comprehensive way that respects clinical care, the health system, community, and patients as equal partners in meeting the triple aim of improving population health, the patient experience, and reducing per capita costs.

Community

Build Healthy Policy Health System Create Supportive Environment Information Self- Decision Management Delivery Strengthen Support System Community Action Redesig n pport

Productive Interactions Activated Activated Proactive Activated and Continuous Community Team Community Patient Relationships

AJH Community Health leaders with support of the Community Benefit Committee recommends using the following model4 to guide planning and programmatic efforts, and to explain to internal and external stakeholders the rationale for the Community Health implementation plan.

Purpose of the Community Health Needs Assessment (CHNA)

Ongoing, unprecedented increases in the demand for healthcare are challenging for communities and healthcare providers in this era of limited fiscal resources. Regulatory changes also have resulted in new obligations. One of the mandates of the Health Care Reform Act is a Community Health Needs Assessment. Starting in 2013, every three years tax-exempt hospitals must conduct an assessment and implement strategies to address priority needs. The Health Reform Act spells out requirements for the Community Health Needs Assessment. This assessment is central to an organization’s community benefit/social accountability plan. By determining and examining the service needs and gaps in a community, an organization can develop responses to address them.

A Community Health Needs Assessment is a disciplined approach to collecting, analyzing and using data, including community input, to identify barriers to the health and well-being of its residents and communities, leading to the development of goals and targeted action plans to achieve those goals. The assessment findings can be linked to clinical decision making within health care systems as well as connected to community health improvement efforts. The assessment engages health care providers and the broader community by providing a basis for making informed decisions, with a strong emphasis on preventing illness and reducing health disparities.

Specifically, the Patient Protection and Affordable Care Act (PPACA) mandates a new section in the IRS Code –Section 501(r) for hospitals to obtain/maintain 501(c)(3) status:

 Each hospital facility must conduct a community health needs assessment at least once every three taxable years and adopt an implementation strategy to meet the community health needs identified through the assessment  The community health needs assessment must take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or public health expertise  The CHNA must be made widely available to the public

For the 2016 CHNA, the Department of Treasury and the IRS is encouraging cross institution collaboration. To that end the Healthcare Improvement Foundation, in partnership with the Hospital and Health System Association of Pennsylvania and the U.S. Department of Health and Human Services (Region 3) has convened the region’s hospitals in the Collaborative Opportunities to Advance Community Health (COACH) Project. The goals of COACH are to:   Gather input from public health authorities and key community stakeholders  Explore growing number of health and epidemiologic data sources  Collaborate with public health and other stakeholders to prioritize needs, coordinate interventions, and establish measures for evaluating results

Additionally, the Health Care Improvement Foundation is facilitating a Montgomery County Hospital Partnership. The partnership's role will be similar to COACH with an exclusive focus on Montgomery County, and all hospitals, whether profit or non-profit, will be involved.

Four principles are guiding the development of a strategy for leveraging community benefit programs to increase their influence: defining mutually agreed-on regional geographic boundaries to align both community benefit and accountable health community initiatives, ensuring that community benefit activities use evidence to prioritize interventions, increasing the scale and effectiveness of community benefit investments by pooling some resources, and establishing shared measurement and accountability for regional population health improvement.5

Overall Roles and Responsibilities

To undertake this mandate, Abington Health Foundation formed a Community Benefit Committee. The committee is responsible for overseeing and recommending policies and programs designed to carry out the charitable mission of Abington-Lansdale Hospital and Abington Hospital, protect its non-profit status, and to enhance the health status of communities served by Abington Jefferson Health based on the results of a community health needs assessment.

Specifically, the Committee was charged to:  Oversee the conduct of a community health needs assessment at least every three (3) years.  Review, and recommend for approval a Community Benefit Plan outlining long-term strategies based on a community health needs assessment and other objective sources of data, and recommend updates to such Plan.  Guide and monitor the planning, development, and implementation of programs aimed at improving the health status of the local community consistent with the Community Benefit Plan.  Establish criteria for priority-setting among potential community benefit activities and projects, consistent with financial capabilities and resource limitations.  Periodically make recommendations for program continuation or termination based on progress toward identified measurable objectives, available resources, level of community ownership, and alignment with criteria for priorities.  Review and make recommendations regarding the annual Community Benefit Report, including the information provided to the IRS on Form 990. Additionally, identify opportunities for disseminating information to the public about the organization’s community benefit activities.  Review annual goals specifying principal work focus areas for the coming year. Review hospital financial assistance policies and practices and provide recommendations as necessary in an effort to increase efforts to communicate these policies.

The Community Benefit Committee are trustees, staff, physicians, dentists, nurses and other clinicians. The Committee may also invite, as guests, various representatives of the communities served by Abington Jefferson Health.

Abington-Lansdale Hospital's Community Benefit areas are defined as the areas proximate to the hospital where approximately 70% of inpatients reside. This includes communities in Montgomery and Bucks counties that are aggregated into 4 geographically contiguous regions defined by zip codes. When analyzing PHMC survey data for older adults and children, the regions are further consolidated into 1 area to ensure that the sample size is adequate for statistically reliable results. For comparisons, the combined data for Bucks and Montgomery counties is provided.

Abington’s Community Benefit Program (CBP) adopts a comprehensive notion of health determinants that are spread across domains of behavioral risk, social and economic circumstances, and medical care. The balance and effects of many of these determinants, e.g. availability of healthy foods, parks and other safe places to play and exercise, and safe housing, are specific to Abington- Lansdale’s locale and are built into the Community Benefit Plan.

Community Health Needs Assessment Methods Literature Review and Secondary Data Sources In preparation for the community health needs assessment more than 20 secondary data sources were reviewed including:

 2015 The Nielsen Company, © 2015 Truven Health Analytics Inc  American Community Survey  American Diabetes Association  Behavior Risk Factor Surveillance System (BRFSS)  Bucks County Area Agency on Aging  Centers for Disease Control and Prevention  Community Commons  Community Needs Index  County Health Rankings and Roadmaps 2015  Enroll America  Feeding America – Map the Meal Gap  Healthy People 2020  Kaiser Family – State Health Facts  Montgomery County Comprehensive Plan: Montco 2040: A Shared Vision  Montgomery County Health Department  Montgomery Office of Aging and Adult Services  Pennsylvania Department of Health  Public Health Management Corporation - Household Health Survey  US Census Bureau  Various articles from academic journals  Various articles from the popular press  Youth Risk Behavior Surveillance System (YRBSS) 2013

Primary Data Sources: Interviews Almost 30 interviews were conducted with individuals representing health care and community based organizations who have knowledge of the health and underlying social conditions that affect health of people in their neighborhood and broader community. These interviews were conducted by Abington Jefferson Health Community Benefit leaders to gain insight about health needs and priorities, barriers to improving community health, and the community assets and efforts already in place or being planned to address these issues and concerns. In addition, interviews were conducted with faculty and health providers from Abington Jefferson Health to gain their perspective about the health issues of their patients and community and to identify Abington's and others' efforts to address these issues. Interviewees were asked to prioritize the needs/recommendations discussed during their interview. The table below lists the affiliation of interviewees, their positions, and the focus of the interview based on their area(s) of expertise.

Organization Position Focus Abington and Lansdale Financial Counseling Access to Care, Older Adults Hospitals Center - Director/Mgr Abington Diversity and Director, Student Intern Workforce/Cultural Competence, Inclusion and Diversity Student Communication, Access to Care, Mental Co-Op health, Social Determinants Abington Hospital Director of Nutrition Food Insecurity and Nutrition, Social Services and Clinical Determinants, Older Adults, Chronic Nutrition Manager Care Abington Hospital Director of Service Safety and Violence Prevention, Social Excellence Determinants of Health, Workplace, Homeless, Cultural, Chronic Care Abington Hospital Director of Rehab Medicine Safety and Violence Prevention, Social Determinants of Health, Workplace, Homeless, Cultural, Chronic Care Abington Hospital Manager of ASU and Care Safety and Violence Prevention, Social Mgr Determinants of Health, Workplace, Homeless, Cultural, Chronic Care Abington Hospital Corporate Director of Access, Social Determinants, PR/Marketing Communication Abington Hospital Director of Clinical Drug/Alcohol, Access, Social Integration Determinants Abington Hospital Manager of Diabetes Center Diabetes, Chronic Care

Abington Hospital Director of Case Safety and Violence Prevention, Social Management/SW and Determinants of Health, Workplace, Manager Homeless, Cultural, Chronic Care Abington Hospital Geriatric Service Line Older adults, Chronic Care, Access, Social Determinants, Communication, Substance Abuse, Obesity/Food Insecurity/Nutrition Abington Hospital Cardiac Service Line Heart disease, Communication, Social Determinants, Chronic Care Abington Hospital Neuro Service Line Neurological disease, Mental Health/Behavioral Health, Older Adults Abington Hospital Care Managers AHP Safety and Violence Prevention, Social Determinants of Health, Workplace, Homeless, Cultural, Chronic Care Abington Hospital Post Acute Access to Care, Workplace, Chronic Care Leadership/Home Care Abington Hospital Chaplain, Pastoral Care, Mental Health, Communication, Domestic Violence Social Domestic Violence, Older Adults, Access Worker to care, Substance Abuse, Nutrition and Food Insecurity

Organization Position Focus Abington Hospital Behavioral Director Mental health/behavioral health Health Abington Hospital Rosenfeld Staff Cancer, Chronic Care Cancer Center Abington Jefferson Health Corporate HR Director Workforce Abington medical staff VP Physician Services Safety and Violence Prevention, Social Determinants of Health, Access Workplace, Homeless, Cultural, Chronic Care Abington population health Director of Population Safety and Violence Prevention, Social physician Health Determinants of Health, Workplace, Homeless, Cultural, Chronic Care Abington Women and Leadership, Physician, and Women and Children; Safety and Children’s Service Line Staff Violence Prevention, Social Determinants of Health, Workplace, Homeless, Cultural, Chronic Care Emergency Services, Director Emergency Response, Drugs, Chronic Warminster area Disease [Stroke/Heart], Access to Care, Social Determinants Indian Valley YMCA Branch Director Nutrition and Food Insecurity, Access to Care Jaisohn Center Current and Retired Koreans, Cultural, Access to Care, President (s) Chronic Care, Language Lansdale Clinics Staff Access to Care, Mental health/Behavioral Health, Nutrition/Food Insecurity Abington - Lansdale Hospital Senior Leaders Food insecurity/Nutrition, Access to Care, Mental Health/Behavioral Health, Chronic Care Abington - Lansdale Hospital HR/Workforce Workforce, Access to Care, Social Development Determinants Abington - Lansdale Hospital Hospitalist Inpatients, Access to Care, Chronic Care, Social Determinants, Mental Health Abington - Lansdale Hospital Emergency Room Team Mental Health Coordinator Latino Ministries, Casa Del Pastor/Outreach Worker Latinos, Access to Care [Dental], Vision, Pueblo, Lehman United Cultural Methodist Church, Hatboro Manna on Main Street Executive Director Food Insecurity, Access for Underserved, Mental Health, Homeless Montgomery County Aging Acting Director Older Adults and Adult Services

Organization Position Focus Montgomery County Health Director of Health/Medical Safety and Violence Prevention, Social Department Director; Deputy Director Determinants of Health, Workplace, of Personal Health Homeless, Cultural, Chronic Care Services; Division Director of Clinical Services and Public Health Nursing; Epidemiologist; Division Director of Health Promotion

Montgomery County Health & Wellness Mental health, Nutrition/Food Insecurity, Intermediate Unit Supervisor Access to Care North Penn Community Health President and CEO Chronic Care, Mental Health, Access to Foundation Care [Dental], Care Coordination North Penn Mosque Leader Muslims, Access to Care, Poverty, Social Determinants North Penn School District District Nurse Coordinator Children, Poverty, Social Determinants, Mental Health North Penn United Way Director Safety and Violence Prevention, Social Determinants of Health, Workplace, Homeless, Cultural, Chronic Care North Penn YMCA Branch Director Nutrition and Food Insecurity, Access to Care Philadelphia Freedom Valley Group Vice Nutrition and Food Insecurity, Access to YMCA - Ambler President/Executive Care Director Souderton Area School District District Nurse Coordinator Children, Mental Health/Substance Abuse, Nutrition/Food Insecurity, Access to Care Target Pharmacy, Abington Pharmacist Safety and Violence Prevention, Social Determinants of Health, Workplace, Homeless, Cultural, Chronic Care Visiting Nurse Association- Executive Director; Social Access to Care, Older Adults, Homeless Community Services, Abington Services Program Manager VNA Foundation of North Executive Director Older Adults, Access to Care Penn Willow Grove United Volunteer and West Chester Safety and Violence Prevention, Social Methodist Church University Nursing Determinants of Health, Workplace, Professor Homeless, Cultural, Chronic Care Wissahickon School District Nurse Coordinator Children, Social Determinants of Health, Mental Health/Substance Abuse, Access to Care, Nutrition/Food Insecurity

Small Group Interviews

A smaller group setting allowed for a concentrated focus and exploration of community needs. Small group interviews were held with representatives of:

Montgomery County Health Department AJH Care Managers Pastoral Care/Domestic Violence Social Work Muller Institute for Senior Health

Additionally, recommendations from the Pennsylvania Department of Health 2015-2020 State Health Improvement Plan stakeholder meetings were considered. In March 2015, 177 attendees participated in six stakeholder meetings as part of a collaborative effort to identify key health issues. The top 5 priorities identified for Southeastern Pennsylvania are:

 integration of healthcare and behavioral/mental healthcare  preventive screenings  obesity  behavioral/mental health for adults  primary care

Community Health Needs Assessment Findings

The results from the Community Health Needs Assessment are organized into the following categories:

 Demographics  Social Determinants of Health o Education o Income and poverty o Access to healthy and affordable food o Employment and job training o Community safety o Family and social support o Built and natural environment o Healthcare access . Health insurance . Source of care . Transportation . Literacy . Cultural competence and language  Health Status o Mortality o Maternal and child health o Morbidity o Preventive care and early detection of disease o Health behaviors  Special Populations o Older Adults o Immigrants and Refugees o Homeless

Bucks and Montgomery Counties and Abington-Lansdale Community Benefit Area Demographics

More than 1.4 million people live in Bucks (627,000) and Montgomery counties (812,000). According to the County Health Rankings and Roadmaps 2015, the population of Bucks County is 86% non-Hispanic white, 4% non-Hispanic African America,a 5% Hispanic or Latinob, and 4% Asian. Montgomery County's racial/ethnic distribution is 78% non-Hispanic white, 9% non-Hispanic African American, 5% Hispanic or Latino, and 7% Asian. The demographic profiles of these counties is fairly similar to the profile of the Commonwealth of Pennsylvania with 78% non-Hispanic white, 10% non-Hispanic African American, 6% Hispanic or Latino, and 3% Asian.

The proportion of residents aged less than 18 in Pennsylvania, Bucks, and Montgomery counties is 21-22%, and the proportion age 65+ is 16% in all three regions.

Median household income in Bucks ($73,662) and Montgomery ($77,021) counties is significantly higher than for Pennsylvania ($52,005). Approximately 2% are not proficient in English in each of the 3 geographies.

Abington-Lansdale Hospital has geographically defined its community benefit (CB) area in the following way:

Area Zip Codes

North Penn 18915, 18936, 19440, 19446, 19454

Indian Valley 18964, 18969, 19438

County Line 18914, 18932

Blue Bell 19422

These zip codes define regions that are in Bucks and Montgomery counties. For comparative purposes throughout this document, the combined area of Bucks and Montgomery counties, or Bucks/Mont, will be used. The map depicts these areas. Each area has been assigned a color which will be used throughout this report in graphs to depict that specific area.

a The terms black or African American are both used in this document depending on the source of the data. According to the Census Bureau website, these terms are used interchangeably and refer to people having origins in any of the black racial groups of Africa. (https://www.census.gov/prod/cen2010/briefs/c2010br-06.pdf) b The terms Latino and Hispanic are both used in this document depending on the source of the data. According to the U.S. Census Bureau "Hispanics or Latinos are those people who classified themselves in one of the specific Spanish, Hispanic, or Latino categories ... -"Mexican," "Puerto Rican", or "Cuban"-as well as those who indicate that they are "another Hispanic, Latino, or Spanish origin." .... The terms "Hispanic," "Latino," and "Spanish" are used interchangeably."

Bucks/Mont and Abington-Lansdale CB Area Demographics

Almost 200,000 people live in Abington-Lansdale's CB area. This represents 14% of all residents of Bucks and Montgomery Counties combined.

Estimated Population: 2015

105,083

54,283

20,630 19,141

North Penn Indian Valley County Line Blue Bell

While Bucks/Mont anticipates a 1.3% increase in population between 2015 and 2020, North Penn is expected to grow by 2.7% and Indian Valley by 2.3%. The other CB areas are projected to grow less than 2%. Compared to the United States, Bucks/Mont and Abington-Lansdale's CB populations are slower growing.

Projected Growth Rate 2015-2020 3.5%

2.7% 2.3% 1.9% 1.3% 1.3%

North Penn Indian Valley County Line Blue Bell Bucks/ Mont USA

Similar to Bucks/Mont, Abington-Lansdale's CB area is 52% female and 48% male and the gender distribution varies little across CB areas. County Line has a higher percent of youth ages 0-17 than the other Abington-Lansdale CB areas, Bucks/Mont, and the United States. Blue Bell has a higher percentage of adults aged 65+ than other CB areas, Bucks/Mont, or the United States.

Age Distribution: 2015 Estimate 17.1% 17.3% 15.1% 21.2% 16.7% 14.7% 14.5% 13.7% 14.2% 14.4% 12.7% 15.8%

46.2% 51.6% 49.5% 47.1% 43.1% 47.4%

21.2% 22.8% 26.9% 19.9% 21.5% 23.2%

In Bucks County, almost 28,000 residents identify themselves as Hispanic and in Montgomery County more than 35,000 people, or 4% of the population is Hispanic. Although they share a common language, each Hispanic community is culturally unique, and internally diverse by gender, generation, class, and race.

The Asian community in Bucks County represents 4% of the total population (25,340 residents) and is predominantly of Asian Indian descent. There are also residents from China, Korea, the Philippines, and Vietnam, as well as Japan and other Asian countries. In Montgomery County, of the 53,000 residents with Asian backgrounds, the highest proportion are from India followed by people of Korean, and Chinese descent. The remainder are from Vietnam, the Philippines, Japan, and other countries.6

See the CHNA Special Population section on Immigrants and Refugees for more information on Hispanics and Asians.

Compared to Bucks/Mont, Abington-Lansdale's CB area has more non-Hispanic Asian and Pacific Islanders (11.2% vs. 4.9%). County Line is the least racial/ethnic diverse, with 88.6% of the population identifying as non-Hispanic White. A higher proportion of Asians and Pacific Islanders live in North Penn (15.4%) and Blue Bell (11.3%). Blue Bell has the highest concentration of Black non-Hispanics (5.8%). The Hispanic population ranges from a low of 2.5% in County Line to 4.6% in Indian Valley.

Race/Ethnicity: 2015 Estimate 100%

80%

60%

40%

20%

0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont USA White Non-Hispanic Black Non-Hispanic Asian & Pacific Islander Non-Hispanic Hispanic All Others

Social Determinants of Health

Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as “place.” In addition to the more material attributes of “place,” the patterns of social engagement and sense of security and well-being are also affected by where people live. Resources that enhance quality of life can have a significant influence on population health outcomes. Understanding the relationship between how population groups experience “place” and the impact of “place” on health is fundamental to the social determinants of health. (Healthy People 2020)7.

To address social determinants of health, Healthy People 2020 uses a “place-based” approach that consists of five key areas: economic stability (poverty, employment status, access to employment, housing stability/homelessness); education (high school graduation rates, school environments, enrollment in higher education); social and community context (family structure, social cohesion, civic participation, incarceration); health and healthcare (access to health services including clinical and preventive care, access to primary care including wellness and health promotion programs); and neighborhood and built environment (crime and violence, access to healthy foods).

Abington Lansdale's community assessment focuses on social determinants of health through a “community benefit neighborhood-based” approach. The information about social determinants that follows relates to the overall population. Social determinant issues that pertain to special populations will be provided in the CHNA section for Special Populations.

Two indices measure social determinants of health in Abington-Lansdale's CB area of Bucks and Montgomery Counties: County Health Rankings and the Community Need Index.

1) In the 2015 County Health Rankings for Pennsylvania, Montgomery County ranked 6th highest and Bucks County ranked 12th among the 67 counties in the state using a variety of measures including social and economic factors.8 2) Community Need Index - In 2005 Dignity Health, in partnership with Truven Health, pioneered the nation’s first standardized Community Need Index (CNI). The CNI identifies the severity of health disparity for every zip code in the United States and demonstrates the link between community need, access to care, and preventable hospitalizations. The CNI accounts for the underlying economic and structural barriers that affect overall health. These barriers include those related to income, culture/language, education, insurance, and housing. The CNI gathers data about a community’s socio-economy (percentage of elderly living in poverty; percentage of the uninsured or unemployed, etc). A score is then assigned to each barrier condition (with 1 representing less community need and 5 representing more community need). The scores are then aggregated across the barriers and averaged for a final CNI score (each barrier receives equal weight in the average). A score of 1.0 indicates a zip code with the lowest socio-economic barriers, while a score of 5.0 represents a zip code with the most socio-economic barriers.9

The CNI score is highly correlated to hospital utilization – high need is associated with high utilization. The CNI considers multiple factors that limit health care access, and therefore may be more accurate than existing needs assessment methods. In addition, the most needy communities experience admission rates almost twice as high as the lowest need communities for conditions where appropriate outpatient care could prevent or reduce the need for hospital admission such as pneumonia, asthma, congestive heart failure, and cellulitis. The chart below provides the CNI for zip codes in Abington-Lansdale's CB area. Only one zip code, 18915 (Colmar) in North Penn, has a CNI above 2.5.

CNI Scores by ZIP Code ZipNorth PennCNI Indian ValleyCNI County LineCNI Blue BellCNI Code Score Zip Code Score Zip Code Score Zip Code Score 18915 2.8 18964 2.4 18914 1.4 19422 2.2

18936 1.6 18969 2.4 18932 1.4 19440 2.4 19438 1.8 19446 2.4 19454 2.0

Education The level of education among residents in Abington-Lansdale's CB area varies. Residents living in Blue Bell are most likely to have college degrees or higher (59.9%) compared to Bucks/Mont (41.2%), while residents in Indian Valley and North Penn are slightly more likely not to have graduated from high school (7.7% and 6.6% respectively) compared to Bucks/Mont (6.5%). Compared to the United States, the residents in Abington-Lansdale's CB area are more educated.

Adult Age 25+ Education Level: 2015 Estimate 100%

80%

60%

40%

20%

0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont USA No High School Degree High School Degree Some College/Assoc. Degree Bachelor's Degree or Greater

Education is one of the factors associated with health literacy. According to the U.S. Department of Health and Human Services, health literacy "is the degree to which individuals have the capacity to

obtain, process, and understand basic health information and services needed to make appropriate health decisions." Low literacy has been linked to poor health outcomes such as higher rates of hospitalization, less frequent use of preventive services, and higher costs. Populations most likely to experience low health literacy are older adults, racial and ethnic minorities, people with less than a high school degree or GED certificate, people with low income levels, non-native speakers of English, and people with compromised health status.10

Income and Poverty

"Being poor in Montgomery County: "what's wrong with them" stigmatization. If you are poor you are marginalized."

Income in the Abington-Lansdale CB area is relatively high. Average Household Income: 2015 Estimate $150,930

$117,796 $103,602 $104,906 $103,246

$45,000

North Penn Indian Valley County Line Blue Bell Bucks/ Mont USA

While the majority of the population enjoy household incomes of more than $75,000, there is poverty in the community. Poverty can result in an increased risk of mortality, prevalence of medical conditions and disease incidence, depression, intimate partner violence, and poor health behaviors. Household Income Distribution: 2015 Estimate 100%

80%

60%

40%

20%

0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont USA <$15K $15-25K $25-50K $50-75K >$75K

In 2015, the federal poverty level (FPL) threshold for a family/household of four was $24,250.11 Abington-Lansdale CB area residents are less likely to live below 100% poverty than others living in Bucks/Mont.

% Below 100% Federal Poverty Guideline

5.8

4.4 4.4

3.6 3.2

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

Communitycommons.org

Many subsequent data in this document compare rates between those living below 200% of the FPL and those above. The percentage of people living below 200% of the FPL in each region is at least twice that compared to people living below the 100% FPL. For example, while 4.4% of people in North Penn were below the 100% FPL, almost 15% are below the 200% FPL.

% Below 200% Federal Poverty Guideline

16.2 14.9 14.6

9.5 8.5

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

Communitycommons.org

In addition, there are people living in deep poverty, defined as below 50% of the federal poverty level, in the Abington-Lansdale CB area.

% Below 50% Federal Poverty Guideline

2.5

2.2 2.0

1.2 0.8

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

Communitycommons.org

Another way to measure economic welfare is to employ the Self-Sufficiency Standard. This measures how much income a household of a certain composition in a given place needs to adequately meet their basic needs—without public or private assistance. Using this measure, twice as many Pennsylvania households lack sufficient income to meet their basic costs compared to the federal poverty level. People of color have higher rates below the self-sufficiency level.12

% PA Households below Self-

Sufficiency: 2010

55%

48%

32% 21%

White Asian Black Latino

While negative health effects resulting from poverty are present at all ages, children in poverty experience greater morbidity and mortality than adults due to increased risk of accidental injury and lack of health care access. Children’s risk of poor health and premature mortality may also be increased due to the poor educational achievement associated with poverty. According to the 2015 County Health Rankings & Roadmaps, 19% of Pennsylvania children live in poverty.13 Except for North Penn, the proportion of children living below 100% FPL in the Abington-Lansdale CB areas is higher than poverty for all ages.

Children: % Below 100% Federal Poverty Guideline

6.8

4.8

4.0 3.9 3.5

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

Communitycommons.org

According to the Self-Sufficiency Standard, households with young children are the most likely to be financially insecure.

% PA Households below Self- Sufficiency: 2010

46%

35% 27% 20%

No children With children Young children* Older children** * youngest child < 6 ** youngest child 6-17

In addition, 20% of children in both Bucks and Montgomery counties live in single parent households. Although this proportion is significantly lower than for Pennsylvania (33%),14 it represents a sizable number of adults and children in single-parent households who are at risk for adverse health outcomes such as mental health problems (including substance abuse, depression, and suicide) and unhealthy behaviors such as smoking and excessive alcohol use.

Access to Healthy and Affordable Food

Although Bucks and Montgomery counties are affluent, food insecurity affects approximately 10% of the population and more than 15% of children according to Feeding America – Map the Meal Gap. In terms of population in Abington-Lansdale's CB areas, this represents almost 20,000 individuals

including more than 6,500 children.15 Food insecurity is dispersed throughout the Abington-Lansdale CB area.16

Food insecurity, defined as limited access to sufficient nutritious food, impacts a child’s development both in terms of brain development and growth, and has been shown to be related to increases in childhood obesity. Children who experience food insecurity and hunger are more likely to require hospitalization, be at risk of chronic health care conditions such as anemia and asthma, and be at increased risk of oral health problems. In addition, food insecurity may affect children's ability to fully engage in daily activities such as school and socializing with peers and they are more likely to be behind academically. Behavioral challenges are also evident among children who experience food insecurity. These children are at greater risk for truancy, and behavioral problems such as aggression at school, hyperactivity, anxiety, mood swings and bullying.17

These health and behavioral risks may contribute to the cycle of poverty and future success as an adult. Food insecure adults are more likely to be at risk for diabetes, hypertension, and high cholesterol. Pregnant women who are food insecure are more likely to experience major depression, have low weight babies, and experience birth complications compared to women who are food secure. Seniors are also adversely affected by hunger.

Not surprisingly, a result of food insecurity is higher health care costs. According to a recently published article by the Canadian Medical Association, households with low food security incurred health care expenses that were 49% higher than those who were food secure. Among those with very low food security (those who missed meals or ate smaller meals because they could not afford food) , health care costs were 121% higher.18

Additionally, in a study of patients in an emergency department, food insecure patients were more likely than food secure patients to:  report a variety of chronic and mental health problems including obesity  delay paying for medication to have money for food  take medication less often because they could not afford more  choose between buying food and medicine  get sick because they could not afford to buy medicine19

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and food stamps, according to Children’s Watch, are the “best medicine” to treat food insecurity. However, according to a 2013 Pennsylvania report, there were 470,000 eligible residents who did not participate in SNAP and only 56% of eligible Pennsylvanians received WIC benefits.20

Statewide participation in the WIC program declined by 2.7% to 245,424 in August 2015.21 Fewer than 2% of Bucks and Montgomery county residents receive WIC benefits. In addition, 15% of children in Bucks and 16% of children in Montgomery County qualify for the free lunch program.22 The proportion of children qualifying for free or reduced lunch is much higher in certain communities: for example, 25.5% of North Penn School District and 19.4% of Souderton Area School District were eligible.23

%Receiving WIC

1.3

1.0

0.0 0.0 0.1 North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

As of August 2015 in Pennsylvania, almost 1.9 million residents received food stamps through the Supplemental Nutrition Assistance Program (SNAP) and the number increased 2.4% from the previous year.24 In April 2014, 6% of Bucks County and 6.5% of Montgomery County residents received SNAP benefits, representing a .5% decline and 4.2% increase respectively in the number of recipients compared to the previous year.25 In Abington-Lansdale's CB area, the percentage of people receiving food stamps ranged from 0% in Blue Bell to 10.2% in County Line.

%Receiving Food Stamps

10.2

8.5 7.5

3.1 0.0

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

The percent of adults who reported cutting a meal due to cost is an indicator of food insecurity. Fewer people in the Abington-Lansdale CB area are food insecurity than Bucks/Mont.

% Who Cut a Meal due to Lack of Money 4.5

2.6 2.0

0.0 0.0

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Although most of Montgomery County is within close proximity to one (or more) full service grocery stores, many of the more densely populated boroughs do not have a full-service grocery store. A recommendation of the Montgomery County Comprehensive Plan is that these places should encourage grocery stores, farmers’ markets, community gardens, home gardens, and food safety net providers within their borders to provide fresh fruit and vegetable options.26

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to access to healthy and affordable food include:

 food insecurity especially affects high risk patients and women and children  lack of healthy food exacerbates substance abuse, depression, and anxiety conditions  those with mental health issues may not know or be aware of nutrition and healthy eating habits  healthy foods are expensive and not always available in convenient locations; cheaper foods can be unhealthy  people eat out more than they cook  lack of access to affordable foods is a well known contributor to obesity related issues for low income and vulnerable populations  there are too many pizza shops

Recommendations include:

1) more local food retailers 2) local government should focus on safe walkable access to healthy food retailers 3) a list of community resources should include information on healthy food 4) turkey giveaways and meals for seniors

Employment and Job training

As of June 2015, unemployment in Bucks (4.7%) and Montgomery (4.3%) counties are among the lowest in the metropolitan area. These rates are lower than the U.S. average of 5.5% and represent decreases in unemployment of about 2% since 2013.27

Weekly wages in Montgomery County in Q1 2015 were the highest of any Pennsylvania county ($1,397). The Bucks County weekly wage at $930 was lower than the Pennsylvania average of $1,031.28

Compared to the employed, those not working in Bucks/Mont are more likely to report their health as fair or poor, and have diabetes, high blood pressure, or a diagnosed mental health condition. In addition, unemployed adults are slightly more likely to smoke compared to employed adults.

Fair/Poor Health Mental Status Diabetes High BP Condition Smoker

Employed 7% 7% 21% 13% 12% Not employed 25% 18% 46% 18% 13% PHMC Household Health Survey 2015

The implications of poor health on labor market outcomes are enormous for patients, families, employers and policy makers. Poorly managed health conditions have been associated with increased absenteeism, poor productivity, decreased job retention, and fragmented work histories. In a survey sponsored by Nationwide Better Health,29 85% of respondents reported that unplanned absences are normally due to a health condition, either their own or that of a family member. Half of these absences were due to a recurring health condition. Mental and physical health illnesses, personal

problems, the need to be with their families or job-related stress also increase lost productivity at work. Absence management leads to a healthier workforce and keeps people on the job at full strength to maximize a company’s productivity and profit.

For Abington-Lansdale CB area's vulnerable adults, finding a job with family-sustaining wages is only the first hurdle on the path to economic stability. Because of physical and mental health challenges, a lack of peer support and limited work experience, low skilled adults often find it difficult to not only obtain jobs, but retain their jobs. Once employed, many residents in these communities need to receive on-going counseling and support services to improve their work habits, manage work-related stress, balance family and work obligations, and effectively manage chronic health conditions.

According to Healthy People 2020, public health infrastructure is fundamental to the provision and execution of public health services at all levels. A strong infrastructure provides the capacity to prepare for and respond to both acute (emergency) and chronic (ongoing) threats to the nation’s health. Infrastructure is the foundation for planning, delivering, and evaluating public health. As minority populations in Bucks and Montgomery counties and the United States increase, a more diverse public health workforce will be needed. In many areas, Hispanics and African Americans are underrepresented in the public health workforce. In addition, while there are Asian providers, language barriers across the area's diverse Asian communities exist. According to Cohen, Gabriel, and Terrell, increasing the racial and ethnic diversity of the health care workforce is essential for the adequate provision of culturally competent care to our nation's burgeoning minority communities. A diverse health care workforce will help to expand health care access for the underserved, foster research in neglected areas of societal need, and enrich the pool of managers and policymakers to meet the needs of a diverse populace. The long-term solution to achieving adequate diversity in the health professions depends upon fundamental reforms of our country's precollege education system.30

There exists a growing literature related to the use of community health workers/navigators/coaches (CHWs) to increase the diversity of the workforce and in care management, facilitation of transitions of care, chronic disease management and bridging cultural divides. Interviews with organizations serving immigrants shared the need to train members of limited-English speaking communities in health professions including health care providers and community health workers. Developing a recruitment and training program for CHWs has the potential to provide job opportunities for minority populations and meaningful employment. It has also been shown to improve the quality and outcomes of care.31

Recommendations include:

1) Recruit people of color, especially for professional and leadership positions 2) Recruit and retain individuals from various backgrounds 3) Develop more connections with schools for workforce development 4) Develop hospital policies to maximize employee flexibility for issues related to FMLA, skills acquisition, and organizational mission/service leave opportunities 5) Invest in time and education to develop motivational interviewing skills for health professionals that will enhance shared decision making with patients

Community Safety

The health impacts of community safety include the impact of violence on the victim, symptoms of post-traumatic stress disorder (PTSD), psychological distress due to chronic exposure to unsafe living conditions and various other health factors and outcomes including birth weight, diet and exercise, and family and social support. Exposure to crime and violence has been shown to increase stress, which may exacerbate hypertension and other stress-related disorders and behaviors such as smoking in an effort to reduce or cope with stress. Exposure to violent neighborhoods has been associated with increased substance abuse and sexual risk-taking behaviors as well as risky driving practices.20

Violent crime is represented as an annual rate per 100,000 population. Violent crimes are defined as offenses that involve face-to-face confrontation between the victim and the perpetrator, including homicide, forcible rape, robbery, and aggravated assault. Compared to the Pennsylvania average violent crime rate (357), Bucks (112) and Montgomery (182) counties are relatively safe places. However, the violent crime rates in Bucks and Montgomery counties equates to more than 2,000 victims annually.32 Statewide, the number of violent crimes decreased 11% from 2009 to 2013.33

Domestic violence is also a concern in the community. AJH and the Women's Center of Montgomery County offer free and confidential counseling, legal advocacy, shelter referrals and support groups.

Abington-Lansdale Hospital refers victims to the specialized forensic nurse examiner program at Abington Hospital, the only program in Montgomery County providing 24/7 availability of specially trained and certified Sexual Assault Nurse Examiners.

Neighborhoods with high violence encourage isolation and therefore inhibit the social support needed to cope with stressful events. New research from Penn Medicine focusing on 10-24 year old primarily African American males, suggests that where they go and how they get there can mitigate or increase the risks of exposure to violence by gunfire and other weapons.34 Additionally, exposure to the chronic stress of community violence and unsafe built environment contributes to the increased prevalence of certain illnesses, such as upper respiratory illness and asthma. In Abington-Lansdale Hospital's CB areas, between 13 and 24% of people reported being uncomfortable visiting a nearby park or outdoor space during the day. These concerns may restrict physical activity.

% Uncomfortable Visiting a Nearby Park or Outdoor Space During the Day 24.3

17.9 17.6 14.2 12.6

North Penn Indian Valley County Line Blue Bell Bucks/ Mont PHMC Household Health Survey 2015

Among the community safety goals articulated in Montgomery County's Comprehensive plan are:

 right-sized roads, traffic calming, green streets, and sidewalks  better walkability by installing sidewalks on county roads in appropriate locations when the roads are rebuilt and walkability audits with local communities  bike-friendly improvements to roads in cooperation with PennDOT, bicycling organizations, and local municipalities

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to community safety included:

 Interpersonal violence o Lack of shelters and undesirable locations of shelters for domestic violence victims o Domestic violence affects children and adults; the mental health issues are just beginning to be recognized o Vulnerable senior abuse includes financial and poor care (e.g. bed sores, infections)

 Drug use o Access to gateway drugs among youth aged 14-18 (marijuana and alcohol)

 Injury/Trauma o Helmets needed for children's bicycle safety o Falls prevention for seniors o Burn prevention for all o Need for safe walking environments o Trauma related to transportation issues (distracted driving, DUI) does not receive enough attention; education and prevention are needed

 Need for more constructive activities for youth and seniors o After school and summer programming for kids/youth in area o " need something to do… if not they get into trouble"

o Senior centers

Recommendations included:

1) Utilize Philly Rising initiative strategies which address violence by reducing substance abuse among youth (focus is on reducing use of entry drugs such as alcohol and marijuana) 2) Explore “walking bus” intervention to improve student safety 3) More education on domestic violence. Awareness that missed appointments may be domestic violence related. Utilize AJH domestic violence social worker who knows the system, works well with security, and is successful obtaining Protection from Abuse orders. 4) Police Athletic Leagues and municipal sports programs are good resources for activities for kids 5) Countywide Youth Aid Panel needed for 18 to 25 year old first offenders 6) Utilize Montgomery County Health Department Distracted Driving Initiatives

Family and Social Support

"Social support stems from relationships with family members, friends, colleagues, and acquaintances. Social capital refers to the features of society that facilitate cooperation for mutual benefit, such as interpersonal trust and civic associations. Individual social support and cohesive, capital-rich communities help to protect physical and mental health and facilitate healthy behaviors and choices.

Socially isolated individuals have an increased risk for poor health outcomes. Individuals who lack adequate social support are particularly vulnerable to the effects of stress, which has been linked to cardiovascular disease and unhealthy behaviors such as overeating and smoking in adults, and obesity in children and adolescents.

Residents of neighborhoods with low social capital are more likely to rate their health status as fair or poor than residents of neighborhoods with more social capital, and may be more likely to suffer anxiety and depression. Neighborhoods with lower social capital may be more prone to violence than those with more social capital and often have limited community resources and role models. Socially isolated individuals are more likely to be concentrated in communities with limited social capital. Individuals with higher educational attainment and higher status jobs are more likely to have greater social support than those with less education and lower incomes. Adults and children in single-parent households, often at-risk for social isolation, have an increased risk for illness, mental health problems and mortality, and are more likely to engage in unhealthy behaviors than their counterparts.

Adopting and implementing policies and programs that support relationships between individuals and across entire communities can benefit health. The greatest health improvements may be made by emphasizing efforts to support disadvantaged families and neighborhoods, where small improvements can have the greatest impacts."35

"In the past everyone knew their neighbor and neighborhood… today it is much different with two parents working or single parent households; there used to be town watch. What happened to "Welcome Wagons? (key informant)" Connectedness to their neighborhoods varies among Abington-Lansdale's CB areas, with residents of North Penn more likely to disagree or strongly disagree with the statement “ I feel I belong in my neighborhood.”

%Who Feel They Do Not Belong in Their Neighborhoods 11.6 10.4

5.1 4.3 2.2

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

North Penn residents participate in organizations at a rate lower than the other Abington-Lansdale CB areas, but higher than the Bucks/Mont average. County Line residents, who feel most connected with their neighborhoods, have the most involvement with organizations.

% Currently Participating in Organizations 11.3 15.7 42.8 26.7 12.7 45.4 44.7 38.9 33.6 41.0 48.2 43.3 39.6 39.6

16.2 North Penn Indian Valley County Line Blue Bell Bucks/ Mont No Organizations 1-2 Organizations 3+ Organizations

PHMC Household Health Survey 2015

Residents of North Penn and Indian Valley report a higher percent of neighbors who are never willing to help each other. 50 % Neighbors Willing to Help Each Other 40

0 North Penn Indian Valley County Line Blue Bell Bucks/ Mont Never Rarely Sometimes PHMC Household Health Survey 2015

Community members in County Line report the highest rate of working together.

% Neighbors Who Worked Together

65.1

50.7 51.8 46.7 41.7

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Almost one-third of Bucks/Mont and County Line residents provide care for family or friends. About 25% of people living in North Penn and Indian Valley assisted family or friends in the past month.

% Providing Care to Family/Friend in the Past Month

32.2 31.7

25.2 24.5 20.7

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

The percentage of adults aged 60+ who provide care to family or friends is less than that of the total adult population (note areas are consolidated due to sampling size).

%Age 60+ Providing Care to Family/Friend During the Past Month

31.1

23.9

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to family and social support included:

 Support o Elderly are taking care of themselves. Care-giving a major issue as well. o Caregiver is usually an adult daughter or son of an older adult. Caregivers need support: they lack sleep; do not take care of themselves; physically hurt themselves in the physical care of another; are deficient in their knowledge. o Caregivers need time to learn about resources during an acute episode. Need to connect to community supports/resources for support such as food, care-giving, and transportation. o Waiting lists are a concern.

Recommendations included: 1) Virtual Care [new technologies]. Electronic medical record in the future may have more linkages. Systems that talk to each other.

Built and Natural Environment

To provide opportunities to make people independent, there needs to be an integrated solution for the needs of the society. Create a built environment with affordable housing, senior living, stores, community center, playground which is close to railroad which connects to an industrial park.

The public health community has become increasingly aware that the design of the built environment can have a major impact on the health of the public. For example, people living in communities with convenient, safe walking paths, bike lanes, bike racks, parks/playgrounds that are in good condition, and access to healthy, affordable food sources may be more physically active and have healthier diets.

Conversely, poorer health indicators may be expected among residents of communities with high crime rates, few parks or walking paths, numerous alcohol and tobacco outlets, and little access to fresh food. The powerful influence of the built environment on health suggests that public health practitioners should be involved in planning and policy decisions related to land use, zoning and community design. Health practitioners can serve an essential role in collaborating with other professionals and working alongside neighborhood residents to create and promote healthy communities. Health practitioners need to engage in actions that support: (1) assessing the health impact of land use and community design options before decisions are made as well as after improvements are implemented; and (2) policymaking on issues related to the built environment to ensure protection from toxins, access to healthy food outlets, places to walk and recreate, and other health promoting environments.36

European research suggests that people who live proximate to areas of greenery are 3 times more likely to engage in physical activity and 40% less likely to be overweight.37 A 2012 study in Philadelphia conducted by researchers from the University of Pennsylvania38 found that greening vacant lots may affect health and safety. Although vacant lots are not a significant issue in the suburbs, the study findings apply in Abington-Lansdale's CB areas. Researchers found significantly lower levels of vandalism and stress among residents, as well as significantly higher levels of physical activity among residents in areas where abandoned lots where cleaned and greened. Green space may also, according to the research, build social ties that are important for health.

The availability of places to recreate and exercise and the availability of fresh produce can promote the health of residents.39 Parks, recreation centers, schoolyards, and community gardens that are in good repair all help foster a sense of community, which leads to strong, safe neighborhoods.

Montgomery County's new comprehensive plan, Montco 2040: A Shared Vision, addresses many issues related to health. Among its goals and success measures are:

 Improve transportation quality and expand options for county residents and workers Reduce pedestrian/vehicle and bike/vehicle accidents; increase pedestrian and bike commuters  Provide more opportunities for residents to exercise and have healthy lifestyles Increase park users, increase farmers markets and farms  Support housing choices and opportunities to meet the needs of all people Approve new municipal ordinances allowing affordable housing, accessory apartments, and special needs housing  Enhance community character and protect neighborhoods Reduced emergency response time 40

In addition, Montgomery County's Walkability and Your Community Health, Safety, and Economics report offers compelling evidence why walking is important to health, why walkable communities are desirable, and funding opportunities that communities can utilize to make their community friendlier for pedestrians and cyclists.41

Health Care Access Health care access is determined by multiple factors including health insurance, transportation, language and literacy, and cultural competency.

Health Insurance

Under the Affordable Care Act, millions of Americans became eligible for new coverage opportunities in 2014. As of September 2015, 17.6 million uninsured Americans gained coverage in large part to the Affordable Care Act and 10.5 million more are uninsured but eligible for Marketplace coverage. Enroll America research found that nearly half of the uninsured lack confidence in choosing a health insurance plan.42

The Healthy People 2020 goal is insurance for everyone. In Bucks/Mont, 5% of adults aged 18-64 are uninsured and 2% of children lack health insurance. The percent of adults aged 18-64 without insurance ranges from 0% in County Line to 9% in North Penn. Black and Hispanic residents, and those age 18-34, are more likely to be uninsured.43

% Insured Adults, Ages 18-64 Healthy People 2020 Target = 100% 100.0 98.8 90.7 94.8 94.6

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

% Insured Children Healthy People 2020 Target = 100% 99.5

98.3

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Cost and employers not offering coverage were the most frequent reasons given for not having insurance. Note: Only Bucks/Mont data is presented because the sample sizes of uninsured respondents in the Abington-Lansdale CB areas is too small for meaningful analysis.

Bucks/Mont Job status change 7.3 Ineligible due to age/left school 1.7 Employer doesn't offer coverage 12.0 High cost 50.7 Other * 28.3 * includes insurance company refused coverage; objections to ACA; difficulties using healthcare.gov; death or divorce PHMC Household Health Survey 2015

About a third of the population in North Penn, Indian Valley, and Bucks/Mont enrolled for health insurance through Healthcare.gov. Almost half of County Line respondents, the area with the highest health insurance coverage rate, used Healthcare.gov, while only 19% of Blue Bell residents enrolled through Healthcare.gov, perhaps because they were already covered with satisfactory insurance. Between November 15, 2014 and February 22, 2015, 33,357 and 39,695 people in Bucks and Montgomery counties respectively selected Marketplace plans (note: not all of these people were uninsured; they may have switched plans).

As part of the Get Covered America initiative, Abington-Lansdale Hospital in partnership with Enroll America sponsored open enrollment opportunities in December 2015 and January 2016 to support people applying for coverage.

% Enrolled through Healthcare.gov

48.0

32.9 33.2 33.6

18.6

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

The majority of residents in Abington-Lansdale's CB area have insurance through work, school, or a union.

Type of Insurance (can have more than one)

North Penn Indian Valley County Line Blue Bell Bucks/ Mont Work, school, union 67.1 52.3 80.7 61.4 59.4 Self or family (incl w gov assist) 43.0 50.7 48.2 45.7 52.2 Medicare A 16.7 28.9 25.2 36.8 28.2 Medicare B 18.0 26.1 23.3 38.4 27.3 Medicaid 4.9 12.9 0.8 7.2 7.4 Champus or Tricare 0.5 4.1 0.6 2.7 2.0 Other group 27.9 25.4 36.1 28.2 24.7

PHMC Household Health Survey 2015

Affordability of health insurance premiums, co-pays, and deductibles is more of a concern for residents of North Penn and Indian Valley than County Line or Blue Bell. Residents of County Line, who enrolled most often through Healthcare.gov, reported the least difficulty finding plans with affordable premiums, co-pays, and deductibles. This contrasts to the 90+% of people living in North Penn who reported that finding an affordable health plan premiums was very or somewhat difficult.

% Finding a Plan with Affordable Monthly Premiums 100% 80% 60% 40% 20% 0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont Not at all difficult 8.7 27.3 80.7 36.6 27.5 Somewhat difficult 41.4 30.4 15.4 63.4 31.2 Very difficult 49.9 42.3 3.9 0.0 41.4

PHMC Household Health Survey 2015

North Penn residents reported less hardship finding a plan with affordable co-pays and deductibles than premiums.

100%% Finding a Plan with Affordable Copays and Deductibles

80%

60%

40%

20%

0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont Not at all difficult 28.0 34.7 77.3 36.6 29.6 Somewhat difficult 30.9 20.7 3.7 63.4 27.0 Very difficult 41.1 44.6 18.9 0.0 43.4

PHMC Household Health Survey 2015

Although Blue Bell residents reported that finding an insurance plan with affordable premiums, co- pays and deductibles was not at all difficult, residents from this area also reported the greatest frequency of not seeking care due to cost, suggesting a group of residents who are struggling financially.

% Sick Who did not Seek Care Due to Cost

11.5 9.7 9.1 7.5

4.4

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

The majority of people in Bucks/Mont have prescription coverage (88.4%).

% with Prescription Coverage

100.0

90.3 90.8 88.4 85.7

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Although residents of Blue Bell report that 91% have prescription coverage, similar to reporting that they forgo care because of cost, they also report the highest rate for not obtaining medication due to cost.

% Who Did Not Obtain Prescription Medicine due to Cost 20.6

16.0

12.5 12.5 10.0

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to health insurance and access to care include:

 Cost for services for the uninsured and under-insured is prohibitive for many o high co pays/ high deductible; out of pocket expenses an issue o "Economics" is a huge crisis o Uninsured, underinsured, and undocumented adults cannot pay for primary care. The Adult Health Center on the Lansdale campus has high office visit fees and low flexibility/availability for appointments.

o The inability to afford medications leads to mismanagement and risk of re- hospitalization o Affordable access for immunizations is more challenging since Montgomery County Health Department decreased availability of free vaccine programs o There is insufficient insurance coverage for acute renal care; Medicare pays only for chronic care

Recommendations included:

1) Increase social workers to assist individuals in enrollment in Medicaid expansion programs, insurance exchanges, pharmacy assistance resources, and other government programs 2) Add a financial assistance counselor at Abington-Lansdale Hospital 3) Evaluate the medical access program (sample Phoenixville Foundation) 4) Expand AJH pharmacy assistance program to Abington-Lansdale Hospital 5) Educate about pharmacy assistance resources such as pharmaceutical companies assistance programs and Walmart

Transportation

Fewer than 10% of people in Abington-Lansdale's CB areas cancelled a doctor appointment due to a transportation problem. Although not an issue for the majority of the population, such cancellations may lead to negative health outcomes. For those in need, it is "harder and harder to get to appointments or keep existing ones."

% Didn't Go to a Needed Doctor Appointment Due to

Transportation Problems 8.8

5.3 3.8

1.4 0.0

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Montgomery County, through its Department of Public Safety, operates the 9-1-1 system; coordinates public safety services among police, fire, and emergency medical responders; and provides public safety training. According to key informants, there are 68 EMS companies in Bucks County and at least 20 ambulance agencies in the Montgomery County that are licensed as for profit transportation ambulance organizations. For Bucks County Medical Assistance clients enrolled in the transportation

program, Bucks County Transport provides free transportation to any health care service that is covered by Medical Assistance, including appointments with doctors, dentists, psychologists or psychiatrists, drug and alcohol treatment clinics, pharmacies for prescriptions, hospital outpatient services, and medical equipment suppliers. In Montgomery County, TransNet provides similar non- emergency transportation for Medical Assistance clients who are traveling to routine medical appointments. The TransNet program also reimburses costs for using public transportation or mileage, tolls, and parking if a private vehicle is used.

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to health care access and transportation include:

 Cost of transportation for public transportation o New SEPTA fare increase will negatively affect patients o It takes resources and navigation to get the patients to their appointment. SEPTA fares, TransNet, and taxi cab vouchers are needed  Convenience o Isolated seniors are in need of transportation

 Access o There is a lack of public transportation and safe sidewalks near Abington-Lansdale Hospital o Community members not able to access services of clinics, medical offices, outpatient services due to transportation issues o It can be difficult to get people from Abington-Lansdale Hospital to specialized clinic services at Abington Hospital

Recommendations included:

1) Transportation to support groups 2) Install safe walkways from the new train station on 9th Street to the hospital, creating a more walkable environment for patients and to enable a more diverse staff to work at Abington-Lansdale Hospital 3) Explore collaboration/partnership with PTMA transportation pilot program

Literacy

Health literacy is a stronger predictor of individual health status than age, income, employment status, education level or racial/ethnic group.44 Inadequate health literacy, as measured by reading fluency, independently predicts all-cause mortality and cardiovascular death among community dwelling elderly persons.45 Health literacy also contributes to disparities associated with race/ethnicity and educational attainment in self-rated health and some preventive measures.46 Race/ethnicity (African American and Latino/Hispanic), age (older than 65), not completing high school, poverty, and not speaking English prior to entering school have also been associated with lower literacy levels (NAALS, 2003).47 Older adults are disproportionately more likely to have below basic health literacy than any other age group. Almost two-fifths (39 percent) of people age 75 and over have a health

literacy level of below basic compared with 23% of people age 65–74 and 13% of people age 50– 64.42 (NAALS, 2003).

Low patient literacy is associated with limited disease-related knowledge and self- management, poor adherence to treatment plans, and a 30-50% increased likelihood of hospitalization. Preventable hospital admissions are also associated with poor health literacy.48 The Joint Commission’s National Patient Safety Goals specifically address communication issues related to provider-patient interaction.49 The health literacy of patients is often underestimated by health care providers and may not even be considered as a factor in patient care.50, 51 The safety of patients cannot be assured without mitigating the negative effects of low health literacy and ineffective communications on patient care. However, there is more to health literacy than understanding health information. Health literacy also encompasses the educational, social, and cultural factors that influence the expectations and preferences of individual, and the extent to which those providing healthcare services can meet those expectations and preferences. In addition, the growing prevalence of chronic conditions and an aging population requires even more attention to effective strategies to address health literacy. Patients with poor health literacy have a complex array of communication difficulties, which may affect health outcomes. Such patients report worse health status and have less understanding about their medical conditions and treatment; they may have increased hospitalization rates. Professional and public awareness of the health literacy issue must be increased, beginning with education of medical students and physicians and improved patient-physician communication skills.52 Many experts suggest that low-literate adults should be educated using simple language geared to the layperson, and using teach-back techniques to confirm patient understanding, as well as visual methods including pictures, multimedia, use of pill-boxes, and graphic medication schedules.53 Recommendations included: 1) "Educate staff first then make changes to how we do things."

Cultural Competence and Language "Non English speaking patients, with their diverse cultural background, may not fit into our hospital blue print." (key informant)

" Needs go beyond language issues alone." (key informant) "Lack of cultural sensitivity is inhibiting the road to wellness" (key informant)

Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. 'Culture' refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. 'Competence' implies having the capacity to function effectively as an

individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.54

Assuring cultural competency is one of the main ingredients in closing the disparities gap in health care and is the way patients and doctors can come together and talk about health concerns without cultural differences hindering the conversation, but enhancing it. Health care services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients can help bring about positive health outcomes.

Culture and language may influence: health, healing, and wellness belief systems; how illness, disease, and their causes are perceived by the patient/consumer; their attitudes toward health care providers; and the delivery of services by a provider who looks at the world through his or her own limited set of values, which can compromise healing for patients from other cultures.

The increasing population growth of racial and ethnic communities and linguistic groups, each with its own cultural traits and health profiles, presents a challenge to the health care delivery. The provider and the patient each bring their individual learned patterns of language and culture to the health care experience which must be transcended to achieve equal access and quality health care. As described above, Abington-Lansdale's community benefit area serves increasingly diverse communities including immigrants and a growing elderly population. As a result of the 2013 Community Health Needs Assessment, AJH assembled a Cultural and Linguistically Appropriate Education and Materials team to develop and implement an action plan focused on interpreters, document translation, cultural competence, and project management. One project was to make the AJH clinics brochure available in Spanish and Korean. The team also created a database of health websites of multicultural translated health education and an intranet inventory of AJH's almost 100 patient education and financial information documents translated into Korean, Spanish and Portuguese for use by hospital staff and medical residents. In addition, a team comprised of diversity and nursing leadership taught classes about cultural competence based on the JCAHO “One Size Does Not Fit All” framework. Included in the classes was education on special populations: the deaf, East Indian, bariatric, geriatric, Muslim, Korean, and Portuguese. More than 300 staff and medical residents attended these classes which addressed health beliefs, expression of pain, male/female caregivers, death, childbirth, and dietary habits.

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to culture and language:

 Communication o Hospital staff lack cultural competency skills; there is a racial divide o Language is a barrier for the Korean community, especially for education on diseases, prevention, and health insurance issues

 Culture o Some immigrants from Mexico and Central America are afraid of going to doctor, fearing outcomes and cost. Language and culture are barriers.

o Asian patients utilize the hospital system differently than other Abington-Lansdale CB area residents. Asians use more clinics and ER visits verses primary care physician visits.  Interpretation o There are limited skilled home care agencies that provide bilingual services to the Korean community. "Needs go beyond language issues alone." o There are opportunities to improve our interpretation to English as a Second Language patients.

Recommendations included:

1) Invite members of the community for ongoing input to develop a formal strategy for how to move forward 2) Need more tailored education with trans-cultural consideration 3) Need more education regarding the medical system and available financial assistance for immigrants; educational programs are planned for a future community center to house such programs to serve the Latino population in and near Hatboro 4) Need more social workers bilingual in Korean who are knowledgeable about benefits, especially for older Korean Americans

Health Status

Mortality

Bucks and Montgomery counties rank 13th and 4th respectively in Pennsylvania in terms of longevity.55

With the exception of accidents and suicide, age adjusted mortality rates per 100,000 population decreased for all causes between 2002 and 2012. Values are not been shown when counts are less than 10.56 Cause Bucks Montgomery Bucks Montgomery Bucks # Montgomery Rate Rate 2012 Rate Rate 2002 Deaths # Deaths 2012 2002 2012 2012

All 664.8 649.2 854.4 801.9 5,333 7,124 Malignant Neoplasms 160.8 155.3 197.7 196.0 1,288 1,631 Heart Disease 130.4 143.4 217.3 203.8 1,085 1,645 Cerebrovascular Disease 32.6 44.3 62.1 63.4 266 512 Accidents 40.2 35.1 32.9 25.0 266 329 Chronic lower 32.9 30.2 52.1 38.7 267 329 respiratory disease Diabetes 16.8 16.5 17.9 16.7 137 177 Nephritis 11.9 13.6 18.2 17.3 99 152 Influenza and 10.3 10.7 20.1 15.2 87 116 pneumonia Septicemia 10.0 10.5 20.2 18.3 83 113 Suicide 11.9 10.0 8.9 9.9 79 88 Homicide - 2.0 - 3.5 9 15 HIV/AIDS - 1.4 - 2.8 3 12 Colorectal Cancer 13.7 13.9 23.1 19.1 109 146 Lung & Bronchus 40.0 38.2 47.4 50.7 320 394 Cancer Breast Cancer 13.5 12.2 17.3 15.7 109 128 Prostate Cancer 16.1 17.0 32.8 34.6 51 73

Non-Hispanic blacks have the highest mortality rates overall and for heart disease, septicemia, and cerebrovascular disease. Sample sizes for many other causes of death were too small.

Non-transport accidents and suicide is the major cause of death among 15 to 24 year olds, and both are the leading causes of death among the 25-44 and 45-64 age groups. Montgomery County ranks in the least favorable quartile in the Center for Disease Control's (CDC) CHSI comparison to peer counties for all age motor vehicle and unintentional (including motor vehicle) deaths.57

Top Causes of Death by Age Group

Age Group Top Causes of Death in Montgomery County, 2011

15-24 Non-transport accidents Motor vehicle accidents Intentional self-harm (suicide) Homicide Malignant neoplasms 25-44 Non-transport accidents Malignant neoplasms Intentional self-harm (suicide) Motor vehicle accidents Heart disease 45-64 Malignant neoplasms Heart disease Non-transport accidents Intentional self-harm (suicide) 65+ Heart disease Malignant neoplasms Mental and behavioral disorders Cerebrovascular disease Chronic lower respiratory diseases Alzheimer’s Disease Non-transport accidents Diabetes mellitus Influenza and pneumonia 2014 Montgomery County Health Department 2014 Annual Health Statistics Report

Although cancer mortality is below the Healthy People 2020 goal for most cancers, according to the CHSI comparison to peer counties, Bucks County is in the least favorable quartile for cancer morbidity and Montgomery County is in the least favorable quartile for cancer mortality.

In Bucks and Montgomery counties, lung and bronchus cancer mortality rates are lower than the Healthy People 2020 goal for lung cancer deaths. Note that this is not an "apples to apples" comparison.

Bronchus and Lung Cancer Age-Adjusted Death Rates per 100,000 Population Bucks Montgomery HP 2020 Goal = 45.5 48.3 43.0 41.9 41.7 40.0 38.2

2010 2011 2012

Pennsylvania Department of Health Epidemiologic Query and Mapping System

Breast cancer mortality rates were higher than the Healthy People 2020 goal.

Female Breast Cancer Age-Adjusted Death Rates per 100,000 Population Bucks Montgomery HP 2020 Goal = 20.7 25.4 23.4 24.5 24.3 24.4 21.7

2010 2011 2012 Pennsylvania Department of Health Epidemiologic Query and Mapping System

Male prostate cancer mortality rate was lower than the Healthy People 2020 goal.

Male Prostate Cancer Age-Adjusted Death Rates per 100,000 Population Bucks Montgomery HP 2020 Goal = 21.8

19.4 20 18.7 17.4 16.1 17

2010 2011 2012 Pennsylvania Department of Health Epidemiologic Query and Mapping System

In 2011 and 2012, the colorectal cancer mortality rates were lower than the Healthy People 2020 goal in both Bucks and Montgomery counties.

Colo-rectal Cancer Age-Adjusted Death Rates per 100,000 Population Bucks Montgomery HP 2020 Goal = 14.5 15.0 14.4 13.7 13.9 12.6 12.7

2010 2011 2012

Pennsylvania Department of Health Epidemiologic Query and Mapping System

Melanoma mortality rates were higher than the Healthy People 2020 goal in Bucks County in 2010 and 2011, but lower than the Healthy People 2020 target in both counties in 2012.

Melanomas of the Skin Cancer Age-Adjusted Death Rates per 100,000 Population Bucks Montgomery HP 2020 Goal = 2.4

2.9 2.7

1.9 1.8 1.8 1.4

2010 2011 2012

Pennsylvania Department of Health Epidemiologic Query and Mapping System

Deaths related to diabetes mellitus in Bucks and Montgomery counties compare favorably to the U.S. median mortality rate. This comparator is used instead of the Healthy People 2020 rate because Healthy People 2020 diabetes-related mortality data are derived from the multiple-cause-of-death files which include all mentions of diabetes on the death certificate and are approximately three times higher than if diabetes only as the underlying cause is counted.

Diabetes Mellitus Age-Adjusted Death Rates per 100,000 Population

Bucks Montgomery US Median = 24.7

16.5 16.8 16.5 13.9 12.3 13.4

2010 2011 2012

Pennsylvania Department of Health Epidemiologic Query and Mapping System

Heart disease mortality rates in both counties are lower than the Healthy People 2020 target.

Coronary Heart Disease Age-Adjusted Death Rates per 100,000 Population Bucks Montgomery HP 2020 Goal = 103.4

102.5 93.2 95.7 84.2 80.7 74.0

2010 2011 2012

Pennsylvania Department of Health Epidemiologic Query and Mapping System

The Healthy People 2020 goal for age-adjusted stroke mortality is 34.8. Mortality for the broader category of cerebrovascular diseases is displayed below, and was lower than the stroke mortality goal for Bucks and Montgomery counties is 2012. In Bucks County, the cerebrovascular mortality rate increased between 2010 and 2012. The Centers for Disease Control Summary Report ranks Montgomery County stroke deaths in the least favorable quartile when compared to peer counties.58

Cerebrovascular Diseases Age-Adjusted Death Rates per 100,000 Population Bucks Montgomery HP 2020 Stroke Goal = 34.8

44.3 39.9 39.3 39.1 32.6 35.8

2010 2011 2012

Pennsylvania Department of Health Epidemiologic Query and Mapping System

Recommendations included:

1) Raise awareness about disease prevention. 2) Raise awareness of "Know your Numbers" for individuals with pre-diabetes and type 2 diabetes who are more likely to have high blood cholesterol, high blood pressure, high blood sugar, and be overweight/obese. 3) Need more ongoing education for adults with diabetes. 4) Promote healthy lifestyles

Maternal and Child Health

Data for natality is derived from the Pennsylvania and County Health Profiles, 2014, 2015 www.countyhealthrankings.org and Healthy People 2020.

The general fertility rate in Bucks and Montgomery counties is 49.3 and 59.0 per 1,000 women ages 15-44 respectively.

Birth Rates per 1,000 Women Age 15-44

85.1 74.7 68.7 59.0 58.1 49.3 48.4 36.1 38.1 36.6

20.7 3.0 18.2 3.7 11.9

Bucks Montgomery PA 15-17 18-19 20-29 30+ All Ages

Pennsylvania and County Health Profiles, 2014 The teen birth rate in Bucks and Montgomery Counties is less than half that of Pennsylvania as a whole. Teen (age 15-19) Births per 1,000 Female

Population 28

12 13

Bucks Montgomery PA 2015 Data, County Health Rankings.org

The Montgomery County Health Department (MCHD) condom distribution program mostly works with colleges, businesses and community-based organizations. Typically, the school districts do not obtain condoms from MCHD or allow the department to provide them at events in the school environment. The school districts have periodically invited MCHD to conduct STD/HIV presentations for the purpose of disease education without distribution of prevention tools.

Some teens may be gaining access to condoms either by visiting MCHD sites and/or via patient interviews to STD positive individuals. If permitted, MCHD will mail condoms directly to the home at no cost to the patient/student. Other organizations such as Planned Parenthood distribute condoms.

The Healthy People 2020 target rate infant and neonatal mortality is 6.0 and 4.1 infant deaths per 1,000 live births respectively. Infant mortality in Bucks and Montgomery counties is below the Healthy People 2020 target. Infant mortality was higher among non-Hispanic blacks than non- Hispanic whites; sample sizes for non-Hispanic Asians and Hispanics were too small.

Infant Mortality per 1,000 Live Births

Healthy People 2020 Target =6.0 7.4

5.3 5.2

Bucks Montgomery PA

2015 Data, County Health Rankings.org

Major reasons for infant deaths were pre-term birth and low birth weight.59 Babies weighing less than 2,500 grams at the time of birth are considered to be low birth weight (LBW). Low birth weight represents two factors: maternal exposure to health risks and an infant’s current and future morbidity, as well as premature mortality risk. From the perspective of maternal health outcomes, LBW indicates maternal exposure to health risks in all categories of health factors, including her health behaviors, access to health care, the social and economic environment she inhabits, and environmental risks to which she is exposed. In terms of the infant’s health outcomes, LBW serves as a predictor of premature mortality and/or morbidity over the life course and for potential cognitive development problems. One maternal health behavior that negatively affects infant health is smoking. The percentage of pregnant women in Bucks and Montgomery counties who smoke is in the lowest quintile in Pennsylvania.

In Bucks and Montgomery Counties, the percentage of low birth weight babies was below the HP 2020 goal. The highest rate of low birth weight babies in Bucks County was among black women, with 11.9 % of babies with LBW, followed by Asian/Pacific Islanders at 10.8%. In Montgomery County, the racial/ethnic group with the highest rate of low birth weight in 2012 was black women; 14.8% of their babies were of low birth weight, followed by 6.5 among whites and Hispanics of all races.

%Low Birth Weight (<1500 grams) Babies

8.3 Healthy People 2020 Target =7.8

7.5 7.2

Bucks Montgomery PA

2015 Data, County Health Rankings.org

Preterm births are defined as births with less than 37 completed weeks of gestation. From 2010-2012, 9.3% and 8.1% of births in Bucks and Montgomery counties respectively were preterm. The Healthy People 2020 target for preterm birth is less than 11.4% of births will be preterm.60 Montgomery County is in the most favorable quartile for preterm births in the CDC CHSI comparison to peer counties.

The Healthy People 2020 target for initiation of prenatal care in the first trimester is 77.9%. Overall, Bucks and Montgomery counties exceed this goal, but there are significant racial/ethnic disparities. In Bucks and Montgomery counties, the highest percentages of no prenatal care in the first trimester in 2012 were among Hispanic women of any race (44.3 % and 49.2%) and among black women (45.1% and 41.3%).

% with First Trimester Prenatal Care

78.2 78.5 Healthy People 2020 Target =77.9%

72.4

Bucks Montgomery PA Pennsylvania and County Health Profiles, 2014

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to Maternal Child Health included:

 Access to OB services o "We have enough people and we have enough money, we need to figure out how to spend our money and get rid of old barriers." o Transportation issues impede access to care o There are a lot of under-utilized services. "We have all the puzzle pieces, but it is hard to put together." o Better follow-up and referral, improved continuity

 Mental and Physical Health o Drug abuse, especially heroin, results in more babies being detained after birth o Teen pregnancy is a concern o Diabetes and obesity among pregnant women is an issue

Recommendations:

1) Each Women and Children's services division should have navigators to assist patients with education, information and referral. Need to reeducate the frontline staff "to change the old mindsets if we are going to be successful." 2) Obstetricians direct patients to prenatal classes. 3) Physicians and all health professionals need to learn all the services offered by the organization.

Morbidity

Montgomery County ranks 6th and Bucks County 12th out of the 67 counties in Pennsylvania for overall health outcomes. Ten percent of adults in Montgomery and 11% in Bucks County rate their health as fair or poor compared to 14% in Pennsylvania and the Healthy People 2020 goal of 10%. Adults in Montgomery and Bucks counties were less likely to report poor physical health days (average number of physically unhealthy days reported in past 30 days - age-adjusted) than Pennsylvania residents (2.9 days and 2.7 days vs. 3.5 respectively) and fewer poor mental health days (average number of mentally unhealthy days reported in the past 30 days (3.1 days and 3.5 days vs. 3.6 days). The national benchmark for poor physical health days is 2.5 and 2.3 for poor mental health days (County Health Rankings 2013).

Adults in Abington-Lansdale's CB area who report fair or poor health range from a low in County Line (1.1%) to a high in Indian Valley (16.7%). In contrast, more than 70% of adults in Blue Bell rate their health as excellent or very good.

Self Reported Health Status 100%

80%

60%

40%

20%

0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont Fair/Poor 10.6 16.7 1.1 8.5 13.5 Good 22.1 26.8 36.2 20.0 25.1 Excellent/Very Good 67.3 56.4 62.6 71.5 61.5

PHMC Household Health Survey 2015

Parents in Greater North Penn are more likely to rate their children's health as fair or poor than Bucks/Mont (5.4% vs. 3.9%).

Childrens' Reported Health Status 100% 80%

60%

40%

20%

0% Greater North Penn Bucks/Mont Fair/Poor 5.4 3.9 Good 5.5 7.9 Excellent/Very Good 89.1 88.2

PHMC Household Health Survey 2015

More education and identification of resources for chronic disease management was identified by key informant interviews as an important community benefit issue:

Education regarding resources is lacking. Resources need to be out in the community and imbedded in more practices or clinics.

Asthma

Asthma rates for adults in Abington-Lansdale CB areas are lower than Bucks/Montgomery rate. However, the rates in all Abington-Lansdale CB areas exceed the rate in Pennsylvania (9.6%).61

% Ever Had Asthma 16.3 14.7 13.2 12.1 10.6

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Children in Abington-Lansdale's CB areas are less likely to have asthma compared to Bucks/Mont (15.2%) and more likely compared to Pennsylvania (13.7%).62 A key informant said that asthma rates among youth have risen, and noted that pollution and lack of tree lined streets contribute to this increase. The informant referred to a 2008 report in Journal of Epidemiology and Community Health that found that children who lived on tree lined streets had lower rates of asthma and fewer

hospitalizations. Asthma is a major reason for absenteeism and truancy among school-aged children (note areas are consolidated due to sampling size).

% Children Ever Had Asthma

15.2

14.7

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

Healthy People 2020 objectives for people with asthma focus on reducing asthma mortality, reducing asthma hospitalizations and increasing the proportion of persons with asthma who receive formal patient education.

Recommendations included:

1) Utilize the Asthma Link Line, a free community-based telephone center that integrates a wide range of services for families of children with asthma. The program helps coordinate medical appointments, asthma education and other services for families affected by asthma. Child Asthma Link Line also helps uninsured families obtain health insurance.

Cardiovascular Disease, Stroke, and Diabetes

Heart disease, stroke and diabetes are among the top seven causes of mortality in Pennsylvania.63 Obesity and hypertension are underlying chronic diseases that increase risk of heart attack, stroke, and complications of diabetes. The goal of Healthy People 2020 for heart disease and stroke is to improve cardiovascular health and quality of life through prevention, detection and treatment of risk factors for heart attack and stroke; early identification and treatment of heart attacks and strokes; and prevention of repeat cardiovascular events. Similarly, the Healthy People 2020 goal for diabetes is to reduce the disease and economic burden and improve the quality of life for all persons who have, or are at risk for, diabetes.

Diabetes

In Pennsylvania, the crude rate of adult diagnosed diabetes in 2013 was 10.1%.64 The percentage of adults with diabetes has risen in Bucks and Montgomery counties since 2004 from 7.2% and 6.3% to 7.8% and 7.3% respectively in 2012.65 This represents approximately 88,000 adults who have been told they have diabetes. Nationally, rates of diagnosed diabetes are higher among non-Hispanic Blacks (13.2%), Hispanics (12.8%) and Asians (9.0%) than non-Hispanic whites (7.6%).66 New federal statistics indicate that fewer cases of diabetes are being diagnosed in the United States: the number of new cases dropped from 1.7 million in 2009 to 1.4 million in 2014.67 In Bucks/Mont, 11.2% of survey respondents report that they have been told they have diabetes. Diabetes rates are highest in Indian Valley and lowest in County Line. The CDC's CHSI methodology ranks adult diabetes morbidity in Montgomery County in the most favorable quartile compared to peer counties.

% Ever Had Diabetes 11.2

9.9 9.2

7.1

3.1

North Penn Indian Valley County Line Blue Bell Bucks/ Mont PHMC Household Health Survey 2015

Compounding the higher rates of diabetes among blacks, African Americans in Southeastern Pennsylvania are three times more likely than whites to have lower extremity amputations. Save Your Soles is a grassroots program focused on eliminating this disparity. Working with community churches and other groups, Save Your Soles teaches the importance of keeping blood sugar under control, taking medications as prescribed, eating healthy foods, and getting regular exercise. Abington podiatrist Dr. Ronald Renzi is publishing research about this topic.68

The increase in the prevalence of diabetes is a result of the obesity epidemic, the causes of which are complex and include food insecurity, poverty, and decreased exercise. Only one third of adults in Bucks/Mont who have diabetes say they exercise 3 or more times weekly compared to one half without diabetes who do exercise regularly.

Diabetes education was identified as a priority by multiple key informants. At Abington Diabetes Center, education is successful. In 2014, 28% of patients had an A1C level less than 7 (target value) prior to entering the program. Post program, 67% of patients had an A1C level less than 7, a rate better than the Healthy People 2020 goal of 58.9%. Other achievements are:

100% coping 98% achieved foot exam goal 94% medications 87% achieved at least a 1% decrease if their pre-program A1C was at least 8% 87% healthy eating 87% monitoring 72% risk reduction 71% exercise 68% complications

Healthy People 2020 objectives for people with diabetes include:  Increasing the proportion of persons at high risk for diabetes with pre-diabetes who report trying to lose weight to 55%  Increasing the proportion of persons at high risk for diabetes with pre-diabetes who report increasing their levels of physical activity to 49.1%  Increasing the proportion of persons with diabetes who receive formal diabetes education to 62.5%

 Increasing the proportion of adults with diabetes who perform self-blood glucose monitoring at least once daily to 70.4%

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to diabetes included:

 Insurance/Cost o Un or underinsured are not able to access care in a timely fashion o The cost of insulin and co-pays/deductibles are barriers to care o Resources for the uninsured and underinsured are lacking  Language barriers impede effective education and management in non-English speakers (key informant, Korean community)  Knowledge o Lifestyle education is needed o Diabetes Center of AJH is resource

Recommendations included:

1) Expand care management into non-owned practices 2) Expand geriatric assessment to all chronic diseases 3) Focus on patients in the middle A1c area between 8-9 4) Work with Department of Nursing to expand diabetes education champions for inpatients 5) Enhance diabetes education for the Korean community

Hypertension

Hypertension rates in Pennsylvania (31.4%) are above the national rate for (28.7%) and well above the Healthy People 2020 goal of 26.9%. Forty-one percent of those living below 200% FPL have hypertension compared to 28% for wealthier people. Rates are highest among non-Latino blacks (33.4%) and non-Latino whites (30.8%). Hypertension increases with age: almost 52% of all older adults (aged 60+) in Bucks/Mont have or had hypertension (see older adult section). Three of Abington-Lansdale's CB areas meet or exceed the Healthy People 2020 goal; however, rate in Indian Valley is higher.

% Doctor Ever Told have High BP Healthy People 2020 Maximum Target = 26.9% 32.9 30.1 26.5 22.2 22.7

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

The majority of Abington-Lansdale CB area residents with high blood pressure take medication; the percentage in all regions exceeds the Healthy People 2020 goal of 69.5%.

% Currently Taking Medication for High Blood Pressure Healthy People 2020 Target = 69.5%

98.8 100.0 89.5 80.0 85.1

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Of those taking medication for high blood pressure, most report taking the medication at least 90% of the time. One fifth of County Line residents with hypertension say they take the medicine less than 90% of the time, and one fifth of Blue Bell residents with high blood pressure report taking their medicine nearly all the time.

Although people may understand the link between high blood pressure and medical management, they do not always change their behaviors to benefit their health. Although respondents in County Line and Blue reported the lowest level of high blood pressure (22-23%), they are the least compliant with taking blood pressure medicine. The complicated interactions between beliefs and behaviors supports the need to educate and halt the increase in stroke mortality recently experienced in Bucks County and the comparatively higher stroke mortality in Montgomery County.

% Taking High BP Medications as Prescribed 100% 80% 60% 40% 20%

0% Indian Bucks/ North Penn County Line Blue Bell Valley Mont Less than 90% of the time 0.2 0.0 20.6 0.0 4.1

Nearly all of the time (90%) 6.2 14.0 6.7 27.9 5.9 All the time (100%) 93.6 86.0 72.8 72.1 89.9

PHMC Household Health Survey 2015

In numerous epidemiologic, clinical, and experimental studies, dietary sodium intake has been linked to blood pressure, and a reduction in dietary salt intake has been documented to lower blood pressure. In young people, blood pressure remains elevated even after a high salt intake is reduced. Older adults, African Americans, and obese individuals are more sensitive to the blood pressure-lowering effects of a decreased salt intake. High salt intake elevates risk of stroke and other conditions.69 In Abington-Lansdale CB areas, those reporting watching or reducing their salt intake varies, with almost two thirds in Indian Valley and County Line reporting they are at least aware of their salt intake compared to less than 45% or less in North Penn.

% Currently Watching or Reducing Salt Intake

64.5 66.2 59.1 51.0 44.8

North Penn Indian Valley County Line Blue Bell Bucks/ Mont PHMC Household Health Survey 2015

The definition of "too much salt" is left to respondent interpretation. Regardless, views on too much salt vary across Abington-Lansdale CB areas. Ninety-six percent of residents of County Line, the Abington CB area with the lowest rate of high blood pressure (22.2%), think that too much salt is very or somewhat harmful to health. In Indian Valley, the area with the highest rate of high blood pressure, 84% consider too much salt to be very or somewhat harmful to health.

% Who Think Too Much Salt is Harmful to Health 100% 90% 80% Very 70% harmful 60% Somewhat 50% harmful 40% A little 30% harmful 20% Not at all 10% harmful 0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Across Bucks/Mont, more than one quarter of residents do not think too much salt affects risk of stroke, while more than one in five in North Penn and Indian Valley have the same view.

% Who Think Too Much Salt Affects Risk of Stroke

45.7 35.8 55.4 36.4 37.1

42.5 50.3 35.9 32.7 39.3

27.0 21.6 21.7 5.3 13.2 North Penn Indian Valley County Line Blue Bell Bucks/ Mont Not at all/ A little Some A lot

PHMC Household Health Survey 2015

Perhaps the higher percentages of County Line and Blue Bell respondents who report always/often buying reduced salt products affect the relatively low presence of high blood pressure (22-23%) in these communities.

% Buying Items Labeled "Low Salt' or 'Low Sodium'

50.5 41.5

35.7 36.4 29.7

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Healthy People 2020 objectives related to hypertension include:  Reduce the proportion of adults with hypertension to 26.9%  Increase the proportion of adults aged 20 and older who are aware of the early warning symptoms and signs of a heart attack to 59.3%  Increase the proportion of adults who have had their blood pressure measured within the past two years and can state whether their blood pressure is high or normal to 92.6%  Increase the proportion of adults with hypertension who are taking the prescribed medications to lower their blood pressure to 69.5%

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to cardiovascular disease included:

 Awareness o Need cardiac education including information on healthy lifestyles and low sodium diets o The Korean community needs education on hypertension; language is a barrier o Cardiac disease in women needs attention, as does peripheral artery disease  Access to healthy (low sodium) is more costly

Recommendations included:

1) Raise awareness about signs and symptoms of heart attack and stroke 2) Increase access to chronic disease management programs 3) Work with the Korean community to improve prevention, education, and care 4) AJH could provide free programming, health fairs, blood pressure screenings 5) Increase community education and involvement in support groups and the Heart Walk. 6) Children's education - focus on hands only CPR 7) Use different approaches for different people: Better messaging needed for "Know Your Numbers" 8) Open ACLS and PALS training to the community

Obesity and Nutrition Education

In the United States, almost 35% of adults are obese, and in Pennsylvania, the self reported obesity rate in 2014 was 30.2%.70 Diet and body weight have been shown to be related to overweight/ obesity, malnutrition, iron deficiency anemia, heart disease, high blood pressure, dyslipidemia, Type 2 diabetes, osteoporosis, asthma, and some cancers. Increases in obesity related diseases are projected to be significant.71

Obesity Related Diseases in Pennsylvania 2010 Cases 2030 Projection %Change

Heart disease 892,129 3,964,312 344% Obesity related cancers 227,588 553,041 143% Diabetes 1,135,646 1,731,248 52% Hypertension 2,752,209 3,483,650 27%

The obesity rate in all Abington-Lansdale CB areas is below the Healthy People 2020 goal of 30.5%. The rate of overweight adults ranges from 18.8% in County Line to 39.7% in North Penn. People in Bucks/Mont with incomes above 200% FPL are less likely to be obese compared to those below this level (26.8% vs. 32.8%). Disparities in obesity exist with Latinos most likely to be obese compared to non-Latino whites, blacks, and Asians (32.6%, 28.3%, 28.6%, and 6.4% respectively). Overall, more than 318,000 adults in Bucks/Mont are obese and 398,000 are overweight.

Obesity Level: % 70 60 50 40 % 30 20 10 0 North Penn Indian Valley County Line Blue Bell Bucks/ Mont Overweight 39.7 37.4 18.8 34.4 34.8 Obese 26.0 26.2 18.4 13.7 27.8 HP 2020 Target 30.5 30.5 30.5 30.5 30.5

PHMC Household Health Survey 2015

At 13.7%, the obesity rate for youth in the Abington-Lansdale CB areas is slightly below the Healthy People goal of less than 14.5%.

Child BMI for Age Percentile Category 100%

80%

60%

40%

20%

0% Greater North Penn Bucks/Mont obese: 95-110 %ile overweight: 85-94 %ile Normal: 5-84 %ile Underweight: 0-4 %ile Healthy People 2020 Target: < 14.5% obese children and adolescents PHMC Household Health Survey 2015

Breastfeeding has been shown to be associated with lower obesity rates in children. For the period 2010 - 2012, 77.4% of mothers in Bucks County and 85.8% in Montgomery County reported breastfeeding their infants, compared to 71.3% in Pennsylvania. The Healthy People 2020 breastfeeding goal is 81.9%.72

The Healthy People 2020 objectives related to obesity and nutrition education include:

 Increase the proportion of worksites that offer nutrition or weight management classes or counseling  Increase the proportion of adults who are at a healthy weight to 33.9%  Reduce the proportion of adults who are obese to 30.5%  Reduce the proportion of children and adolescents who are considered obese to 14.5%  Increase the proportion of physician office visits made by adult patients who are obese that include counseling or education related to weight reduction, nutrition or physical activity to 31.8%

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to obesity included:

o Increase awareness o There are a lack of resources for obesity o Co-morbidities are related to BMI o Obesity among pregnant women, African Americans, and other minorities o Increase physical activity o Sedentary lifestyles are problematic o People need to take time out of their day for physical activity. Exercise or walk at work o Promote lifestyle coach programs and train more coaches

o Employers are providing time, support and expertise at workplace for exercise and stress reduction o Physical activity opportunities at the boys and girls club near Abington-Lansdale Hospital have decreased o Improve access to healthy, affordable food o The need for affordable healthy grocers/markets was identified o Raise community awareness that eating well is more costly o More publicity of AJH's nutrition center o Improve access to weight management programs o People are accessing their insurance for weight management/visits; more education is needed with an emphasis on lifestyle behaviors o Some medications cause weight gain

Recommendations included:

1) Install an exercise wall in the lobby of the children's clinic at Abington-Lansdale Hospital

Mental Health

Mental and physical healthcare are inter-related. Mental health plays a major role in people’s ability to maintain good physical health. However, mental illness, such as depression and anxiety, can limit the ability to integrate health-promoting behaviors into one’s life. Conversely, physical health issues, such as chronic disease, can have a serious impact on mental health and may inhibit full participation in treatment and recovery.

Just under 15% of all adults in Bucks/Mont have been diagnosed with a mental health condition. People living below 200% FPL are much more likely to have a mental health condition (22.9%) compared to those who live above 200% of the federal poverty level (13.2%). Diagnosed mental health conditions vary greatly by race/ethnicity, perhaps due to cultural perceptions regarding recognition and acceptance of mental disorders. Non-Latino whites were most often diagnosed (15.6%), compared to 12.9% of non-Latino blacks, 11.3% of Latinos, and 4.9% of non-Latino Asians.

Residents living in Indian Valley and County Line report the highest rates of people diagnosed with a mental health condition, while in Blue Bell just 6.3% report such conditions.

%With Diagnosed Mental Health Condition 16.9 15.1 14.9

11.0

6.3

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Almost four in ten of those with a mental health diagnosis in Bucks/Mont report they are not receiving treatment for their condition. Among Abington-Lansdale CB areas, the percentage not receiving treatment varies greatly, with more than half not receiving treatment in North Penn and almost 40% not receiving care in County Line, compared to 3.3% in Blue Bell.

% Not Currently Receiving Treatment for a Mental

Health Condition 54.0

39.3 37.6

3.3 11.3

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Mental Health issues for Older Adults are discussed in the Special Population section.

Healthy People 2020 objectives related to mental health include:

 Increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral to 87%  Increase the proportion of adults with serious mental disorders who receive treatment to 72.3%  Increase the proportion of adults aged 18 years and older with major depressive episodes (MDEs) who receive treatment to 75.9%  Increase the proportion of primary care physicians who screen adults aged 19 years and older for depression during office visits to 2.4%

 Reduce the suicide rate to the Healthy People goal of 10.2 per 100,000 population. The Pennsylvania rate for 2015 was 13.6,73 Bucks was 11.4 and Montgomery was 10.1 and rising.74

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to mental health included:

 Training o Mental health diagnoses in the community, including among pregnant women, are often missed  Cultural issues o " There is still a stigma about seeking help" o Jaisohn is spending more resources and manpower for the Korean community but it is not enough  Access o No psychologist or psychiatrist is in-house at Abington-Lansdale Hospital o From the Abington-Lansdale ER, it can take up to 36 hours for a 302 placement at Horsham Clinic or Norristown Building 50 o Have to use remote tele-health at Abington-Lansdale Hospital for patients in crisis o Lack of staff psychiatrist at Abington-Lansdale Hospital to prescribe needed medications to children for such conditions as ADHD or depression can result in the child losing CHIP coverage. When a child accesses behavioral health more than one visit per month, that child needs to go onto Medical Assistance. o Shortage of affordable and available psychologists and counselors  Stress and work life balance o Constant job worries, more hours expected, more pressures. Mental health issues relate to other conditions including obesity issue and diabetic crisis

Recommendations included:

1) Hire a staff psychiatrist and in-house behavioral health specialists to a implement psych program on site at Abington-Lansdale Hospital

HIV Status

The prevalence rate of HIV in Bucks and Montgomery counties is 133 and 140 per 100,000 population, compared to 292 for Pennsylvania (as reported by countyhealthrankings.org). This equates to 1,637 individuals living with diagnosed HIV in Bucks/Mont. According to the CDC CHSI, AIDS morbidity in Montgomery County is in the most favorable quartile compared to peer counties. In Southeastern Pennsylvania, 71% of people living with HIV at the end of 2014 were male. Sixty percent of these people were Black compared to 23% White and 13% Hispanic. According to Pennsylvania statewide data for 2001-2014, the most common mode of transmission is heterosexual transmission (38%) followed by men who have sex with men (MSM) (35%), and injection drug use (IDU) (16%). HIV is much more likely to be transmitted by MSM among Whites

compared to Blacks (52% vs. 29%) and among Blacks, heterosexual transmission is twice as common compared to Whites (46% vs. 23%).75

According to PHMC Household Health Survey 2015 data, residents living in half of Abington- Lansdale CB areas are less likely to have been tested for HIV than in Pennsylvania statewide (37% ages 18-64 were tested)76; all testing rates are well below the Healthy People 2020 goal. Testing rates exceed the state rate only in Blue Bell.

Montgomery County's Health Department HIV/STD program offers free confidential testing for sexually transmitted infections including the OraQuick Advance Method for rapid HIV testing at its clinics and provides condoms and prevention materials at its clinics and by mail to Montgomery County residents.77 Bucks County Department of Health also offers free confidential or anonymous HIV testing.

% Ever Tested for HIV

Healthy People 2020 Target = 73.6%

60.7

37.7 37.9 32.3 22.6

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Hospital Readmissions

The Centers for Medicare & Medicaid Services (CMS) defines readmission as an admission to a hospital within 30 days of a discharge from the same or another hospital. Readmissions are prevalent and expensive. Avoidable complications and readmissions due to inadequate care coordination and poor management of care transitions were responsible for $25 to $45 billion in wasteful spending in 2011. As of October 2012, the Affordable Care Act requires CMS to decrease Medicare payments to hospitals for excess readmissions, providing the policy lever that induces hospitals to act quickly to reduce readmissions. Thousands of hospitals have already faced penalties for high readmissions for pneumonia, heart failure and heart attack.

Nationally, and in Pennsylvania, the re-hospitalization rate among Medicare beneficiaries within 30 days is 20%, and 50% of the patients readmitted within 30 days were not seen by an outpatient provider prior to readmission.78 These re-hospitalizations are costly and, for the most part, preventable through timely and effective outpatient care and adequate patient disease self- management practices. The Pennsylvania Health Care Cost Containment Council published a report

on re-admissions within 30 days for adult patients who were discharged January 2013 through August 2014 and were initially admitted with any of these 4 conditions: abnormal heartbeat; chronic obstructive pulmonary disease (COPD); congestive heart failure (CHF); and medical management of diabetes. Abington-Lansdale Hospital's 30 day same condition readmission rates were not statistically different than expected for each of these conditions, and readmission rates for residents of Montgomery County were close to the state average for 3 of the four conditions. Montgomery County residents fared better than the state average in terms of readmissions for medical management of diabetes, and Bucks County residents had better than average readmission rates for CHF and diabetes medical management.79

30 Day % Readmitted for Same Condition PA Bucks Montgomery Abnormal heartbeat 3.6 3.7 3.7 COPD 7.7 7.9 7.9 CHF 7.7 6.5 7.5 Diabetes Medical Management 8.4 6.1 7.6

In FY 2015, the 30 day overall readmission rate at Abington-Lansdale was 11%. As previously stated, health literacy is one factor related to readmission to the hospital within 30 days of discharge.

Abington-Lansdale Overall 30 Day

Readmission Rate 10.80%

9.99%

9.24%

FY 2013 FY 2014 FY 2015

Abington-Lansdale internal data

AJH's 3R's program, Reducing Readmissions Remotely, shows promise for reducing readmissions. AJH developed preferred relationships with 6 local skilled nursing facilities (SNF) with the goal of reducing costs while maintaining and improving the quality of care for stroke, heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, coronary artery bypass graft, pneumonia, and orthopedic patients. Remote pharmacists reconcile medication discrepancies for omissions, wrong medication strength, dose, and frequency during transitions of care from the acute hospital to the SNF. Although a statistical analysis was not performed, the readmission rate at the end of the initial period had decreased.

While most patients could benefit from improved discharge planning and care coordination and management, non-English speaking patients, homeless/sheltered patients, the elderly and those with both mental illness and chronic diseases may be most likely to benefit.

An important subset of readmissions due to chronic illness affects a particularly vulnerable population struggling with complex medical and psychosocial challenges and may be addressed by improved discharge planning, care coordination, and care management. Care coordination and care management can include components such as patient navigators, care or case managers, community health workers, nurses, social workers, and coaches for target patient groups. Models include design of individualized plans with and for patients in the context of the patients’ assets (social support, existing relationships with providers, etc.). These plans must be dynamic, and the process of care coordination includes feedback loops to respond in an ongoing way to the changing needs of the patient. Coordination can be performed by a person or team with three primary responsibilities: value proposition, service design, and service delivery, requiring skill sets of social workers, nurses, and community health workers, depending on the primary needs of the individual patient.

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to hospital readmissions included:

 Post acute system of care has not kept pace with need  Need more home visits post discharge

Preventive Care and Early Detection of Disease

People who have a regular health care provider are more likely to have better health outcomes. Having a regular source of care can help to reduce health disparities and costs and increase preventive health screenings. This is key to detecting signs/symptoms that are precursors to disease and to detecting disease earlier when it is often more treatable.

With the exception of County Line, residents in Abington-Lansdale CB areas and Bucks/Mont do not meet the Healthy People 2020 target for having a specific source for ongoing care.

% With Regular Source of Care

Healthy People 2020 Target for all ages with a specific source for ongoing care = 95%

98.7 92.4 87.4 88.7 81.2

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

The majority of residents receive their care in a private physician's office. Indian Valley residents receive their regular care somewhat differently than residents in other Abington-Lansdale CB areas: 87.6% are seen in a private doctor's office, 7.2% in a hospital clinic, and 4.6% in a community health center or public clinic.

Regular Source of Care Other place 100%

Hospital 95% emergency room

90% Hospital outpatient clinic

85% Community Health Center or public clinic 80% Private doctor's North Penn Indian Valley County Line Blue Bell Bucks/ Mont office

PHMC Household Health Survey 2015

The majority of residents in Abington-Lansdale CB areas have visited a health care provider at least once in the past year. However, approximately 1 in 7 who live in North Penn or Indian Valley did not visit a health care provider during the past year. Lack of physician counseling and referral is known to negatively impact preventive screen rates. More County Line and Blue Bell residents visited providers at least 3 times over the last year.

# of Visits to Health Care Provider in Past Year 100% 80% 60% 40% 20% 0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont 3 or more 36.6 34.3 46.2 45.0 43.9 1 to 2 49.2 50.1 52.3 46.9 42.8 No visits 14.3 15.5 1.5 8.1 13.3

PHMC Household Health Survey 2015

Almost all children in Abington-Lansdale's CB areas have a regular source of care and nearly meet the Healthy People 2020 goal of 100% children age 0-17 have a specific source of ongoing care.

% Children With Regular Source of Care

Healthy People 2020 Target for a specfic source of ongoing care = 100% for children aged 0-17 98.3

96.6

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Ninety-seven percent of children in Abington-Lansdale's CB areas receive care at private doctor's offices.

Childrens' Source of Care 100%

95%

90% Greater North Penn Bucks/Mont Other place Hospital emergency room Hospital outpatient clinic Community health center or public clinic Private Doctor's Office

PHMC Household Health Survey 2015

Residents in North Penn reported the lowest use of emergency departments. People living in this area also visited their regular source of care less often than residents of most other regions.

# of Visits to ER in Past Year 100% 80% 60% 40% 20% 0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont 2 or more 7.2 11.4 8.0 4.1 8.9 1 13.6 13.2 17.9 24.3 16.2 0 79.2 75.3 74.1 71.6 74.9

PHMC Household Health Survey 2015

According to FY 2015 data for Abington-Lansdale Hospital, there were 26,961 emergency room visits. Overall, 33% of these visits were rated a 4 or 5 on the ESI acuity scale that is used in the emergency department.80 Acuity scores of 4 or 5 are considered non-emergent or ambulatory care sensitive conditions and preventable through primary care. Eighty seven percent of all emergency care visits with an acuity scale of 4 or 5 were from Abington-Lansdale's primary service area. The majority of these visits were for complaints related to ankle, leg, shoulder joint pain (17%), general symptoms related to open wounds (14%), limb swelling and other soft tissue disorders (13%), back disorders (7%), general symptoms related to the head and neck (headaches, sore throat, jaw pain, etc.) (6%), respiratory symptoms (4%), and skin disorders (rashes, swelling, etc.) (3%). These chief complaints account for 64% of all ED visits with acuity scores of 4 or 5. More than one third of ED visits for conditions with acuity scores of 4 or 5 were among 18 to 44 year olds, and almost a quarter of visits were for children up to age 17 and another quarter for adults aged 45-64.

Lack of health insurance and low socio-economic status are factors most related to disparities in cancer incidence and death. The Healthy People 2020 objectives for cancer reflect the importance of promoting evidence-based screening for cervical (PAP), breast cancer (mammography), and colorectal (fecal occult blood testing, sigmoidoscopy, or colonoscopy). These objectives are to:

 Increase the proportion of women aged 21-65 who receive a cervical cancer screening based on the most recent guidelines to 93%  Increase the proportion of women aged 50-74 who receive a breast cancer screening based on the most recent guidelines to 81.1%  Increase the proportion of adults aged 50-75 who receive a colorectal cancer screening based on the most recent guidelines to 70.5%

The percentage of women in Bucks/Mont and in Abington-Lansdale's CB area who were screened for cervical cancer with a PAP test in the past 3 years was well below the Healthy People 2020 goal of 93%. According to the CDC CHSI methodology, Bucks County ranks in the least favorable quartile compared to peer counties for PAP tests. Women living in Indian Valley were least likely to have been screened for cervical cancer and women in North Penn were most likely to have been screened. Non-Latina blacks report the highest rate of PAP test in the past 3 years (89.8%), followed by Latinas (85.6%), non-Latina Asians (79.3%) and non-Latina whites (75.3%). Efforts to reach non-Latina blacks are most successful and need to be expanded to women of other races and ethnicity.

% Having Pap Test within 3 Years Healthy People 2020 Target = 93%

84.1 76.8 76.3 71.4 72.6

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Breast cancer is the second most common type of cancer (skin cancer is more common) for women in the United States81 and in Pennsylvania and Montgomery County, accounts for the second highest 82,83 number of cancer deaths behind lung cancer.

Women in Blue Bell and North Penn were less likely than women in Bucks/Mont to have had a breast exam in the past year. However, the majority (87%) of North Penn residents report having a mammogram within the past 2 years.

% No Breast Exam by Health Care Professional

Within the Past Year 55.4

38.7 35.0 28.4 22.4

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

The Healthy People 2020 goal for women aged 50-74 who had a mammogram based on the most recent guidelines is 81.1%. Women in most Abington-Lansdale CB areas are close to or exceed this goal. Fewer women living below 200% federal poverty level had mammography screening within the past two years (56.5%) than non-poor women (81.5%). Interestingly, white non-Latina women were less likely to have had a mammogram in the past two years (75.3%) compared to non-Latina black women (98.4%) and Latinas (84.9%). Non-Latina Asian women were least likely to have had a mammogram in the past two years (72.9%). This speaks well for breast screening efforts to reach some minority women, but highlights a need to ensure white and Asian women also reach the screening goals.

Time Since Last Mammogram 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont

one year or less > 1 year, up to 2 years > 2 years Healthy People 2020 Goal = increase % of women aged 50-74 years who had a mammogram based on the most recent guidelines to 81.1% PHMC Household Health Survey 2015

Although the breast and cervical cancer burden index for Bucks and Montgomery counties is elevated, Bucks County has no Healthy Women Program providers.84 Abington-Lansdale participates in Pennsylvania’s Healthy Woman Program for breast screening services and can treat patients enrolled in Pennsylvania’s Breast Cancer and Cervical Cancer Prevention and Treatment

Program. These programs assist un- and underinsured women with low incomes to obtain cervical and breast cancer screening and assist women in getting treatment if they are diagnosed with cancer.

The Healthy People 2020 target for colon cancer screening is for 70.5% of people aged 50-75 to meet the most recent screening guidelines. Twenty two percent of adults aged 60+ in Greater North Penn and Bucks/Mont have never had or not had a colonoscopy/sigmoidoscopy in more than 10 years. Bucks/Mont residents living below 200% FPL were more likely not to have had colon cancer screening in more than 10 years compared to those living above this level of poverty (36.8% vs. 18.7%). Only 6.7% of non-Latino blacks say they have not had a colonscopy/ sigmoidoscopy in the past 10 years. Non-Latino whites (23.3%), non-Latino Asians (29.8%), and Latinos (38.2%) report higher rates of never had or greater than 10 years since last colonscopy/sigmoidoscopy.

% Age 60+ Never Had or > 11 Years Since Last Sigmoidoscopy/Colonscopy 22.3 22.3

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to preventive health screening included:

 Cancer o Although most are insured, the cost of cancer care including medications and co-pays creates financial stress and the need for financial assistance o Many cancer patients need assistance at home, including child care for dependent children, in-home care for seniors living alone, and family support o Special diet and diet teaching is lacking o Substance abuse can be rampant due to lack of hope o Denial of outcomes by both patients and physicians lead to underuse of hospice o Need to raise awareness about the cultural and language barriers that impede compliance with protocols and some aspects of care o Cancer prevention, education, and insurance issues are a concern in the Korean community

Recommendations included:

1) More options for affordable in home personal assistance 2) Availability of and access to dietitians 3) Education and sufficient, competent interpreters for patients with cultural and language barriers 4) Better education for providers, patients, and families to prepare for end of life

Dental Care

More than one quarter (27%) of Bucks/Mont residents did not see a dentist in the past year. Between 1 and 18% have not seen a dentist in more than 2 years. People living below 200% of the poverty level were less likely to have seen a dentist in the past year (51.7%) compared to those above this poverty level (76.6%) and non-Latino blacks, non-Latino Asians, and Latinos were more likely than non-Latino whites to not have seen a dentist (29.6%, 38.5%, 27.4% and 26.8% respectively).

Time Since Last Dentist Visit 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont one year or less More than one year, up to 2 years > 2 years Healthy People 2020 Goal - increase the proportion of children and adults who use the oral health care system each year by 10% PHMC Household Health Survey 2015

Children were more likely to have seen a dentist in the past year than adults, although approximately 1 in 7 in Bucks/Mont did not. Almost 90% of children living in Greater North Penn had a dental visit in the past year.

%Children without a Dental Examination in

the Past Year

15.3 11.9

Greater North Penn Bucks/Mont Healthy People 2020 Goal - increase the proportion of children and

adults who use the oral health care system each year by 10% PHMC Household Health Survey 2015

Cost was a barrier to receiving dental care for 2% of Greater North Penn children.

%Children Not Receiving Dental Care due to Cost

4.2

2.2

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

AJH supports two dental clinics. Comprehensive dental services are provided by resident dentists with oversight from attending dentists on the Abington Hospital campus. The AJH Dental Care Access Program is designed to provide basic dental services to underinsured and uninsured residents of the greater North Penn community through a network of participating local dentist members of the Montgomery-Bucks Dental Society. Information about these services is available in English, Spanish, and Korean.

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to dental care included:

 Children in need of advanced dental care have to travel to CHOP or Abington Hospital, which then presents transportation issues.  There is a lack of affordable advanced dental care  There are not enough dentists registered in Abington-Lansdale CB areas for the dental access program  Community members are in need of more extensive dental work. Volume exceeds capacity.

Health Behaviors

The figure below depicts the leading reported causes and actual causes of death in the United States at the turn of the century - tobacco, poor diet and lack of physical activity, and alcohol. Counseling for these health behaviors and policy changes to create a healthier environment and improved access to healthy affordable food are keys to improving health in the United States and Bucks/Mont. Community-level initiatives such as tobacco-free restaurants and campuses, pedestrian-friendly cities, and increasing access to nutritious food sources play a critical role in changing health-related behaviors.

The following describes the current health behaviors of adults and youth in Abington-Lansdale CB areas and Bucks/Mont.

Smoking

Tobacco use is the single most preventable cause of death and disease in the United States. Tobacco use costs the U.S. $300 billion annually in direct medical expenses and lost productivity.85 Close to 13% of Bucks/Mont residents smoke – a percentage just above the Healthy People 2020 target of 12%. Nearly 22% of those living below 200% FPL smoke compared to 11% of those living above 200% FPL. In Bucks/Mont, smoking rates are higher among non-Latino blacks (12.7%) and non- Latino whites (13.4%) than Hispanics (9.6%). The percentage of adults living in all Abington- Lansdale CB areas who smoke is lower than the HP 2020 target. Adult smoking in Montgomery County is rated in the least favorable quartile by the CDC CHSI methodology when compared to peer counties.

% Who Smoke Healthy People 2020 Target = 12% 12.6

7.1 7.5 7.5

1.5

North Penn Indian Valley County Line Blue Bell Bucks/ Mont PHMC Household Health Survey 2015

Fifty-five percent of smokers in Bucks/Mont attempted to quit smoking in the past year, a rate much lower than the Healthy People 2020 target. Fewer than half the smokers North Penn and Indian Valley tried to quit smoking.c

% Who Tried to Quit Smoking in Past Year 82.0 Healthy People 2020 Target = 80%

55.1 48.7 40.8

0.0

North Penn Indian Valley County Line Blue Bell Bucks/ Mont PHMC Household Health Survey 2015

Methods used to try to quit smoking vary across Abington-Lansdale CB areas. Counseling was mentioned by a minority of smokers. Free smoking cessation resources are available at the state (PA QUIT Line and FAX to QUIT programs). Abington-Lansdale Hospital is a member of the Coalition for a Tobacco-Free Montgomery County, a group of concerned individuals from businesses, organizations, health care and public health groups and the community working to reduce tobacco use and exposure to tobacco smoke pollution. The Bucks County Health Improvement Partnership (BCHIP) coordinates free smoking cessation programs on a rotating basis at many locations throughout Bucks County including the six hospitals, parks and recreation departments, and local churches.

c The small number of smoker respondents reduces the reliability of this data.

Newer JCAHO standards require identifying smoking status of patients and helping them develop a plan to quit.

% Smoking e-cigarettes/Frequency of Use in the Past 8.0 7.0 Month 6.0 5.0 4.0 3.0 2.0 1.0 0.0 North Penn Indian Valley County Line Blue Bell Bucks/ Mont

Once/ a few times At least once per week Daily

PHMC Household Health Survey 2015

Fewer than 8% of Bucks/Mont residents report smoking e-cigarettes, and less than 2% smoke e- cigarettes daily.

Healthy People 2020 objectives related to smoking cessation include:

 Reduce cigarette smoking by adults to 12%  Increase smoking cessation attempts by adults to 80%  Increase recent smoking cessation success by adult smokers to 8% and adolescent smokers to 64%  Increase tobacco screening in office-based ambulatory care setting to 68.6%  Increase tobacco screening in hospital ambulatory care setting to 66.2%  Increase tobacco cessation counseling in office based ambulatory care settings to 21.1%  Increase tobacco cessation counseling in hospital ambulatory care settings to 24.9%

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to preventive health screening included:

 Teen smoking and smoking among the African American and other minority populations is a concern  Those with mental health issues may not know or be aware smoking cessation assistance  Resources for smoking cessation are a barrier

Physical Activity

Regular physical activity is important to reducing overweight and obesity rates and has been shown to lower adults’ risk of early death, coronary heart disease, stroke, high blood pressure, Type 2 diabetes, breast and colon cancer, falls, and depression. Among youth and adolescents, regular physical activity improves bone health, improves cardiorespiratory and muscular fitness, decreases body fat levels, and helps to reduce symptoms of depression. Even small increases in physical activity have been associated with benefits to health. People who are more physically active are more likely to have higher education levels, income, self-efficacy, support from others, access to exercise/recreational facilities they find to be satisfactory, and live in neighborhoods that are perceived to be safe. Advancing age, low income, lack of time, lack of motivation, perception of poor health, overweight/obesity and being disabled negatively impact physical activity. Healthy People 2020 supports a multi-disciplined approach to addressing physical inactivity. These approaches include expanding traditional partnerships (schools, health care, recreational organizations such as the YMCA and biking coalitions) to include non-traditional partners such as transportation, zoning, streets departments (sidewalks, street crossings), parks and recreation departments, and city planning. Policies that promote physical activity in schools, workplaces and childcare as well as improvements to the environment that support physical activity are needed (Healthy People 2020). Healthy People 2020 includes the following objectives:

 Increase the proportion of adults who participate in moderate aerobic physical activity for 150 minutes per week to 47.9%  Increase the proportion of adolescents who meet the current federal guidelines for physical aerobic activity to 31.6%  Increase the proportion of public and private schools that require daily physical education in elementary schools to 4.2%; in middle schools to 8.6%; and high schools to 2.3%  Increase the proportion of adolescents who participate in daily school physical education to 36.6%  Increase the proportion of school districts that require regularly scheduled elementary school recess to 62.8%  Increase the proportion of youth/adolescents who view television, videos or play video games for no more than 2 hours daily. The target for children age 2-5 is no more than 83.2%; for ages 6-14 to no more than 86.8%; and the proportion of adolescents in grades 9-12 to no more than 73.9%.  Increase the number of states with licensing regulations for physical activity provided in child care  Increase the proportion of the nation’s public and private schools that provide access to their physical activity spaces and facilities for all persons outside of normal school hours (that is, before and after the school day, on weekends, and during summer and other vacations) to 31.7%  Increase the proportion of physician office visits that include counseling or education related to physical activity for children and adults to 8.7%  Increase legislative policies for the built environment that enhance access to and availability of physical activity opportunities

In Bucks/Mont, 51.2% of adults do not get the recommended daily amount of physical activity. Adults in Indian Valley are least likely to exercise regularly (3 or more times weekly for at least 30

minutes) and residents of North Penn are most likely to meet this goal (80.5%). Twenty two percent of Bucks/Mont adults say they exercise less than once per week. North Penn also has the highest percentage of sedentary people, with more than 20% of adults saying they are physically active less than once weekly, compared to 11% in County Line.

% Exercising > 30 Minutes: # Days/Week 100%

90% 80% =>3 70% days/week 60% 1-2 50% days/week 40% < once/week 30% None 20% 10% 0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Reported exercise patterns do not correspond to the proportion of adults who are comfortable visiting an outdoor space or park during the day. Residents of County Line, who report the highest percentage of being active at least once a week, also are the most uncomfortable being in an outdoor space or park during the day. Frequency of exercise does not appear to be directly related to availability of safe outdoor areas.

% Uncomfortable Visiting a Nearby Park or Outdoor Space During the Day

24.3

17.9 17.6 14.2 12.6

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Regardless, Montgomery County has been strategically working to improve the environment to increase opportunities for safe places for physical activity (See the Social Determinants section on the Built Environment).

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to being physically active included:

 Too much work at computers leads to a sedentary lifestyle  Need safe walking environment  Need more municipal sports programs  Lyme disease, a bacterial infection from the bite of an infected tick, is epidemic in this area  The morbidity section on obesity also provides key informant and focus group comments about physical activity

Recommendations included:

1) Promote bike share programs and walkable communities 2) More school and community physical activity opportunities for youth and older adults 3) More education of healthcare professionals about Lyme disease

Healthy and Affordable Food

As mentioned previously, obesity is a major cause for concern both nationally and in Bucks and Montgomery counties (see Morbidity section on Obesity). Interventions to address a healthier diet should include improving nutrition knowledge, attitudes, and skills of individuals, increasing access to healthy and affordable food through systems and policy changes, and access to food assistance programs. For example, retail venues that sell healthier food can impact diet and nutrition. Low income communities may have less access to healthier food choices. Marketing also has a major influence on people’s food choices (Healthy People 2020).

Healthy People 2020 objectives related to healthier diet and access to healthy food include:  Increase the proportion of schools that offer nutritious foods and beverages outside of school meals  Increase the proportion of schools that do not sell or offer calorically sweetened beverages  Increase the proportion of schools districts that require schools to make fruits and vegetables available whenever other foods are offered or sold  Increase the number of states that have nutrition standards for food and beverages provided to school aged children in childcare

AJH initiated several projects to improve access to healthy foods, reduce food insecurity, and enhance communication about existing resources. As part the CHNA process, members of the community health department collected contact information on all Montgomery County food pantries and posted this list on the organization's intranet to enable AJH colleagues to refer those in need. AJH shared this list with other non-profits and key community stakeholders so more food insecure residents can benefit from a convenient food pantry. In addition, Abington-Lansdale Hospital is in the process of

removing kitchen fryers as a cooking method. A future endeavor will use new digital menu boards in the cafeteria to highlight nutritional values and the selection will include healthy food themes.

PHMC Household Health Survey 2015 findings indicate that approximately 95% of residents are satisfied with the quality of groceries available in their neighborhoods.

% Reporting Fair/Poor Quality of Groceries in Neighborhood 7.5

6.5

5.5 5.6

2.8

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

Very few residents in Abington-Lansdale's CB areas report difficulty finding fruit and vegetables in their neighborhoods.

% Who Have Difficulty Finding Fruit and Vegatables 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 North Penn Indian Valley County Line Blue Bell Bucks/ Mont

Difficult 0.1 1.8 4.3 0.0 1.4

Very Difficult 0.0 0.0 0.0 0.0 0.8

PHMC Household Health Survey 2015

Although access to fruits and vegetables is not problematic, 50% of adults in North Penn and Indian Valley report eating less than 3 servings of fruit and vegetables daily. Blue Bell is the exception, with almost two thirds of adults reporting that they eat at 3 or more servings of fruits and vegetables each day.

# Servings of Fruits & Vegetables per Day 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% North Penn Indian Valley County Line Blue Bell Bucks/ Mont 0 1-2 3-4 5+

PHMC Household Health Survey 2015

Adults in North Penn and Indian Valley are more likely to eat food from a fast food restaurant compared to adults in Bucks/Mont. Fewer than 2% report in Abington-Lansdale CB areas report eating fast food 3 or more times a week.

40 # Times Eat Fast Food in Per Week 1-2 3+ 35 0.6 1.5 30 33.0 31.3 3.5 25 27.4 24.8 20

15 %Respondents 10

5 3.4 0 North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

The table below provides information on poverty (<200% FPL) and race/ethnicity related to healthy eating in Bucks/Mont. Overall, poverty (<200% FPL) and minority race/ethnicity appear to negatively impact healthy eating lifestyles.

Healthy Eating Behaviors by Poverty and Race/Ethnicity in Bucks/Mont < 200% > 200% % White % Black % non- % FPL FPL non- non- Latino Latino Latino Latino Asian Ate less than 3 servings of 64.0 49.0 50.4 60.8 55.2 56.0 fruits/vegetables daily in past week Difficult/very difficult to find fruit 5.2 1.7 2.0 4.2 1.1 3.8 in neighborhood Eat fast foods 3+ times/week 4.3 3.2 3.4 5.2 0 3.9 PHMC Household Health Survey 2015

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to healthy eating included:

 Increasing access to healthy, affordable food o Lifestyle, habit, culture, unfamiliarity with healthy foods, and access to healthy foods close to home are factors related to healthy eating o Socialization and healthy meals close to home at an affordable price are important for seniors o The morbidity section on obesity also provides key informant and focus group comments about healthy eating

Recommendations included: 1) Referrals to United Way's 2-1-1 SEPA including food banks 2) Share an asset map that includes food resources with AJH staff

Alcohol and other Substance Abuse

Speaking of drugs: "We mirror any other suburban community outside of a city, i.e., Chicago" (Key informant)

Dr. Loren Robinson "sees a heroin-related issue almost every shift at Lansdale that is a big change from even a few years ago. 'The heroin epidemic is a huge problem for Philadelphia and our state' "86

Almost 95 percent of people with substance use problems are considered unaware of their problem and as a result many do not seek care. Substance abuse has a major impact on individuals, families, and communities. The effects of substance abuse significantly contribute to costly social, physical, mental, and public health problems including teenage pregnancy, HIV/AIDS, other sexually transmitted diseases, domestic violence, child abuse, motor vehicle crashes, physical fights, crime, homicide and suicide (Healthy People 2020). Binge drinking is particularly problematic. The Healthy People 2020 objective for binge drinking is to reduce the proportion of adults aged 18+ who engaged in binge drinking in the past 30 days to 24.4%. For adolescents age 12 to 17, the Healthy People goal is to reduce the proportion of students who report using alcohol or any illicit drug in the past 30 days to 16.6%.

Pennsylvania leads the country in drug overdose deaths among men ages 19 to 25; within Pennsylvania, Bucks County had the highest rate at 73.3 per 100,000 male residents in that age group, and Montgomery had the second highest rate at 41.6.87 These rates far exceed the Healthy People 2020 substance abuse goal of 11.3 all-age deaths per 100,000 population.

While the percentage of youths ages 12 to 17 nationally who abuse most drugs has decreased, marijuana use is edging upward, from 6.2% in 2002 to 8.4% in 2014. Additionally, the potency of marijuana has increased. Daily marijuana use by teens is associated with 60% lower high school graduation rate and 7 times higher suicide rates.88

Healthy People 2020 also desires to increase the number of Level I and Level II trauma centers and primary care settings that implement evidence-based alcohol Screening and Brief Intervention.

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to alcohol and other substance use included:

 Need to address alcohol and marijuana use o Access to gateway drugs among youth aged 14-18 (marijuana and alcohol) o Kids make fun of health education in the school system o Prescription drug abuse and heroin are problems for teens and adults. Resources to aid recovery are limited. Law enforcement and government agencies are aware of the issue o In Bensalem near the casino, "DUIs are up 900%" o Resources to screen for drug and alcohol abuse and functional alcoholics are lacking  Heroin, both with and without Fentanyl, is "cheap and easy to get"  Mixing of prescription drugs among the total population and older adults is common. Those on high dose narcotics and other pain management medications are especially at risk  Babies are detained because of their mothers' drug abuse; heroin is an issue  Mental health issues such chronic stress, anxiety and depression can lead to addictions  There are not enough drug and alcohol resources or beds  There are not enough behavioral and addiction counselors

Recommendations included:

1) Increase access to constructive activities for youth and adolescents 2) Review drug education curriculum in schools and revise as needed 3) Need more education in schools, beds, and counselors 4) Need education regarding mixing prescription drugs 5) Implement drug screening for all patients, not just those in clinic settings 6) Create a fact sheet on AJH Behavioral Health to serve as a resource 7) Utilize the expertise of a navigator who has knowledge of insurance coverage and connections with community services

Health Behaviors and Adolescents

The leading causes of illness and death among adolescents and young adults are largely preventable. During adolescence behavioral patterns are established that can affect current health status and impact risk for developing chronic diseases in adulthood. Social and environmental factors such as family, friends, school, neighborhood, and social norms can support or challenge adolescents’ health and well-being. Addressing the positive development of young people facilitates their adoption of healthy behaviors and helps to ensure a healthy and productive future adult population.

Except where noted, the information provided in this section is based the 2013 Youth Behavior Risk Surveillance (YBRS) for high school students.89 This data is being used because it is self-reported by youth, not their parents and is therefore more likely to represent actual behaviors of adolescents in the United States.

Tobacco Use  15.7% of students report being current smokers, down from a high of 21.9% in 2003  8.6% of students report smoking 10 or more cigarettes per day  9.3% of students report initiation of smoking before age 13  52% did not try to quit smoking in the past 12 months  E-cigarette use (use on at least 1 day in the past 30 days) among high school students increased from 4.5% in 2013 to 13.4% in 2014, rising from approximately 660,000 to 2 million students. Among middle school students, e-cigarette use more than tripled from 1.1% in 2013 to 3.9% in 2014—an increase from approximately 120,000 to 450,000 students90

Alcohol Use  34.9% of students reported alcohol use within the last 30 days  20.8% reported binge drinking (5 or more drinks in a row)  18.6% of students report drinking alcohol for the first time (more than a few sips) before age 13 Use of other drugs  23.4% of students report current marijuana use  Ever used: prescription drugs without a prescription (17.8%), inhalants (8.9%), hallucinogenic drugs (7.1%), ecstasy (6.6%), cocaine (5.5%), methamphetamines (3.2%), steroids without prescription (3.2%), heroin (2.2%)  22.1% of students reported being offered or sold drugs on school property

Body Weight, Nutrition and Physical Activity  13.7% of students are classified as obese based on self-reported height and weight  16.6% are classified as overweight based on self-reported height and weight  13% did not eat for 24 hours or more to lose weight or keep from gaining weight  5% reported eating no fruits and 6.6% reported eating no vegetables in the past 7 days  27% report daily consumption of non-diet soda  15.2% reported zero days of > 60 minutes of physical activity in the past week, including more females than males

 32.5% watched three hours or more of TV daily: more African American students (53.7%) than Hispanic (37.8%) and non-Hispanic whites (25%)

Safety and Violence  7.6% never or rarely wear seat belts  87.9% of students report never or rarely wearing a bicycle helmet while riding a bike  49% of juniors and 60.3% of seniors report ever texting or emailing while driving  5.9% carried a weapon on school grounds  24% were in a physical fight during the last year  7% stayed home from school within the past year due to safety concerns  16.8% reported being bullied at school  14.9% reported being bullied electronically  18.2% seriously considered suicide  7.5% reported a suicide attempt within the last year

Sexual Activity  54.6% report ever having sexual intercourse: 30% of 9th graders and 64.1% of seniors  5.6% report sexual intercourse prior to age 13  Among sexually active students: o 59.1% used a condom during last sexual intercourse o 13.7% did not use any method of birth control during last intercourse o 22.4% reported use of alcohol and/or other drugs prior to last sexual intercourse o 14.7% were never taught about AIDS or HIV

Healthy People 2020 objectives for adolescents include:

 Increase the proportion of adolescents who have had a wellness checkup in the past 12 months to 75.6%  Increase the proportion of adolescents who participate in extracurricular and/or out-of-school activities to 90.6%  Increase the proportion of students who graduate with a regular diploma 4 years after starting 9th grade to 82.4%  Decrease school absenteeism among adolescents due to illness or injury  Reduce the proportion of students who report using alcohol or any illicit drug in the past 30 days to 16.6%.  Reduce the proportion of adolescents who have been offered, sold, or given an illegal drug on school property to 20.4%  Increase the proportion of middle and high schools that prohibit harassment based on a student’s sexual orientation or gender identity to 92.2%  Reduce the percent of adolescents aged 12 to 19 years who are considered obese to 16.1%  Increase fruit and vegetable consumption  Reduce the percent of adolescents in grades 9 through 12 who smoked cigarettes in the past 30 days to 16%  Increase the percent of adolescents who meet the current physical activity guidelines for aerobic physical activity to 31.6%

 Increase the percent of adolescents in grades 9 through 12 who viewed television, videos, or played video games for no more than 2 hours a day to 73.9%  Increase the percent of adolescents in grades 9 through 12 who used a computer or played computer games outside of school (for non-school work) for no more than 2 hours a day to 82.6%  Reduce the percent of students in grades 9 through 12 who reported that they engaged in physical fighting in the previous 12 months to 28.4%  Reduce the percent of students in grades 9 through 12 who reported that they were bullied on school property in the previous 12 months to 17.9%  Reduce the percent of students in grades 9 through 12 who reported that they carried weapons on school property during the past 30 days to 4.6%  Increase the percent of motor vehicle drivers and right-front seat passengers that used safety belts to 92%

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to healthy behaviors and adolescents included:

 Need constructive things to do. "If not they get into trouble."  Rise of children on the autism spectrum including Aspergers  Sexual behavior among young people  Rising asthma rates among youth  Health plans not always covering treatment for allergies  Young people need healthy eating/exercise combination  Students with limited resources need eye exams and glasses  Bike safety, helmet safety are "not always on the radar." Need more education on how to safely ride.  School related issues o School districts are concerned with smoking. o School districts cutting more in classroom. There is less support in classroom- not as many aides or volunteers. There is less volunteerism. Greater focus on test scores. Many single parent families with competing responsibilities limit parental support. Children diagnosed with autism need support. o Well rested and fed children results in success for school district

Recommendations included:

1) Increase youth access to constructive, positive activities in the community

Communication

Between approximately 30 and 40% of Abington-Lansdale CB area residents did not use social media in the past three months.

% Not Using Social Media in the Past 3 Months

41.6 40.3 36.1 31.3 28.3

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

E-mail and postal mail are the preferred ways to receive health or social service information, with social media a distant third choice in some Abington-Lansdale CB areas.

Preferred Way to Receive Health or Social Service Information 100% Other* 90% 80% Television 70% Newspapers 60% Social Media ** 50% Postal Mail 40% 30% Email 20% * Other includes 10% telephone, text 0% messaging, and North Penn Indian Valley County Line Blue Bell Bucks/ Mont other

PHMC Household Health Survey 2015

Issues, challenges, unmet needs and priorities identified by key informants and focus group participants related to communication included:

 Individuals with limited social or community networks cannot substitute social media for personal contact. Social media or virtual visits without in-person contact leads to depression and isolation.  Social media is for young people.  Not everyone uses social media

Recommendations included:

1) AJH should use social media to post educational alerts 2) Explore using social media for health messages on lifestyle and behavioral changes 3) AJH has an opportunity to utilize new and future social media strategies to reach an extended audience for prevention and wellness education messages

Special Populations – Older Adults, Immigrants and Refugees, Homeless

Older Adults

Older adults are among the fastest growing age groups, and the first “baby boomers” (adults born between 1946 and 1964) turned 65 in 2011. Older adults are at high risk for developing chronic illnesses and related disabilities including diabetes mellitus, arthritis, congestive heart failure, and dementia. Illness, chronic disease, and injury can create physical and mental health limitations in older adults, affecting their ability to live independently at home. Regular physical activity is a protective factor for such declines. While most adults want to age in place and remain in their homes for as long as possible, the supports they need to do so may not be available. Caregivers are often family members or friends who volunteer and may not be prepared for the stressors of caregiving. Elder abuse by a caregiver has unfortunately become more common with up to 2 million older adults affected (Healthy People 2020).

The Healthy People 2020 objectives on older adults focus on:  Increased adherence to a core set of clinical preventive services  Increased older adult confidence in managing chronic health conditions  Increased diabetes self-management benefits to 2.2%  Increased physical activity among those with reduced physical or cognitive impairment to 35.9%  Increased proportion of the healthcare workforce with geriatric certification (target – physicians 3%; psychiatrists 4.7%; registered nurses 1.5%; physical therapist 0.7%; registered dietitians 0.33%)  Reducing ED visits due to falls (Target: 4,711.6 ED visits per 100,000 due to falls among older adults)

Bucks and Montgomery counties have Area Agencies on Aging, and in accordance with Pennsylvania Act 70 and the Older Americans Act, each must produce an Area Plan for Aging Services every four years. For the years 2012-2016, the Bucks County Area Agency on Agency established three main focus areas:

 to help ensure that Pennsylvanians will age and live well and that communities will be designed to help them age and live well  to move the discussion away from Institution vs. Home and Community-Based Services and to refocus on access to the appropriate services and care for the right time, with the right intensity, in the right setting, for the right duration  to bring the best of Pennsylvania to Pennsylvanians91

To meet its goals, the Bucks County plan describes the following long term services and supports:

The Information and Referral department typically receives more than 30,000 calls annually from consumers, families, professions, and other stakeholders seeking services and supports for older adults.

Nutritional Services provided meals to an average of 2,979 consumers per year from 2007 to 2011. Hot meals are served at lunch time in the Congregate Meal program at 11 senior centers and 2 satellite centers, Monday through Friday. The Home Delivered Meals Program delivers to those in need who are unable to attend the senior center lunches. In fiscal year 2011-12, a total of 113,822 home delivered meals and 75,938 congregate meals were expected to be provided. The goal is to satisfy 1/3 of food insecure seniors' recommended dietary allowance.

To promote community involvement and independence, partially subsidized transportation is available through the Shared Ride Program to take individuals age 65+ to destinations such as senior centers, medical facilities, human service agencies, libraries, adult day services, pharmacies, banks, retired and senior volunteer program assignments, and food shopping. In fiscal year 2011-12, 1,600 eligible residents received 70,935 trips to approved destinations.

The APPRISE Program offers health insurance counseling to older adults and their families. In fiscal year 2011-12, 56 community presentations were completed and 2,000 consumers received benefits counseling.

The Prime Time Health Program provides information on a wide range of subjects to encourage disease prevention and health promotion such as falls prevention, exercise classes, health screenings, medication and alcohol use and misuse, and healthy cooking. In fiscal year 2011-12, educational literature regarding Project Meds was distributed to 1,100 people at 15 health fairs across the county.

The Employment Assistance Program assists unemployed adults age 55+ with incomes that do not exceed 125% of the federal poverty level with work based training opportunities.

Volunteer Opportunities with a variety of non-profit organizations are available. In 2011, 646 volunteers provided over 116,600 hours of service to 138 partner agencies, accounting for $2.5 million of volunteer service.

Senior Community Centers facilitate the social, emotional, and physical well being of older adults. In FY 2011-12, more than 286,000 visits to senior centers were expected.

Long Term Care uses case managers to assess residents for services such as medical assistance funding for nursing facility care, in-home services, adult day care, personal emergency response systems, home delivered meals, home modifications, counseling and behavioral health needs, and medical equipment and supplies. Subsidies depend on income level.

The Nursing Home Transition offers alternatives to residing in an institutional setting by offering supports to enable residents to transition to the community.

Older Adult Protective Services investigates reports alleging abuse, neglect, financial exploitation, and abandonment of older adults. From fiscal year 2007-08 through fiscal year 2010-11, 1,141 reports were completed with 170 cases substantiated.

Ombudsman investigates and helps resolve complaints related to the health, safety, and rights of older residents receiving long term care services.

100

Legal Services provides benefits and rights counseling and legal representation to assist older adults. The five main focus areas in the Montgomery County Office of Aging and Adult Services (MCAAS) plan for 2012-2016 are:

 work collaboratively to enhance the existing system of coordinated and comprehensive services and programs to support stronger communities for older and disabled adults who choose to age at home in a community setting  provide enhanced access to information, benefits, and programs for older and disabled adults seeking to make informed choices regarding their options along the long term care continuum  support health and wellness programs for older and disabled adults to enhance each person's mental and physical wellbeing within their communities  support efforts to enhance the quality of life for older residents who are most at risk  continue to support an individual's right to choose home and community-based options, despite shrinking public resources available in this current economic environment92

There is a concern that existing resources will not be able to adequately respond to the growing numbers of aging residents. Trends, such as aging Baby Boomers, the increased numbers of non- English speaking older adults, particularly in the Asian communities, and the needs of grandparents as caregivers, inform the MCAAS plan.

Population trends: The number of the most frail elderly age 85+ grew 28% between 2000 and 2010, and the number of centenarians increased 44% from 147 to 221 during this time frame. Although Philadelphia County has a larger number of adults over age 60, Montgomery County has a higher percentage and projections indicate that Montgomery County will continue to be the oldest county in southeastern Pennsylvania. A significantly higher percentage of lower income households exists for those over age 65, as older residents deal with the financial pressure from living in a region with a high cost of living, and many on a fixed income are challenged to meet increased costs for the basics needed to remain at home. The gender mix for those over age 65 is 60% female and 40% male. The needs of older women living alone continues to be a concern, as gender relates to poverty and abuse. MCAAS also notes that according to reliable sources, the numbers of Asian and Hispanic individuals has increased more than as reported in the official census. The increasing population of foreign-born and non-English-speaking elders places new demands on service providers for interpretation, translation, and cultural sensitivity.

Housing: The majority of Montgomery County older adults live in a private home, apartment, or continuing care retirement community. They report their desire to remain at home in the community, and cite affordable housing as a major concern for the future. Many of the age-restricted housing projects/communities are built on multiple levels, and/or are located in areas distant from services, transportation, or medical care. More local and county-wide planning efforts to meet the needs of older people needing specialized housing are needed, and Montgomery County continues to support the work of the Delaware Valley Regional Planning Commission to create more "aging friendly" communities.

Grandparents as caregivers: The estimated number of grandparents living with one or more of their own grandchildren under age 18 increased 8% over the decade ending in 2010, when more than 11,000 grandparents were estimated to be in this living situation. For those with limited resources,

101

the economic squeeze is noteworthy, since many older caregivers make choices related to self care versus care for the children in their homes.

MCAAS plans to work with hospitals and long term care facilities to promote supportive care transitions, reduce hospital readmissions, and strengthen health promotion efforts for the aging residents of the county.

Health Status

Health status data for older adults is from the PHMC Household Health Survey conducted in 2015. Abington-Lansdale CB areas are combined because the number of older adults who participated in the survey from each community was too small to be analyzed individually.

Access to Care:

Fewer older adults age 60+ in Greater North Penn have an ongoing source of care than in Bucks/Mont. Both are below the Healthy People 2020 goal of all people 65+ having a specific source for ongoing care.

%Age 60+ With Regular Source of Care

Healthy People 2020 Target for people age 65+ with a specific source for ongoing care = 100%

93.8 92.7

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

The majority in Bucks/Mont (58.1%) saw their health care provider three or more times in the previous year. Fewer (47.5%) from Greater North Penn reported visiting their provider 3 or more times in the past year. Six percent of adults age 60+ living in Greater North Penn did not see a health care provider in the past year.

Age 60+ # of Visits to Health Care Provider in Past Year

47.5 58.1

46.5 36.6

6.1 5.2 Greater North Penn Bucks/Mont No visits 1 to 2 3 or more PHMC Household Health Survey 2015

102

Emergency utilization among older adults in Greater North Penn and Bucks/Mont was similar, with more than 25% visiting the ER at least once in the past year.

Age 60+ # Visits to ER in Last Year 100% 80%

60% 40%

20% 0% Greater North Penn Bucks/Mont 3 or more 3.1 4.3 1-2 23.5 23.7

0 73.3 72.0

PHMC Household Health Survey 2015

Although less than 5% of adults age 60+ reported cancelling a doctor’s appointment because of transportation problems, a key informant cited transportation for the aging population "to get where they need to go including physicians and hospital appointments" as a key concern.

% Age 60+ Who Didn't Go to a Needed Doctor Appointment Due to Transportation Problems

4.7

4.3

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

Fewer than 5% of older adults in Greater North Penn used transportation services.

103

%Age 60+ Used Transportation Services in Past Year

6.9

4.7

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

More adults age 60+ in Greater North Penn say they are not aware of transportation services than in Bucks/Mont.

%Age 60+ Unaware of Transportation Services

12.8

9.2

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

Cost of health care was also problematic for 5% of older adults in Abington-Lansdale's CB areas.

% Age 60+ Sick Who did not Seek Care Due to Cost

5.3

3.4

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

104

In Greater North Penn, 9% of adults age 60+ did not purchase needed medication due to cost.

% Age 60+ Who did not Obtain Prescription Medicine due to Cost

8.9

7.1

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Compared to Bucks/Mont. slightly more older adults in Greater North Penn were unaware of PACE, Pennsylvania's Pharmaceutical Assistance Contract for the Elderly. Promoting this program will assist those who have hardship paying for prescriptions. In Montgomery County, offices located in Abington/Willow Grove, Lansdale, Pottstown and Norristown provide access, information, and navigation to county and state programs including PACE. AJH’s Community Health department disseminates such benefit information to case managers, patient centered medical home care managers, home care personnel, and social workers. Although the North Penn Foundation supports several nonprofits to provide navigators for health insurance benefits, there is continued opportunity to educate, promote, and communicate PACE to health professionals, social service agencies, and area nonprofit organizations.

%Age 60+ Unaware of PACE

20.9

20.0

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Chronic Disease

Obesity is an underlying cause of hypertension, heart disease, cancer, asthma and diabetes. Rates of chronic disease among older adults in Greater North Penn are lower than Bucks/Mont. Obesity rates

105

among older adults in Greater North Penn are below the Healthy People 2020 target. More than 6 in ten are obese or overweight.

70%Age 60+ Obesity Level 60 50 40 30 % 20

10 0 Greater North Penn Bucks/Mont Overweight 42.1 38.5

Obese 24.4 27.8

HP 2020 Target 30.5 30.5

PHMC Household Health Survey 2015

Ever had asthma rates for adults age 60+ are lower in Greater North Penn than Bucks/Mont.

%Age 60+ Ever Had Asthma

10.9

7.4

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Ever had high blood pressure rates among Greater North Penn adults age 60+ are lower than Bucks/Mont. Not surprisingly, rates are much higher than the total population.

%Age 60+ Doctor Ever Told have High BP

Healthy People 2020 Maximum Target for All Ages = 26.9%

51.7 44.5

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

106

Almost all adults age 60+ in Greater North Penn with hypertension report taking medication for this condition.

% Age 60+ Currently Taking Medication for High Blood Pressure Healthy People 2020 Target for All Ages = 69.5%

98.8 94.6

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

In Greater North Penn, approximately 85% of adults age 60+ take their blood pressure medication as prescribed. Very few take it less than 90% of the time.

%Age 60+ Taking High BP Medications as Prescribed 100%

80%

60% Greater North Penn Bucks/Mont Less than 90% of the time 0.5 2.9 Nearly all of the time (90%) 14.8 5.0 All the time (100%) 84.7 92.0

PHMC Household Health Survey 2015

As noted previously, a reduction in dietary salt intake has been documented to lower blood pressure and older adults are sensitive to the blood pressure-lowering effects of a decreased salt intake. Almost two thirds of adults age 60+ in Greater North Penn and Bucks/Mont report watching or reducing their sale intake.

107

%Age 60+ Currently Watching or Reducing Salt Intake

66.3

64.3

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Almost three quarters of these adults age 60+ believe that excessive salt intake is very or somewhat harmful to health.

% Age 60+ Who Think Too Much Salt is Harmful to Health

100%

80% 33.0 35.7

60% 40.8 38.8 40%

20% 17.7 17.6 0% 8.5 7.8 Greater North Penn Bucks/Mont Not at all harmful A little harmful Somewhat harmful Very harmful

PHMC Household Health Survey 2015

The majority think there is a link between too much salt and risk of stroke. As noted earlier, stroke mortality increased in Bucks County between 2010 and 2012, and salt intake is correlated with risk of stroke.

108

% Age 60+ Who Think Too Much Salt Affects Risk of Stroke

44.1 39.5

34.6 30.8

29.6 21.3

Greater North Penn Bucks/Mont Not at all/ A little Some A lot

PHMC Household Health Survey 2015

Over 80% of adults age 60+ report buying items with reduced salt. Buying patterns do not appear to directly correlate with beliefs about the relationship of dietary salt and health risks. Seventy four percent of respondents from Greater North Penn thought too much salt is very or somewhat harmful to health and 44% thought risk of stroke was high, yet 54% do not always or often buy reduced sodium products.

%Age 60+ Buying Items Labeled "Low Salt' or 'Low Sodium'

16.2 14.0 37.4 38.3

46.5 47.6

Greater North Penn Bucks/Mont Always/Often Sometimes/Rarely Never

PHMC Household Health Survey 2015

Twelve percent of Greater North Penn residents report ever having diabetes, a rate considerably lower than Bucks/Mont.

109

%Age 60+ Ever Had Diabetes

19.0

12.2

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

Most older adults have never been tested for HIV. HIV screening in the older adult population may be warranted.

% Age 60+ Never Tested for HIV

82.5

75.0

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

Older adults in Greater North Penn have a lower rate of diagnosed mental health conditions than the total adult population, suggesting that there may be undiagnosed cases.

% Age 60+ With Diagnosed Mental Health Condition

10.1

6.7

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

110

Major depression among older adults in Greater North Penn is reported less than in Bucks/Mont, also suggesting that there may be undiagnosed cases. The CDC CHSI methodology rated older adult depression in both Bucks and Montgomery Counties in the least favorable quartile when compared to peer counties.

%Age 60+ With Signs of Major Depression

8.5

3.1

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

Older adults in Greater North Penn are less likely to be receiving treatment for their mental health conditions than in Bucks/Mont. The inability of the formal aging system to respond to mental health issues will remain a barrier to serving the older adult population.

% Age 60+ Not Currently Receiving Treatment for a Mental Health Condition

66.4

34.9

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

Alzheimer's and dementia are chronic conditions affecting the older adult population. Alzheimer’s disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks. In most people with Alzheimer’s, symptoms first appear in their mid-60s. Estimates vary, but experts suggest that more than 5 million Americans may have Alzheimer’s. Alzheimer's disease is currently ranked as the sixth leading cause of death in the United States, but recent estimates indicate that the disorder may rank third, just behind heart disease and cancer, as a cause of death for older people.93 To address these conditions, the Muller Institute for Senior Health initiated sessions on Alzheimer’s and dementia education and trained more than 500 AJH employees, clinical and medical staff.

111

Ethnic minority background and income are associated with risk for functional health impairments, and the combination of poverty and ethnic minority background appears to increase that risk. Almost a fifth of older adults in Greater North Penn have an Instrumental Activity of Daily Living (IADL) that limits their everyday functioning.

% Age 60+ With IADL Limitation

21.2

19.4

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Of those with an IADL, about half in Greater North Penn had more than one limitation.

% Age 60+ Number of IADL Limitations

4.1 2.5 3.5 3.4

3.5 4.7 10.0 9.1

Greater North Penn Bucks/Mont 1 2 3 4-7

PHMC Household Health Survey 2015

Doing housework was the IADL that was challenging for the most older adults living in Greater North Penn and Bucks/Mont.

112

%Age 60+ Completely Unable or Need Some Help To: Greater North Penn Bucks/Mont

Use phone 1.4 1.5 Walk 7.2 9.9 Shop 8.5 10.5 Prepare meals 3.2 5.0 Do housework 12.0 15.8 Take medicine 3.0 2.4 Handle money 2.1 3.3 PHMC Household Health Survey 2015

Four percent of older adults in Greater North Penn have at least one Activity of Daily Living (ADL) that limits their functioning, a rate lower than Bucks/Mont.

% Age 60+ With ADL Limitation

10.2

4.2

Greater North Penn Bucks/Mont Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Of those older adults with an ADL in Greater North Penn, very few had 3 or more ADLs.

% Age 60+ Number of ADL Limitations 0.6 1.3 1.9

6.3 0.2 1.5 2.6

Greater North Penn 1 2 3 4-7 Bucks/Mont

PHMC Household Health Survey 2015

113

Older adults in Greater North Penn received volunteer help with IADLs at rates much higher than Bucks/Mont.

% Age 60+ With Volunteer Help with ADLs

56.3

23.1

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Slightly more Greater North Penn older adults also received volunteer help with ADLs than Bucks/Mont seniors.

% Age 60+ With Volunteer Help with IADLs

32.9

31.0

Greater North Penn Bucks/Mont Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

However, Greater North Penn older adults receive daily volunteer help for either IADLs or ADLs less often than others in Bucks/Mont.

% Age 60+ Frequency of Getting Volunteer Help

23.5 23.9

31.8 23.3

52.8 44.6

Greater North Penn Bucks/Mont Everyday Several times a week Once a week or less

PHMC Household Health Survey 2015

114

Fewer older adults in Greater North Penn received paid help with ADLs than in Bucks/Mont.

% Age 60+ With Paid Help with ADLs

7.7

5.3

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015 They also reported a higher rate of coverage with long term care insurance.

% Age 60+ with Long Term Care Insurance

29.0

27.2

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Although 29% of older adults in Greater North Penn reported having long term care coverage, they did not report using it for home care services. Age 60+ Payers of Home Care Services 100% 90% Agency 80% 70% Out-of-pocket 60% 50% Private 40% Insurance 30% Medicaid 20% 10% Medicare 0% Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

115

Preventive Health Care Services

Women over age 60 in Greater North Penn had a PAP test in the previous 3 years at a rate well below the Healthy People 2020 target of 93% for all age women; this rate was also lower than for Bucks/Mont.

Age 60+ % Having Pap Test within 3 Years

Healthy People 2020 Target = 93%

61.5 48.6

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

A slightly higher percentage of Greater North Penn women aged 60+ had a breast exam in the prior year compared to older women in Bucks/Mont. Rates of breast exam by professionals for older women were somewhat lower than for all age women.

% Age 60+ No Breast Exam by Health Care Professional Within the Past Year 38.2

36.4

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

However, a much higher percentage of older adult women in Greater North Penn had a mammogram in the previous two years (77%), a rate approaching the Healthy People 2020 target of 81%.

116

Age 60+ Time Since Last Mammogram 100% 22.9 24.1 80% 13.4 12.6 60%

40% 63.6 63.3

20%

0% Greater North Penn Bucks/Mont

one year or less more than one year, up to 2 years More than 2 years

Healthy People 2020 Goal = increase % of women aged 50-74 years who had a mammogram

based on the most recent guidelines to 81.1%

PHMC Household Health Survey 2015

As mentioned in the earlier all ages section on Preventive Care and Early Detection of Disease, 22% of older adults in Greater North Penn and Bucks/Mont did not have had a colonoscopy in the past 10 years. The Healthy People 2020 goal is for 70.5% of adults aged 50 to 75 years to have a colorectal cancer screening based on the most recent guidelines.

% Age 60+ Never Had or > 11 Years Since Last

Sigmoidoscopy/Colonscopy

22.3 22.3

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

These finding suggest that health care providers need to recommend preventive screenings, especially PAP and colonoscopy, to their older patients living in Greater North Penn.

Health Behaviors

Smoking

Older adults in Greater North Penn are less likely to be smokers than are older adults in Bucks/Mont as a whole. The percentage of smokers in both areas is below the Healthy People 2020 target and lower than the total population in both geographies.

117

%Age 60+ Who Smoke

Healthy People 2020 Target = 12%

9.5

5.0

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Greater North Penn respondents age 60+ report a slightly higher rate of having a smoker inside the home than the percentage of smokers. The deleterious effects of second hand smoke are well documented.

% Age 60+ with Smoker Inside Home

7.1

6.6

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Smokers in Greater North Penn were less likely to have tried to quit smoking compared to the Healthy People 2020 goal. Physicians should refer patients to state and local free programs including FAX to QUIT and the Pennsylvania QUIT line.

%Age 60+ Who Tried to Quit Smoking in Past Year

Healthy People 2020 Target = 80%

51.9 48.1

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

118

Fewer than 5% of older adult respondents smoke e-cigarettes in Greater North Penn and Bucks/Mont.

Age 60+ % Smoking e-cigarettes/Frequency of Use in

the Past Month

1.1

1.4

3.2 2.3

0.2 Greater North Penn Bucks/Mont

Once/ a few times At least once per week Daily

PHMC Household Health Survey 2015

Physical Activity

Physical activity is important to healthy aging. It maintains muscle strength, bone density, and helps to prevent weight gain and depression. Compared to Bucks/Mont, Greater North Penn adults age 60+ are more physically active.

%Age 60+ Exercising > 30 Minutes: # Days/Week 100%

80% 49.6 43.0 60%

26.0 40% 26.2 10.5 20% 7.4 16.8 20.6 0% Greater North Penn Bucks/Mont None < once/week 1-2 days/week =>3 days/week PHMC Household Health Survey 2015

As physical activity increases, so does falls risk. Although they exercise more, seniors in Greater North Penn are falling less frequently than their Bucks/Mont colleagues.

119

%Age 60+ Who Fell in Last Year

22.8

15.3

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Physical activity in Greater North Penn may correspond to being more comfortable visiting a park or outdoor space during the day compared to Bucks/Mont.

%Age 60+ Comfortable Visiting a Park or Outdoor

Space During the Day 78.5

74.5

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Poverty and Dual Eligibility

In 2015, the poverty threshold for an individual was $11,770 and a family/household of two was $15,930.94 In Bucks/Mont, the percentage of adults age 60+ living below 100% poverty is less than the poverty rate for the total population (5.8%). However, as previously noted, poverty can result in an increased risk of mortality, prevalence of medical conditions and disease incidence, depression, intimate partner violence, and poor health behaviors, factors that are exacerbated in an older, more vulnerable populations.

120

% Age 60+ Below 100% Federal Poverty Guideline

4.9

3.7

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Many of the low income adults age 60+ in Greater North Penn live in deep poverty, below 50% of the federal poverty guideline.

% Age 60+ Below 50% Federal Poverty Guideline

2.3

1.0

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

According to a 2014 report prepared by the Montgomery County Planning Commission, Montgomery County estimated that 7,833 individuals age 65 and over are duel eligible for both Medicare and Medicaid. This population has a higher incidence of cognitive impairment, mental disorders, diabetes, pulmonary disease, and stroke. In addition to having lower incomes, they are more vulnerable, frail, and isolated than non-dual eligible elderly. These problems contribute to additional challenges with housing, food, and transportation. Sixty-one percent of this population lives in the community, and the remainder are in nursing facilities.

The report outlined the following 9 recommendations to plan a better future for Montgomery County's dual eligible elderly:

1. Pilot test managed long-term supports and services (MLTSS) program 2. Implement program of all-inclusive care for the elderly (PACE) 3. Explore "duel eligible specific" accountable care organization (ACO)

121

4. Develop and facilitate primary care medical homes (PCMHs) 5. Continue and expand primary care medical home severe mental illness integration program 6. Push supports and services into naturally occurring retirement communities (NORCs) - "NORC PLUS supports and services" or "NORC as anchor for array of supports and services" model 7. Add independence at home (IAH) to home and community-base services (HCBS) waiver 8. Offer dual eligible targeted case management 9. Enhance dual eligible care setting transitions 95

Nutrition and Food Access

Access to healthy affordable food can play a role in the overall health of seniors. Some barriers that affect seniors related to having enough food are: inability to shop for oneself, lack of transportation, other living expenses, lack of familial support, lack of education about assistance programs, lack of affordable groceries, dementia, specific food diets or recommendations from doctors, and daunting paperwork.

All older adults in Greater North Penn say the quality of groceries in their neighborhood is excellent or good and more than half eat at least 3 servings of fruits and/or vegetables each day.

Age 60+ # Servings of Fruits & Vegetables per Day 100% 14.5 14.3 80% 38.8 31.7 60%

40% 51.8 20% 45.6

0% Greater North Penn Bucks/Mont 0 1 to 2 3 to 4 5 or more PHMC Household Health Survey 2015

It is important to note that a small percentage of the adults age 60+ in Abington-Lansdale's CB areas cut a meal in the past month due to lack of money. This is a sign of food insecurity. Food insecure seniors are:

 40% more likely to report an experience of CHF  53% more likely to report a heart attack  twice as likely to develop asthma  60% more likely to experience depression96

122

% Age 60+ Who Cut a Meal due to Lack of Money

4.4

1.7

Greater North Penn Bucks/Mont PHMC Household Health Survey 2015

More than 90% of seniors in Greater North Penn were aware of a meal or food program, while 1% needed a meal program in the past year. Although the number in need is relatively small, food insecurity is a significant issue for this population. Furthermore, since people taking medicine often need to take medicine with food, lack of food security may impede medication adherence.

%Age 60+ Unaware of Meal/Food Programs

7.4

6.6

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

%Age 60+ Needed Meal Programs in Past Year

1.2

1.0

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

123

Social Connectedness

Feeling connections to the community is important to prevent isolation and depression in seniors. Social networks are protective factors for health and wellness. More than half of older adults in Greater North Penn currently participate in at least one organization and more than 1 in 8 participate in 3 or more organizations. Abington's Muller Institute for Senior Health Eldermed initiative sponsors social events for members as part of its free wellness program.

% Age 60+ Currently Participating in Organizations

15.9 14.9 40.6 42.8

43.6 42.2

Greater North Penn Bucks/Mont No Organizations 1-2 Organizations 3+ Organizations PHMC Household Health Survey 2015

Almost one quarter of older adults in Greater North Penn say they are caring for a family member or friend. This may reflect a need for caregiver supports such as respite care. The Lansdale Adult Day Service Program offers caregivers an Alzheimer's support group.

%Age 60+ Providing Care to Family/Friend During the Past Month 31.1

23.9

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Seniors also stay connected by talking with friends and family on the telephone. Almost 14% of adults in Greater North Penn who talk with friends or family once a week or less are at risk for social isolation and the resulting health issues.

124

% Age 60+ Frequency of Talking with Friends or Relatives on the Telephone

9.1 9.8

5.2 3.7 0.7

Greater North Penn Bucks/Mont Never < once a week Once a week

PHMC Household Health Survey 2015

Housing

In Greater North Penn, more than 80% of adults age 60+ own their homes.

% Age 60+ Home Ownership 3.1 5.8

83.2 80.5

13.7 13.7 Greater North Penn Bucks/Mont Rent Own Other arrangement

PHMC Household Health Survey 2015

Some older adults in Greater North Penn are faced with home repairs that are not possible due to low fixed incomes. For elders who want to age in place, remaining in their homes for as long as possible is important emotionally and economically. Older homes often have stairs and are multiple dwellings. Having a home on the first floor is often not possible. These barriers affect seniors’ ability to take care of basic needs and to participate fully in the community.

%Adults Age 60+ with Home that Need Repair Greater North Bucks/ Mont Penn Roof 2.9 6.3 Plumbing 5.2 5.0 Heating 1.4 3.1 PHMC Household Health Survey 2015

125

One quarter of Greater North Penn seniors report difficulty in affording housing costs.

% Age 60+ Reporting Difficulty Affording Housing Costs in Past Year

29.4

24.9

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Seventeen percent of Greater North Penn adults age 60+ plan on moving from their current home in less than 5 years. % Age 60+ Desired Duration of Stay in Current Home

57.9 62.0

25.1 17.7

17.0 20.3

Greater North Penn Bucks/Mont < =5 Years > 5 but <10 years 10+ years

PHMC Household Health Survey 2015

Almost no older adults from Greater North Penn say they plan to move into affordable senior housing in the next 5 years.

% Age 60+ Likelihood to Move into Affordable Senior 100% Housing in Next 5 Years

50%

0% Greater North Penn Bucks/Mont Very likely Somewhat likely Not very likely Not at all likely

PHMC Household Health Survey 2015

126

Communications

The majority of adults age 60+ in Greater North Penn do not use social media.

%Age 60+ Not Using Social Media in the Past 3 Months 61.7

58.6

Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

Postal mail is the preferred format to receive health or social service information in this age group. Email is also a desirable way to receive such information for almost 20% in Greater North Penn. Social media is not a preferred way for receipt of this type of information. Age 60+ Preferred Way to Receive Health or Social Service Information 100% Other* 90% Television 80% Newspapers 70% 60% Social Media ** 50% Postal Mail 40% * Other includes 30% telephone, text 20% messaging, and other

10% ** such as Facebook or 0% Twitter Greater North Penn Bucks/Mont

PHMC Household Health Survey 2015

127

Issues and challenges, unmet needs and priorities identified by key informants and focus group participants related to older adults included:

 Well Elderly o A senior center is needed. In lieu of a bricks and mortar facility, a virtual senior center was developed through a grant with Visiting Nurses Association Community Services. o Need more low income subsidized housing, especially for those over 60. Females around 60 are falling through the cracks. o There is not enough communication of what activities for seniors are available. While social media is effective for younger populations, "grassroots" communication is appropriate for older adults. o Need chest pain awareness and education - awareness of heart disease as the leading killer include "Know Your Numbers" and sudden cardiac death. Staff need to be able to have time to educate and go into the community.  Safety o Need to protect older adults against fraud o Abuse and neglect, including financial, physical, emotional, affects seniors. Waiting lists for protective services are long o Trauma related to falls for seniors needs more attention  Care Coordination o Pan Asian Senior Services (PASSi) does not offer skilled services o Need more education regarding the medical system and financial assistance for older immigrants and those who do not speak English well. Fear of going to doctor and fear of outcomes/cost are related to cultural backgrounds. A community center to house educational programs is needed. o Seniors struggle with knowledge of where to go regarding available services o Care is not available at all levels. Care managers and case managers are increasingly integrating skilled nursing facility [SNF] care as a response to newer reimbursement structures and changing health care delivery system issues. o There is a lack of social responsibility towards family members which reflects issues in the state of our community connectedness. o Dehydration is a concern o Discharged older adults lack follow up after returning home o Seniors living alone and low income seniors cannot afford homecare assistance o After discharge from homecare, there is lack availability of skilled in-home medical oversight for the homebound elderly, increasing their risk of falls, frailty, and medication mismanagement o Post discharge from homecare, there is a lack of support for an informal continuum of care o Most older adults and their caregivers do not know the cost of the care and medications associated with stroke o Meeting the need for rehab in the weeks following discharge for stroke could be improved o After discharge from post acute services, stroke patients experience unresolved disabilities, are unable to return to full function, and are homebound  End of Life care - Palliative Care and Hospice

128

o People are living longer and are spending their resources but worried about end of life decision-making  Care Giver Stress o "Caregivers can't always get out to do it all"  Mental Health o From the Abington-Lansdale ER, it can take up to 36 hours for a 302 placement at Horsham Clinic or Norristown Building 50. There is no geriatric psych at Horsham, only at Abington Hospital.  Transportation to offices and hospital o Assess van use to reduce no shows at support groups and physician appointments. Seniors can't take the bus and care givers can't always provide transport o Seniors need financial assistance for transportation needs  Food insecurity o Barriers to healthy lifestyles include eating well

Recommendations included:

1) Communicate that Abington-Lansdale Hospital's cafeteria is open for meals and conversation to those who need it, i.e., isolated seniors 2) Build networks of linked community services and agencies to benefit the elderly, especially the "old old" living alone. Disseminate information about these services. 3) Need reasonable transportation services 4) Need a Lifecare or senior center 5) Support for care givers 6) Expand the Matter of Balance Program, an evidence-based fall reduction program promoted by Healthy Montgomery.org 7) Provide fans or air conditioners to seniors, or those with chronic conditions

129

Immigrants and Refugees

There are multiple concerns regarding data on immigrants. Undocumented immigrants are likely to be undercounted. Census data are presented as estimates and are subject to sampling error. When analyzing smaller geographies, the margin of error increases. PHMC data is skewed due to sampling bias. While Spanish language interviewers were available, no interviews were conducted in Asian (or other) languages, biasing the results to include only people who spoke adequate English. Although PHMC data was collected using land and cellular telephone interviews, there may be a small population that does not have either. With these cautions, the following data is presented.

Immigrants

According to the US Census Bureau,97 of Bucks/Mont's total population of 1.4 million residents, 9.2% are foreign born. Of these, 92% entered the country before 2010, and 41% are not citizens. The majority of immigrants coming to Bucks/Mont are from Asia (47%) and Europe (26%).

Bucks/Mont Foreign Born Origin

20% Europe 26% Asia Africa 0% Oceania 5% Latin America North America

47%

2010-2014 American Community Survey 5 year Estimates

Asian Indians and Koreans represent the largest Asian immigrant populations in Abington-Lansdale CB areas, accounting for 59% of those with Asian heritage. North Penn has the highest number of Asians including a Bangladeshi community.

Southeast Asians have been seen to differ significantly from more acculturated Asian ethnic groups, especially in their immigration patterns. Unlike the more upwardly mobile East and South Asian immigrants who immigrated to the U.S. for economic and social reasons, the vast majority of Southeast Asians arrived in the U.S. as political refugees from Vietnam, Cambodia, and Laos beginning in the 1970s. Many Southeast Asians were forced to leave their homes to preserve their

130

lives and escape persecution, leaving without preparation or knowledge of the country of their settlement. Since then, the U.S. government has resettled many Southeast Asians in places where they are culturally and linguistically isolated. In Abington-Lansdale CB areas, 11% (2,800 people) of the Asian immigrant population are estimated to be from these countries. Cultural and linguistic differences have created a number of structural and behavioral barriers to health care for these populations.

Asian Population Estimates, 2014 Abington- Korean Asian Chinese , Vietna- Filipino Bangla- Other* Total Lansdale CB Indian except mese deshi Area Taiwanese

North Penn 3,460 4,984 1,707 1,150 1,119 1,001 802 14,223 Indian Valley 572 1,179 248 845 25 - 280 3,149 County Line 324 317 583 77 77 - 38 1,416 Blue Bell 960 655 636 20 27 - 72 2,370 Grand Total 5,316 7,135 3,174 2,092 1,248 1,001 1,192 21,158 * Includes Cambodian, Indonesian, Japanese, Hmong, Laotian, Malaysian, Pakistani, Sri Lankan, Taiwanese, Thai, Other Asian, and not specified

Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates, Table B02006 Asian Alone by selected group

People from Puerto Rico account for the largest group of Hispanics living in Abington-Lansdale CB areas. As American citizens, they do not face challenges related to legal status, and are free to move between the mainland and their island. They are concentrated in North Penn and Indian Valley.

Mexicans are more concentrated in North Penn, where the highest number of Hispanic/Latinos of all origins reside.

The populations from South and Central America originate from a wide variety of counties. Other than Mexico, the population from any individual country is estimated to be less than 500 in Abington- Lansdale CB areas.

Hispanic or Latino Population Estimates, 2014 CB Area Puerto Mexican South Central Domin- Cuban Other* Total Rican American American ican North Penn 1,396 791 672 465 138 66 158 3,686 Indian Valley 502 226 297 602 120 178 178 2,103 County Line 22 107 65 25 1 - 62 282 Blue Bell 272 20 45 - 128 18 23 506 Grand Total 2,192 1,144 1,079 1,092 387 262 421 6,577 *Other includes Spanish and unspecified Source: U.S. Census Bureau, 2010-2014 American Community Survey 5-Year Estimates, Table B03001 Hispanic or Latino Origin by specific origin.

131

More than one quarter of residents of North Penn and Blue Bell report speaking a language other than English at home, a percentage much higher than other Abington-Lansdale CB areas and Bucks/Mont. In North Penn the most frequently spoken foreign languages are Asian Indian (e.g. Hindi, Malayalam, Gujarati, Urdu, Telugu)(20%), Italian (15%), Spanish (14%), and a Chinese language (11%). In Blue Bell the most frequently spoken foreign languages are in the Other category which includes American Sign Language, French, German, Korean, Polish, Russian, Vietnamese, Yiddish, and Others, followed by Spanish.

%Speaking a Language Other than English at Home

29.3 26.9

10.7 11.3 6.1

North Penn Indian Valley County Line Blue Bell Bucks/ Mont

PHMC Household Health Survey 2015

According to PHMC data, non-Latino Asians and Latinos fare worse on many health status questions when compared to the non-Latino whites who live in the same Bucks and Montgomery counties. %Non- %Non- %Latino HP 2020 Latino Latino Goal % White Asian Fair/Poor health status 10.9 5.2 21.0 No health insurance 1.7 3.4 13.2 0 No prescription insurance 7.2 2.7 10.2 No regular source of care 7.8 13.8 12.3 5 No visits to healthcare provider in past year 11.5 17.2 17.5 Last visit to dentist > 2 years 15.9 26.5 19.1 Last PAP > 3 years 24.7 25.5 18.9 7 Last mammography> 2 years 24.7 27.2 15.2 19 Last sigmoidoscopy >10 years or never (age 60+) 23.3 29.8 38.2 Has diagnosed mental health condition 15.6 4.9 11.3 Ever had asthma 14.6 15.8 18.9 Ever had diabetes 10.3 5.3 11.4 Ever had high BP 30.8 22.0 17.9 26.9 Obese 28.3 6.4 32.6 30.5 Overweight 34.4 32.9 28.2 Total Obese/Overweight 62.7 39.3 60.8

132

%Non- %Non- %Latino HP 2020 Latino Latino Goal % White Asian Due to cost, went without:

Medical care 7.3 5.2 14.2 Prescription 10.8 12.1 16.0 Meal 3.9 17.6 0 PHMC Household Health Survey 2015

Furthermore, when the results of a 2007 Southeast Asian Mutual Assistance Associations Coalition, Inc. (SEAMAAC) survey in Philadelphia were compared with results of the 2004 PHMC survey of the Asian population, there were many discrepancies between the two. It is likely that similar disparities continue in the 2015 PHMC survey results. In most cases, health status and access to care were understated in the PHMC data compared to the SEAMAAC data. The SEAMAAC data shows significantly higher rates of hypertension and mental health conditions, but also reported lower rates of insurance coverage and less health care utilization. Access to healthcare services was not available in respondent’s native language for 68% in the study and health resources in native languages was not available for 76% of those surveyed. This provides challenges for those seeking health care and disease self-management. Preventive health care practices may also be challenged as a result of differing health paradigms related to health beliefs and medical practices. Health care providers may lack the awareness and competency to address these differences. There is a general lack of appropriate and accessible mental health services for the Southeast Asian population, and concepts of mental health diagnosis and treatment may differ among population subgroups. Southeast Asians clearly lack much-needed access to health care and experience diminished quality of health care because of their socioeconomic status, lack of citizenship, and limited English proficiency. Improving services such as those that address resettlement needs, insurance, and social service options are needed to help these populations access health care services.

Many of the same issues apply to the Latino population. Abington-Lansdale does have written materials available in Spanish and some Spanish speaking staff. Cultural competence, recognizing the variety of Latino cultures, belief systems, and health conditions, is important in addressing the needs of this diverse population.

Issues and challenges, unmet needs and priorities identified by key informants and focus group participants related to immigrants and refugees included (repeated from other sections):

 Communication o Hospital staff lack cultural competency skills o Language is a barrier for the Korean community, especially for education on diseases, prevention, and health insurance issues o Koreans have difficulty finding appropriate healthcare  Culture o Some immigrants from Mexico and Central America are afraid of going to doctor, fearing outcomes and cost. Language and culture are barriers.

133

o Asian patients utilize the hospital system differently than other Abington CB area residents. Asians use more clinics and ER visits verses primary care physician visits. o Asians have inappropriate locker room behavior, notably spitting, and need education to understand why this is a problem  Interpretation o There are no skilled home care agencies that provide bilingual services to the Korean community. "Needs go beyond language issues alone." o There are opportunities to improve our interpretation to English as a Second Language patients.

Recommendations included (repeated from other sections):

1) Need more tailored education with trans-cultural consideration 2) Need more education regarding the medical system and available financial assistance for immigrants; educational programs are planned for a future community center to house such programs to serve the Latino population in and near Hatboro 3) Need more social workers bilingual in Korean who are knowledgeable about benefits, especially for older Korean Americans

134

Homeless

The number of homeless individuals is counted at various points in time. On January 28, 2015 in Montgomery County, there were 249 homeless members of households, all sleeping in shelters. On August 27, 2015, the number increased to 411 individual members of households, with 28 unsheltered. There were also homeless individuals. The number of homeless people in winter census declined 7% from 464 in 2013 to 430 in 2015. At the time of the 2015 winter homeless count, 25% of the people were victims of domestic abuse, 39% were children under age 18, and 8% were chronically homeless.98

The causes of homelessness and the characteristics of the homeless differ greatly across subpopulations. In Montgomery County, the majority of people who are homeless or at risk of homelessness are families with financial hardship. For a portion of the 8% who are chronically homeless, their mental illness involves a personality disorder that makes them averse to being around and living with other people. The street population is made up almost exclusively of single adults, as emergency housing programs are utilized to a greater extent by families, especially single mothers with children. Among those individuals are service-resistant chronically homeless people with serious mental illness. While these people make up a relatively small proportion of the homeless population, they are the most frequent and expensive users of the system. Characterized by serious mental illness, substance abuse and personality disorder, this subset of the homeless population is adverse to being around and living with other people. For people suffering from personality disorder as part of their mental illness, living alone on the streets is preferable to being around other people, much less abiding by a strict set of externally imposed rules. Understanding this aversion to be around other people provides an opportunity to help them. Nationally, there is a move away from the Continuum of Care approach to dealing with the service-resistant, seriously mentally ill homeless. This emphasis has led to interest among practitioners in the Housing First approach to serving this population. Montgomery County has also moved in this policy direction by supporting initiatives to move individuals into permanent housing.

Launched in January 2014, Your Way Home (YWH) Montgomery County is a partnership between government, philanthropy, and community organizations to end homelessness and housing instability for families and vulnerable residents. By forging new networks, innovating, leveraging existing community assets and planning for dramatic changes in federal policy and funding priorities, YWH Montgomery County's ultimate goal is to end homelessness in the county and its 5 year goal is reduce homelessness by 50%.99 An individual or family must be homeless to get YWH assistance. The homeless live in shelters or on the streets, parks, in cars or garages, in tents or in shelters and the majority of them are families. Finding stable and safe housing reduces depression, physical and mental illness and child neglect.100

YWH Montgomery County reports the following successes in 2014:  Shelters provided 690 families and individuals with a place to sleep in 2014. Exits directly to permanent housing increased from 29% in 2013 to 41% in 2014.  51% of YWH clients of uninsured patients were connected to health insurance by the time they exited to permanent housing in 2014  240 people with significant barriers to housing stability were placed in permanent housing in 2014

135

 YWH helped 520 people end their housing crisis, a 200% increase from the previous year

Issues, challenges unmet needs and priorities identified by key informants and focus group participants related to the homeless included:

o Homelessness affects all ages. The homeless are living in their cars in every town but are not seen on the streets. Montgomery County has begun a blueprint for action under the "Your Way Home" initiative. All information/support/case management is being centralized at the county level and via non-profit organizations to one communication point. o Shelters are at capacity; there are not enough beds in Montgomery County o The wait list is long for subsidized housing. "Females around 60 are falling through the cracks." o Identifying the homeless and getting them to resources is a challenge o The "housing system is broken in Montgomery County" o Some low income housing is not adequately suited for underserved with chronic illness, e.g. there are not always kitchens which influences nutritional intake; fans could make a difference; some cannot pay for heat

Recommendations included: 1) Partner with community based organizations serving the homeless 2) Resources committed to getting people back to work are needed 3) Hospital personnel should work with collaborative partners and the county departments will assist in facilitating access and coordination of already existing services

136

Recommendations

To address the community health needs identified in the CHNA, recommendations for initiatives were prioritized based on secondary data findings, primary data gathered through key informant interviews, and the focus groups with community residents. Participants in key informant interviews and focus groups were asked to identify the health needs of the community and were then asked to identify those they felt were most important to address. They were also asked to recommend potential initiatives to address these needs. The identified priority health needs and recommended initiatives were then grouped into the following domains:

 Internal organizational structure  Access to care  Chronic disease management,  Health screening and early detection  Healthy lifestyle behaviors and community environment To further prioritize these initiatives, a team of Community Benefit professionals developed thirteen criteria with weighted values. Scoring could range from 0-3 depending on the assigned weighted value. Community benefit professionals independently ranked each health need/issue using the agreed upon criteria. Criteria scores were then summed for each identified health need/issue and the totals were averaged using input from each scorer. The criteria and weighted values are provided below:

Criteria Maximum Weighted Value Does not meet HP 2020 2 Regional priority (SHIP priority for Southeastern Pennsylvania) 3 Disparity exists compared to Bucks/Mont 3 Focus groups and key informants perceive problem to be important 2 Sub-population is special risk 3 Problem not being addressed by other agencies 1 Has great potential to improve health status 3 Positive visibility for AJH 1 # people affected 3 Feasibility/resources available/existing relationships in place 2 Links to AJH strategic plan and/or service line plan 2 Sustainability 2 Collaboration opportunities 2

The prioritization and rankings inform the implementation plan and the timeline for phasing in these interventions. The list below summarizes the results of the prioritization process:

137

Domain Priority Health Needs/Issue Ranking Priority Level Score

Access to Care Mental Health Services 26.3 Most Important Access to Care and Healthy Social and Health Care Needs of 25.7 Most Important Lifestyle Behaviors and Older Adults Community Environment Chronic Disease Management Obesity 24.3 Most Important Healthy Lifestyle Behaviors Alcohol/ Substance Abuse 23.3 Most Important and Community Environment Health Screening and Early Women's Cancer 22.7 Most Important Detection Chronic Disease Management Chronic Disease Management 21.7 Most Important (diabetes, heart disease and hypertension, stroke, asthma) Access to Care Health Education, Social Services 20.7 Most Important and Regular Source of Care Health Screening and Early Colon Cancer 20.3 Most Important Detection Access to Care ED Utilization and Care 18.3 Important Coordination Healthy Lifestyle Behaviors Youth Health Behaviors 18.0 Important and Community Environment Access to Care Medication Access 18.0 Important Access to Care Language Access, Health Literacy 17.3 Important and Cultural Competence Access to Care Maternal and Child Health 17.0 Important Healthy Lifestyle Behaviors Physical Activity 16.3 Important and Community Environment Access to Care Health Insurance 16.0 Important Internal Organizational Hospital Readmissions 14.3 Less Important Structure Healthy Lifestyle Behaviors Access to Healthy Affordable Food 14.0 Less Important and Community Environment and Nutrition Education Healthy Lifestyle Behaviors Food Security 14.0 Less Important and Community Environment Healthy Lifestyle Behaviors Community Safety 13.7 Less Important and Community Environment Access to Care Access: Transportation 13.3 Less Important Healthy Lifestyle Behaviors Smoking Cessation 13.0 Less Important and Community Environment Internal Organizational Workforce Development and 12.3 Less Important Structure Diversity Healthy Lifestyle Behaviors Built Environment 9.7 Less Important and Community Environment Health Screening and Early HIV 8.3 Less Important Detection

138

Working under the guidance of the Abington Health Foundation Community Benefit Committee since 2011, the Community Health Department of Abington Jefferson Health is responsible for developing CHNAs and resultant implementation plans focusing on priority issues. Eight Community Benefit Action teams consisting of key community stakeholders and Abington Health administrative and clinical leaders were formed in 2013 to develop and implement goals and action plans to address the needs identified in the 2013 CHNA process. Leaders of these teams reported on progress quarterly through reports shared with the Community Benefit Committee. Similar to the process initiated in 2013, new teams and leaders will be identified and responsible for the development and coordination of the 2016-2019 implementation plans subsequent to thorough review of the 2016 CHNA. The Community Benefit Committee will continue to monitor and guide the progress of the implementation plans.

In addition, Abington Jefferson Health professionals will collaborate with Jefferson colleagues to improve health status in conjunction with the hospital’s partnerships. Best practices will be shared with the aim of enhancing infrastructure, stretching resources, and incorporating knowledge about social determinants of health and health literacy to better the population's health and well-being.

139

Appendix A - Hospital Asset Listing Hospitals- Bucks County Name Phone Address City Zip Website Aria Health 215-949-5000 380 N Oxford Langhorne 19047 https://www.ariahealth.org Bucks County Valley Road /bucks-county Doylestown 215-345-2200 595 West State St Doylestown 18901 https://www.doylestownhe Health alth.org/ Grand View 215-453-4000 700 Lawn Ave Sellersville 18960 https://www.gvh.org/ Health Lower Bucks 215-785-9200 501 Bath Road Bristol 19007 http://www.lowerbuckshos Hospital p.com/ St Mary 215.710.2000 1201 Newtown- Langhorne 19047 http://www.stmaryhealthc Medical Center Langhorne Rd are.org/ St. Luke's 215-538-4500 1021 Park Avenue Quakertown 18951 http://quakertown.slhn.org Hospital /Locations- Quakertown Directions/Quakertown- Campus Hospitals- Montgomery County Abington 215-481-2000 1200 Old York Abington 19001 http://www.jefferson.edu/a Hospital Road bington Jefferson Health Bryn Mawr 484-337-3000 130 South Bryn Bryn Mawr 19010 http://www.mainlinehealth Hospital Mawr .org/brynmawr Eagleville 610-539-6000 100 Eagleville Eagleville 19403 http://www.eaglevillehosp Hospital Road ital.org/ Einstein 484-622-1000 559 West East Norriton 19403 http://www.einstein.edu/lo Medical Center Germantown Pike cations/einstein-medical- Montgomery center-montgomery/ Holy Redeemer N/A 1648 Huntingdon Meadowbrook 19046 http://www.holyredeemer. Health System Pike com/Main/Home.aspx Lankenau 484-476-2000 100 Lancaster Ave Wynnewood 19096 http://www.mainlinehealth Hospital .org/Lankenau Abington- 215-368-2100 100 Medical Lansdale 19446 http://www.jefferson.edu/a Lansdale Campus Dr bington Hospital Jefferson Health Mercy Suburban 610-278-2000 2701 DeKalb Pike East Norriton 19401 http://www.mercyhealth.or Hospital g/locations/mercy- suburban/ MossRehab 215-663-6000 60 Township Line Elkins Park 19027 http://www.einstein.edu/lo Hospital Road cations/mossrehab/ Pottstown 610-327-7000 1600 East High Pottstown 19464 http://www.pottstownmem Memorial Street orial.com/pottstown- Medical Center memorial-medical- center/Home.aspx Valley Forge 610-539-8500 1033 W Norristown 19401 http://www.vfmc.net/index Hospital Germantown Pike .html

140

Appendix B - Health Assets Listing

Health Assets- Bucks County Name Phone Address City Zip Type Website Code Aldie Counseling 215-642-3230 2291 Cabot Langhorne 19047 Mental Health/ http://www.aldie.org/ Center Boulevard Substance Abuse Center Ann Silverman 215-345-2260 595 W. State Doylestown 18901 Community Health http://aschealthclinic.org/ Community Health Street Center Clinic BCHIP Children's 215-453-4382 700 Lawn Sellersville 18960 Dental Care http://www.bchip.org/incr Dental Program Ave eased_access_to_dental_c ar.html BCHIP Lower 215-633-8397 2546B Bensalem 19020 Community Health http://bchip.org/bchip_adu Bucks Clinic Knights Road Center lt_health_clinic.html BCHIP Volunteer 215-529-7250 261 Quakertown 18951 Community Health http://www.trivalleypc.co Doctors Care Upper California Center m/content/pdf/Volunteer- Bucks Road Doctors-Care.pdf Bethanna 215-355-6500 1030 Second Southampton 18966 Mental Health/ http://bethanna.org/ Street Pike Substance Abuse Center Bristol Bensalem 610-260-4600 600 Louis Warminster 18974 Mental Health/ http://www.nhsonline.org/ Human Services Drive Substance Abuse Center (NHS) Center Bucks County 215-345-3318 1282 Doylestown 18901 Health Department http://www.buckscounty.o Health Department Almshouse rg/government/healthservi Doylestown Road ces/HealthDepartment Bucks County (215) 547- 7321 New Levittown 19055 Health Department http://www.buckscounty.o Health Department 3423 Falls Road rg/government/healthservi Levittown ces/HealthDepartment Bucks County 215-529-7000 261 Quakertown 18951 Health Department http://www.buckscounty.o Health Department California rg/government/healthservi Quakertown Road ces/HealthDepartment Bucks County 215-788-5730 1270 New Bristol 19007 Mental Health/ http://bucks.pa.networkofc Mental Health Rodgers Rd Substance Abuse are.org/mh/services/agenc Clinic Center y.aspx?pid=BucksCounty MentalHealthClinic_361_ 2_0 Bucks County 215-773-9313 600 Louis Warminster 18974 Mental Health/ http://www.buckscounty.o Mental Health/ Drive Substance Abuse rg/government/humanserv Development Center ices/MHDP Delaware Valley 215-598-0223 2288 Second Newtown 18940 Mental Health/ http://www.pmhccares.org Children's Center Street Pike, Substance Abuse /bucks/ Ste. 6 Center Delta Community 215-953-9255 720 Warminster 18974 Mental Health/ http://www.deltaweb.org/ Supports Inc Johnsville Substance Abuse Blvd Center Family Services 215-538-1616 515 S. West Quakertown 18951 Mental Health/ http://www.fsabc.org/ Association of End Blvd Substance Abuse Bucks County Center

141

Health Assets- Bucks County Name Phone Address City Zip Type Website Code Family Services 215-345-0550 708 Shady Doylestown 18901 Mental Health/ http://www.fsabc.org/ Association of Retreat Rd Substance Abuse Bucks County Center Family Services 215-757-6916 4 Cornerstone Langhorne 19047 Mental Health/ http://www.fsabc.org/ Association of Drive Substance Abuse Bucks County Center Foundations 215-345-0444 833 East Doylestown 19801 Mental Health/ http://www.fbh.com/ Behavioral Health Butler Substance Abuse System Avenue Center HealthLink Dental 215-364-4247 1775 Street Southampton 18966 Community Health http://www.healthlinkdent Center Road Center al.org/ Ivyland Counseling 215-444-9204 1210 Old Warminster 18974 Mental Health/ http://ivylandcounselingce Center York Road Substance Abuse nter.com/ #202 Center Lenape Valley 215-345-2273 595 N West Doylestown 18901 Mental Health/ http://www.lenapevf.org/c Foundation Crisis Street Substance Abuse risis-services/central- Center at Center bucks-crisis-services/ Doylestown Health Libertae Halfway 215-639-8681 5245 Bensalem 19020 Mental Health/ http://www.libertae.org/ House Bensalem Substance Abuse Boulevard Center Live Well Services 215-968-7600 203 Floral Yardley 19067 Mental Health/ http://www.livewellservic Inc Vale Substance Abuse esinc.com/ Boulevard Center Livengrin 215-638-5200 4833 Bensalem 19020 Mental Health/ https://www.livengrin.org/ Foundation Hulmeville Substance Abuse Road Center Maternal Child 267-525-7000 800 Clarmont Bensalem 19020 Mental Health/ http://www.warwickfamil Consortium Avenue Substance Abuse yservices.com/ Warwick Family Center Services Mother Bachmann 215-245-4334 2546 Knights Bensalem 19020 Women's Health http://www.stmaryhealthc Maternity Center Road Center are.org/motherbachmann maternitycenter New Life of 215-638-8600 3103 Bensalem 19020 Mental Health/ http://livewellservicesinc. Community Health Hulmeville Substance Abuse com/contactus.aspx Services Inc. Road Center New Vitae Inc 215-538-2424 16 South Quakertown 18951 Mental Health/ http://newvitaewellness.co Main Street Substance Abuse m/ Center NHS Bucks County 215-752-5760 2260 W. Langhorne 19047 Mental Health/ http://www.nhsonline.org/ Cabot Blvd Substance Abuse Center No Longer Bound 215-788-9511 1230 Norton Bristol 19007 Mental Health/ http://www.uwbucks.org/r Prevention and Ave Substance Abuse esources/no-longer- Training Services Center bound-prevention-and- training-services/

142

Health Assets- Bucks County Name Phone Address City Zip Type Website Code Pan American 215-788-6080 1 N. Wilson Bristol 19007 Mental Health/ http://www.uwbucks.org/r Mental Health Avenue Substance Abuse esources/pan-american- Services Inc. Center behavioral-health-clinic/

Penn Foundation 215-257-6551 807 Lawn Sellersville 18960 Mental Health/ https://www.pennfoundati Behavioral Health Avenue Substance Abuse on.org/services- Services Center programs/mental-health- services/mental-health- services.html Penndel Mental 215-752-1541 1517 Durham Langhorne 19047 Mental Health/ http://www.penndelmhc.o Health Center Inc Road Substance Abuse rg/ Center Project Transition 215-997-9959 1 Highland Chalfont 18914 Mental Health/ http://www.projecttransiti Drive Substance Abuse on.com/ Center Project Transition 215-491-2578 1700 Street Warrington 18976 Mental Health/ http://www.projecttransiti Road Substance Abuse on.com/ Center Pyramid Healthcare 215-536-9070 2705 Old Quakertown 18951 Mental Health/ https://www.pyramidhealt Quarkertown (Teen Bethlehem Substance Abuse hcarepa.com/locations/eas Center) Pike Center tern- pennsylvania/inpatient- residential-treatment- quakertown/ Reach Intensive 215-257-6551 712 Lawn Sellersville 18960 Mental Health/ https://www.pennfoundati Psychiatric Avenue Substance Abuse on.org/services- Rehabilitation Center programs/mental-health- services/reach-intensive- psychiatric- rehabilitation.html Reach Out 215-970-5462 152 Monroe Penndel 19047 Mental Health/ http://rofbucks.com/ Foundation of Bucks Street Substance Abuse County: Dual Center Diagnosis Southern Bucks 215-788-3738 1286 Bristol 19007 Mental Health/ https://www.councilsepa.o Recovery Veterans Substance Abuse rg/locations/southern- Community Center Highway Center bucks-recovery- community-center/ St. Mary Children's 215-245-8873 2546 Knights Bensalem 19020 Community Health http://www.stmaryhealthc Health Center Rd. Center are.org/body.cfm?id=142 Today, Inc. 215-860-1463 1990 North Langhorne 18940 Mental Health/ http://todayinc.org/ Woodbourne Substance Abuse Road Center Women's Recovery 215-289-6120 25 Beulah New Britain 18901 Mental Health/ https://www.councilsepa.o Community Center Road Substance Abuse rg/programs/pro-act- Center womens-recovery- community-center-and- central-bucks-recovery- support-services/

143

Health Assets- Montgomery County Name Phone Address City Zip Type Website Code Abington Family 215-481-2725 500 Old York Jenkintown 19046 Community Health http://www.jefferson.edu/ Medicine of Road, Suite Center abington Abington Jefferson 108 Health Abington-Jefferson 215-855-8296 51 Medical Lansdale 19446 Community Health http://www.jefferson.edu/ Health Children's Campus Center abington Clinic Drive Abington-Jefferson 215-481-6334 1200 Old Abington 19046 Community Health http://www.jefferson.edu/ Health Physicians York Road Center abington Adult Health Center 215-855-2899 51 Medical Abington 19046 Community Health http://www.jefferson.edu/ with Gwynedd- Campus Center abington Mercy University Drive Ambulatory 215-481-2180 1200 Old Abington 19046 Community Health http://www.jefferson.edu/ Services of York Road Center abington Abington Jefferson Health Aldersgate Youth 215-657-4545 42 N. York Willow 19090 Mental www.aldersgateservices.o Service Bureau Road Grove Health/Substance rg Abuse Service Corinne Santerian 215-481-6605 1400 Old Abington 19046 Community Health http://www.jefferson.edu/ Newborn Center of York Road, Center abington Abington Jefferson Suite D Health Carson Valley 484-534-2989 1419 Flourtown 19031 Children and www.cvca-pa.org Children's Aid Bethlehem Youth Services Society Pike Central 610-279-9270 1201 Dekalb Norristown 19401 Mental Health/ www.centralmhmr.org Montgomery Pike Substance Abuse MH/MR Center Center Community Health 610-326-9460 11 Robinson Pottstown 19464 Community Health www.ch-dc.org and Dental Care St Center Creative Health 610-326-8712 11 Robinson Pottstown 19464 Mental Health/ www.creativehs.org Services St Substance Abuse Center Dental Clinic of 215-481-2193 1200 Old Abington 19046 Community Health http://www.jefferson.edu/ Abington Jefferson York Road Center abington Health Discovery House 215-657-8882 329 West Hatboro 19040 Mental Health/ www.discoveryhouse.com Country Line Substance Abuse Road Center Financial Assistance 215-481-2185 1200 Old Abington 19046 Community http://www.jefferson.edu/ Program of York Road Service abington Abington Jefferson Health Project Hope 610-630-2111 3125 Ridge Eagleville 19408 STD Clinic www.std- Pike clinic.healthgrove.com Gaudenzia 610-239-9600 106 West Norristown 19401 Mental Health/ www.gaudenzia.org Addicition Main St Substance Abuse Treatment and Center Recovery

144

Health Assets- Bucks County Name Phone Address City Zip Type Website Code HealthLink Dental 215-364-4247 1775 Street Southampto 18966 Community Health http://www.healthlinkdent Clinic Road n Center al.org Jaisohn Medical 215-224-2000 6705 Old Philadelphi 19126 Community Health http://jaisohn.com Center York Road a Center Jaisohn Medical 215-997-2101 2506 N. Colmar http://jaisohn.com Center Broad Street, Suite 202 Life Counseling 1-800-882- 1170 E. Lansdale 19446 Mental Health www.lifecounseling.org Services 2799 Main Street Livengrin 215-540-8301 550 Ft. 19034 Mental www.livengrin.org Pinetown Washington Health/Substance Road Abuse Service Mental Health 267-507-3490 700 E. Main Norristown 19401 Mental Health/ www.mhasp.org Association Street Substance Abuse Center Mental Health 267-507-3510 536 DeKalb Norristown 19401 Mental Health/ www.mhasp.org Association Street Substance Abuse Center Mental Health (215) 751- 1211 Philadelphia 19107 Mental Health/ http://www.mhasp.org/ Association of 1800 Chestnut St Substance Abuse Southeastern Center Pennsylvania Montgomery 215-784-5415 102 York Willow 19090 Community Health http://www.jefferson.edu/ County Health Road, Suite Grove Center abington Department 401 Communicable Disease Clinic (Willow Grove Health Center ) Montgomery 610-278-5145 1430 DeKalb Norristown 19401 Community Health http://www.jefferson.edu/ County Health Street Center abington Department Communicable Disease Clinic (Norristown Health Center) Montgomery 610-272-1899 1430 DeKalb Norristown 19401 Mental Health/ www.montcopa.org County Mental Street Substance Abuse Health Center Montgomery 610-279-6100 50 Beech Norristown 19401 Mental Health www.mces.org County Mental Drive Crisis Team Health Montgomery 610-272-3710 316 DeKalb Norristown 19401 Mental Health/ www.rhd.org County Methadone Street Substance Abuse Center Center NAMI (215) 361- 100 W. Main Lansdale 19446 Mental Health/ http://www.nami.org/ 7784 St Substance Abuse Center

145

Health Assets- Bucks County Name Phone Address City Zip Type Website Code Norristown Public 610-278-5145 1430 DeKalb Norristown 19401 Community Health www.pa- Health Center Street Center (STD, HIV, montgomeryco.civicplus.c IMMUN, TB) om Norristown 610-278-7787 1401 DeKalb Norristown 19401 Community Health www.dvch.org Regional Health St Center Center North Hills Health 215-572-0302 212 Girard Glenside 19038 Community Health www.jefferson.edu/abingt Center of Abignton Ave Center on Jefferson Health Northwestern 215-362-7955 200 N. Lansdale 19446 Mental Health/ www.nhsonline.org Human Services Chestnut Substance Abuse Street Center Northwestern 888-647-0020 2506 N Broad Colmar 18915 Mental Health/ www.nhsonline.org Human Services Street Substance Abuse Center Northwestern 888-647-0020 620 E Lafayette 19444 Mental Health/ www.nhsonline.org Human Services Germantown Hill Substance Abuse Pike Center Nurse Family 610-278-5117 1430 DeKalb Norristown 19401 Maternal and Early www.nursefamilypartners Partnership Street Childhood hip.org OB/GYN Center of 215-481-6784 1200 Old Abington 19046 OB/GYN Care http://www.jefferson.edu/ Abington Jefferson York Road abington Health Personal Navigator 1-800-591- 1421 Abington 19001 Community Health http://www.vnacs.org/inde Program of Visiting 8234 Highland Center x.php?page=personal- Nurses Association Avenue navigator-program Community Services [VNACS] Planned Parenthood 610-279-6095 1221 Powell Norristown 19401 Reproductive www.plannedparenthood. Norristown Street Health/Sex org Education Planned Parenthood 610-326-8080 2081 High Pottstown 19464 Reproductive www.plannedparenthood. Pottstown Street Health/Sex org Education Pottstown Public 610-970-5040 364 King Pottstown 19464 Community Health www.pa- Health Center Street Center montgomeryco.civicplus. com Resources for 6109-278-0700 901 DeKalb Norristown 19401 Mental Health/ www.rhd.org Human Street Substance Abuse Development Center Salisbury 215-884-5566 614 N. Glenside 19038 Mental Health/ www.salisb.com Behavioral Health Easton Rd Substance Abuse Center Spring-Ford Drug 610-948-0393 201 N Fourth Royersford 19468 Mental Health/ www.springfordcounselin and Alcohol Avenue Substance Abuse g.org Counseling Center Valley Forge 610-539-8500 1033 W. Norristown 19401 Mental Health/ www.vfmc.net Medical Center Germantown Substance Abuse Outpatient Pike Center VNA Community 215-572-7880 1421 Abington 19001 Visiting Nurse, www.vnacs.org Services Highland Ave Social Service

146

Health Assets- Bucks County Name Phone Address City Zip Type Website Code VNA Community 610-272-3373 1109 DeKalb Norristown 19401 Visiting Nurse, www.vnacs.org Services Street Social Service VNA Foundation of (215) 847- P.O Box 867 Lansdale 19446 Visiting Nurse, http://www.npvnafoundat Greater North Penn 4401 Social Service ion.org/ Willow Grove 215-784-5415 102 York Willow 19090 Community Health www.pa- Public Health Center Road Grove Center montgomeryco.civicplus. com

147

Appendix C - Social Assets Listing

Social Assets- Bucks County Name Phone Address City Zip Type Website Code American Red 800- 810-4434 1909 Veteran's Levittown 19056 Homeless http://www.uwbucks.or Cross Lower Highway Shelter g/resources/bucks- Bucks County county-emergency- Homeless Shelter homeless-shelter/ BARC 215-794-0800 4950 York Holicong 18928 Disability http://www.barcprogra Developmental Road Services ms.org/PublicPages/Ho Services me.aspx Benjamin H. 215-672-8380 580 Delmont Warminster 18974 Senior http://www.wilsonsenio Wilson Senior Ave Services rcenter.com/ Center Bensalem Senior 215-638-7720 1850 Byberry Bensalem 19020 Senior N/A Citizens Center Road Services Bensalem WIC 215-244-2674 2546 Knights Bensalem 19020 WIC https://www.pawic.com Clinic Road / Boy Scouts of 215-348-7205 1 Scout Way Doylestown 18901 Youth http://www.washington America Services crossingbsa.org/ (Washington Crossing Council) Bristol Bensalem 610-260-4600 600 Louis Drive Warminster 18974 Mental http://www.nhsonline.o Human Services Health/ rg/ Center (NHS) Substance Abuse Center Bristol Borough 215-788-9238 Wood and Bristol 19007 Senior N/A Active Adult Mulberry Services Center Streets Bristol Township 215-785-6322 2501 Bath Road Bristol 19007 Senior http://www.theyoungin Senior Center Services heart.com/ Bucks County 215-348-6900 4259 West Doylestown 18902 Social http://www.buckscount Children and Swamp Rd Services y.org/LivingAndWorki Youth Social ng/Services/ChildAbus Services Agency e Bucks County 215-949-1727 7301 New Falls Levittown 19055 Homeless http://www.buckscount Homeless Shelter Road Shelter y.org/livingandworking /services/homeless- shelters Bucks County 215-598-3566 2324 Second Wrightstown 18940 Social http://www.buckscount Housing Group, Street Pike Services y.org/livingandworking Inc. /services/homeless- shelters Central Bucks 215-348-8131 2500 Lower St Doylestown 18901 YMCA/Y http://www.cbfymca.or Family YMCA Road WCA g/ Center Central Bucks 215-348-0565 700 Shady Doylestown 18901 Senior http://www.uwbucks.or Senior Center Retreat Rd Services g/resources/central- bucks-senior-activity- center/

148

Social Assets- Bucks County Name Phone Address City Zip Type Website Code Chandler Hall 215-860-4000 99 Barclay Newtown 18940 Senior http://ch.kendal.org/ Health Services, Street Services Inc. Child Home & 215-348-9770 204 N. West Doylestown 18901 Social http://chcinfo.org/index Community Street #101 Services .php Community 215-752-3729 340 E. Maple Langhorne 19047 Disability http://www.comop.org/ Options Avenue #102 Services Doylestown WIC 215-345-3494 1282 Doylestown 18901 WIC N/A Clinic Almshouse Road Eastern Upper 610-647-8178 8040 Easton Ottsville 18942 Senior https://www.facebook.c Bucks Seniors, Road Services om/Eastern-Upper- Inc. Bucks-Seniors-Inc- 172654929525424/ Falls Township 215-547-6563 282 Trenton Fairless 19030 Senior http://www.fallstwpseni Senior Center Road Hills Services orcenter.org/ St. Mary Family 215-245-8563 2546 Knights Bensalem 19020 Social http://www.stmaryhealt Resource Center Road Services hcare.org/body.cfm?id= 143 Levittown WIC 215-580-3570 7321 New Falls Levittown 19055 WIC https://www.pawic.com Clinic Road /local.php?cid=107 Lower Bucks/ 215-949-3400 601 S. Oxford Fairless 19030 YMCA/Y http://lbfymca.org/locat Fairless Hills Valley Rd Hills WCA ions/fairless-hills- Family YMCA branch Middletown 215-945-2920 2142 Trenton Levittown 19056 Senior N/A Senior Citizens Rd Services Center Morrisville 215-295-0567 31 E. Cleveland Morrisville 19067 Senior http://www.morrisvilles Senior Service Ave Services eniorservicenter.org/Ho Center me.html Morrisville 215-736-8077 200 N. Morrisville 19067 YMCA/Y http://www.lbfymca.org YMCA Child Pennsylvania WCA /locations/morrisville- Care Avenue branch Neshaminy 215-355-6967 1842 Trevose 19053 Senior http://neshaminyac.org/ Activity Center Brownsville Rd Services Northampton 215-356-8199 165 Township Richboro 18954 Senior http://www.northampto Township Senior Road Services ntownship.com/departm Center ents/senior-center- services.aspx Pennridge 215-453-7027 146 E. Main Perkasie 18944 Senior http://www.pennridgece Community Street Services nter.org/ Center Quakertown WIC 215-529-7482 261 California Quakertown 18951 WIC http://www.womeninfa Clinic Road ntschildrenoffice.com/q uakertown-wic-clinic- wc4038 Shared Support 267-247-5833 258 W. Ashland Doylestown 18901 Disability http://www.sharedsupp Inc. Street Services ort.org/ The Salvation 215-945-0717 215 Appletree Levittown 19058 Social http://pa.salvationarmy. Army Drive Services org/levittown

149

Social Assets- Bucks County Name Phone Address City Zip Type Website Code The Wellness 215-949-3400 555 S. Oxford Fairless 19030 YMCA/Y http://www.lbfymca.org Center at Fairless Valley Road Hills WCA /locations/fairless-hills- Hills YMCA branch Tri-Hampton 215-579-6200 190 S. Newtown 18940 YMCA/Y http://lbfymca.org/locat YMCA Sycamore St WCA ions/tri-hampton- (Newtown newtown-branch YMCA) Upper Bucks 215-536-8841 401 Fairview Quakertown 18951 YMCA/Y http://www.ubymca.org County YMCA Ave WCA / Upper Bucks 215-536-3066 2183 Milford Quakertown 18951 Senior N/A Senior Citizen Square Pike Services Center Valley Youth 215-442-9760 800 N. York Rd Warminster 18974 Homeless http://www.valleyyouth House Shelter house.org/ Warminister 215-442-1099 605 Louis Warminster 18974 WIC http://www.womeninfa WIC Clinic Drive, Suite ntschildrenoffice.com/ 508B warminster-wic-clinic- wc4052 Wellspring 215-257-4760 700 S. Main Sellersville 18960 Education http://www.paclubhous Clubhouse Street al/ e.org/WellspringClubho Employm use.php ent Center Woods Services 215-750-4000 40 Martin Gross Langhorne 19047 Disability http://www.woods.org/ Inc. Dr Services YWCA Bucks 215-672-2974 120 E. Street Warminster 18974 Social http://www.uwbucks.or Landing Family Road, Apt. L4- Services g/resources/ywca-of- Center 2, L4-4 bucks-county/ YWCA Bucks 215-633-1768 3131 Knights Bensalem 19020 Social http://www.uwbucks.or Meadow Family Road, Apt. 6-20 Services g/resources/ywca-of- Center bucks-county/ YWCA Country 215-639-5853 3338 Richlieu Bensalem 19020 Social http://www.uwbucks.or Commons Road Services g/resources/ywca-of- Family Center bucks-county/ YWCA 215-639-9550 2500 Knights Bensalem 19020 Social http://www.uwbucks.or Creekside Family Road, Apt. 160- Services g/resources/ywca-of- Center 01, 02 bucks-county/ YWCA Glen N/A 1100 Croydon 19021 YMCA/Y http://www.ywca.org/si Hollow Newportville WCA te/pp.asp?c=gwKUJbN Community Road YJxF&b=991971 Room YWCA Program 215-953-7793 2425 Trevose Trevose 19053 YMCA/Y http://www.ywca.org/si Outreach Center Road WCA te/pp.asp?c=gwKUJbN YJxF&b=991971

150

Social Assets- Montgomery County Name Phone Address City Zip Type Website Code Abington WIC (215) 887-8006 1128 Old York Abington 19001 WIC http://www.wicprogr Nutrition Center Road ams.org/li/pa_19001_ wic-office-abington Abington YMCA (215) 884-9622 1073 Old York Abington 19001 YMCA/ https://philaymca.org/ Road YWCA locations/abington/ Along The Way Inc (267) 382-9607 P.O Box 711 Souderton 18964 Social http://www.alongthe Services waypa.org/#along- the-way Ambler YMCA (215) 628-9950 1325 McKean Ambler 19002 YMCA/ https://philaymca.org/ Road YWCA locations/ambler/ CARIE (215) 545-5728 1500 JFK Blvd Philadelphia 19102 Senior http://www.carie.org/ Services Cradle of Hope (215) 572-5937 2238 Mount Glenside 19038 Home- http://cradleofhope.ne Carmel Ave less t/ Services Eldernet (610) 525-0706 9 S. Bryn Mawr Bryn Mawr 19010 Senior http://www.elderneto Avenue Services nline.org/ Encore Experiences at (215) 256-6900 312 Alumni Harleysville 19438 Senior http://www.ghnpss.or Harleysville Ave Services g/encore_experience/ home Family Services of (610) 630-2111 3125 Ridge Eagleville 19403 Social http://fsmontco.org/ Montgomery County Pike Services Generations of Indian (215) 723-5841 259 North Souderton 18964 Commu http://generationsofiv Valley Second St nity .org/ Center Hatboro YMCA (215) 674-4545 440 S. York Rd Hatboro 19040 YMCA/ https://philaymca.org/ YWCA locations/hatboro/ Home Helpers (215) 631-9126 213 N. Broad St Lansdale 19446 Senior http://local.homehelp Services ershomecare.com/buc ks/home/ Inter-faith Housing (215) 628-2334 31 South Ambler 19002 Home- http://www.i-fha.org/ Alliance Spring Garden less S Services Interfaith Hospitality (610)277-0977 1449 Dekalb St Norristown 19002 Home- http://philashelter.org Network less / Services Indian Creek (267) 203-1500 420 Cowpath Souderton 18963 Disabili https://www.indcreek Foundation Rd ty .org/ Services Keystone Opportunity (215)723-5430 104 N. Main St Souderton 18964 Social http://keystoneopport Center Services unity.org/ Lansdale WIC Clinic (215) 368-9826 607 North Lansdale 19446 WIC http://www.fns.usda. Broad St gov/wic/women- infants-and-children- wic Mental Health (267) 507-3510 538 DeKalb Norristown 19401 Home- http://montgomery.pa Association: Halfway Street less .networkofcare.org/m There Services h/services/agency.asp x?pid=MentalHealth AssociationHalfwayT here_801_2_0

151

Social Assets- Montgomery County Name Phone Address City Zip Type Website Code MFHS Norristown (610) 272-4042 1340 DeKalb Norristown 19401 WIC http://www.mfhs.org/ Pike, Suite 1 montgomery-county- locations/ MONTCO SAAC (215) 619-8863 45 Forest Ave Ambler 19002 Senior http://montcosaac.co Services m/ MONTCO SAAC (610) 275-1960 536 George St Norristown 19401 Senior http://montcosaac.co Services m/ Montgomery Co (610) 278-3769 1430 Dekalb Norristown 19404 Social http://www.montcopa Aging and Adult Center Services .org/index.aspx?nid= Services 148 Montgomery Co. (215) 661-9800 25 E. Marshall Norristown 19401 Disabili http://www.mcab.org Association for the St ty / Blind Services Montgomery Co. (610) 279-7372 353 East Norristown 19401 Social http://cssphiladelphia. Catholic Social Johnston Services org/ Services Highway Montgomery Co. (610) 631-1893 540/550 Port Norristown 19403 Youth http://www.montcopa Youth Center Indian Rd. Detenti .org/index.aspx?nid= on 508 Center Morning Star (215) 723-8103 526 E Broad St Souderton 18964 Pregnan http://www.mornings Maternity Home cy tarmaternityhome.org Crisis / Center North Penn YMCA (215) 796-5206 2506 N. Broad Colmar 18915 YMCA/ http://www.northpen Street, Suite YWCA nymca.org/ 208 Office of Vocational (484) 250-4340 1875 New Hope Norristown 19401 Educati http://montgomery.pa Rehabilitation St on/Emp .networkofcare.org/m loyment h/services/agency.asp Center x?pid=OfficeofVocat ionalRehabilitation_8 01_2_0 Peaceful Living (610) 287-1200 569 Yoder Rd Harleysville 19438 Disabili http://www.peacefulli ty ving.org/ Services Penn Asian Senior (215) 572-1234 6926 Old York Philadelphia 19126 Senior http://passi.us/ Services Rd Services Peter Becker (215) 256-9501 800 Maple Ave Harleysville 19438 Senior http://peterbeckercom Community Center Services munity.com/ Positive Aging in (610) 642-9730 117 Ardmore Ardmore 19003 Senior http://www.palmseni Lower Merion Ave Services ors.org/ (PALM) Pottstown Area (610) 323-5305 724 North Pottstown 19464 Senior http://www.greaterpa Seniors' Center Adams St Services sc.com/ Pottstown WIC Clinic (610) 232-8160 262 King St Pottstown 19464 WIC http://www.wicprogr ams.org/li/pa_19464_ wic-office-pottstown Project Haven (267) 281-4768 104 Main St East 18041 Youth http://www.theproject Greenville Services haven.org/projects.ht ml

152

Social Assets- Montgomery County Name Phone Address City Zip Type Website Code Resources for Human (610) 292-9244 1001 Norristown 19401 Home- http://www.rhd.org/P Development CHOC Stanbridge less rogram.aspx?pid=37 Services RSVP (610)834-1040 925 Harvest Blue Bell 19422 Other http://www.rsvpmc.o Drive rg/ Salem Adult Citizens (215) 884-7664 610 Summit 19046 Senior http://sbcoj.com/adult Ave Jenkintown Services Citizens.aspx Salvation Army (610) 326-1621 137 King St Pottstown 19464 Social http://pendel.salvatio Services narmy.org/easternpa/ pottstown The Giving Tree (215) 872-9328 P.O Box 823 Gwynedd 19437 Social http://givingtreefamil Valley Services ies.org/ The Hospitality (610) 277-1321 530 Church St Norristown 19401 Homele http://www.hospitalit Center ss ycenter.org/ Services The Ministries at (610) 970-2444 256 South Pottstown 19456 Home- http://ministriesatmai Main Street Hanover Street less nstreet.org/ Services The Peak Center (215) 362-7432 1292 Allentown Lansdale 19446 Senior http://www.ghnpss.or Rd. Suite A Services g/peak_center/home Upper Main Line (610) 647-9622 1416 Berwyn Berwyn 19312 YMCA/ https://www.ymcagb YMCA Paoli Rd YWCA w.org/ Upper Perkiomen (215) 679-6550 517 Jefferson St East 18041 Senior http://www.theopenli Senior Center Greenville Services nk.org/ Variety- The (215) 735-0803 100 N. 18th St Philadelphia 19103 Disabili http://varietyphila.org Children's Charity ty / Services Veterans Community (215) 527-6203 137 E. Woods Harleysville 19438 Social http://www.veteransc Network Dr Services ommunitynetwork.co m/ Victim Services (610) 277-0932 325 Swede St Norristown 19491 Social http://www.victimser Center Services vicescenter.org/ Youth Center Shelter (610) 631-1893 550 Port Indian Norristown 19403 Home- http://www.montcopa Road less .org/index.aspx?nid= Services 508 YWCA Tri-County (610) 323-1888 315 King St Pottstown 19464 YMCA/ http://www.ywcatrico YWCA untyarea.org/

153

Appendix D - Food Assets Listing

Food Assets- Bucks County Name Phone Address City Zip Type Website Code Active Acres Farms 215-860-6855 429 Stoopville Newtown 18940 Farmers www.activeacresfarm. Rd Market/ com Produce Stand Amish Bristol Market 215-826-9971 498 Green Lane Bristol 19007 Farmers http://www.bristolami Market/ shmarket.com/ Produce Stand Bedminster Orchard 215-795-0303 1024 Kellers Perkasie 18944 Farmers https://www.facebook Church Road Market/ .com/Bedminster- Produce Orchard- Stand 199296833464631/ Bolton Farm Market 215-257-6047 1005 Main Silverdale 18962 Farmers http://boltonfarmmark Street Market/ et.com/ Produce Stand Bristol Amish Market 215-826-9971 498 Green Lane Bristol 19007 Farmers http://www.bristolami LLC Market/ shmarket.com/ Produce Stand Bristol Borough 215-785-3296 99 Wood Street Bristol 19007 Food http://www.foodpantri Community Action Pantry es.org/li/bristol- Group, Inc. borough-community- action-group-inc Brumbaugh's Farm 215-723-3508 2575 County Telford 18969 Farmers http://www.brumbaug Line Road Market/ hsfarm.com/ Produce Stand Cares Cupboard 215-750-7651 152 Monroe Penndel 19047 Food N/A Street Pantry Charlann Farms 215-493-1831 586 Stony Hill Yardley 19067 Farmers http://www.charlannf Rd Market/ arms.com/ Produce Stand Coordinating Council of 215-672-9422 73 Downey Warminster 18974 Food http://www.foodpantri Health and Welfare Drive Pantry es.org/li/coordinating- council-of-health-and- welfare-emergency- food-cupboard Country Commons 215-639-5853 3338 Richlieu Bensalem 19020 Food http://www.foodpantri Family Center Food Rd Pantry es.org/li/ywca-of- Pantry bucks-county- country-commons- family-center-food- pantry Deep Well Farm 215-679-0206 1400 Fennel Pennsburg 18073 Farmers http://agmap.psu.edu/ Road Market/ Businesses/index.cfm Produce ?fid=6613 Stand

154

Food Assets- Bucks County Name Phone Address City Zip Type Website Code Deere Acres 215-536-8859 2165 Quakertown 18951 Farmers http://agmap.psu.edu/ Trumbauersville Market/ Businesses/index.cfm Road Produce ?fid=3893 Stand Doylestown FM 215-345-5355 West State Doylestown 18901 Farmers http://doylestownfarm Street & Market/ ersmarket.com/ Hamilton Produce Avenue Stand Doylestown Food Pantry 215-345-4311 470 Old Dublin Doylestown 18901 Food http://www.bchg.org/f Pike Pantry ood-pantries/ Eastburn Farm 215-598-3396 1085 Durham Pineville 18946 Farmers http://www.eastburnp Road Market/ umpkins.com/ Produce Stand Emergency Relief 215-547-1676 8525 New Falls Levittown 19054 Food http://www.ucclevitto Association of Lower Road Pantry wn.org/#!era/cfi3 Bucks County Fairless Hills Produce 215-428-2420 636 Lincoln Fairless Hills 19030 Farmers http://fhproduce.com/ Center Highway Market/ Produce Stand Family Service 215-757-6916 4 Cornerstone Langhorne 19047 Food http://www.fsabc.org/ Association of Bucks Dr. Pantry County Greater Works Food 215-741-0525 5918 Bensalem 19020 Food http://www.foodpantri Pantry Hulmeville Pantry es.org/li/greater- Road works-food-pantry Heaven's Bounty 215-536-1317 455 Quakertown 18951 Food https://pa211.commun Trumbauersville Pantry ityos.org/zf/profile/ser Road vice/id/1578694 Hellerick's Family Farm 215-766-8388 5500 Easton Doylestown 18902 Farmers http://www.hellericks Road Market/ farm.com/ Produce Stand Indian Valley Farmer's 215-723-6627 Main Street and Telford 18969 Farmers http://www.stmainst.o Market Penn Avenue Market/ rg/#!farmers- Produce market/c1fzx Stand Jesus Focus Ministry 215-953-2000 1150 Bristol Southampton 18966 Food https://www.facebook Road Pantry .com/jfmpantry?rf=11 1665482197957 Langhorne FM 215-436-7448 E Richardson Langhorne 19047 Farmers https://www.facebook Ave Market/ .com/Langhorne- Produce Borough-Farmers- Stand Market- 525475107572780/ Lapinski Farm 215-249-3431 1003 Middle Dublin 18917 Farmers N/A Road Market/ Produce Stand Loaves and Fishes Pantry 215-946-5800 840 Trenton Fairless Hills 19030 Food N/A

155

Food Assets- Bucks County Name Phone Address City Zip Type Website Code Road Pantry Manoff Market Gardens 215-297-8220 3157 Comfort Solebury 18963 Farmers http://www.manoffma Road Market/ rketgardens.com/ Produce Stand Mary's Cupboard 215-949-1991 100 Levittown Levittown 19054 Food N/A Parkway Pantry Maximucks Farm Market 215-297-9894 5793 Long Lane Doylestown 18902 Farmers http://www.maximuc Market/ ks.com/ Produce Stand McArdle's Holiday Farm 215-794-7655 4316 Mechanicsville 18934 Farmers http://www.holidayfar Mechanicsville Market/ mbuckscounty.com/ Road Produce Stand Milford Square Shelter 215-538-9383 2155 Milford Milford 18935 Food http://www.shelterlisti Square Pike Pantry ngs.org/details/36251/ Milk House Farm Market 215-852-4305 1118 Slack Rd Newtown 18940 Farmers http://www.milkhouse Market/ farmmarket.com/ Produce Stand Morrisville Presbyterian 215-295-4191 771 N. Morrisville 19067 Food http://mpcusa.net/ Church Pennsylvania Pantry Avenue Myerov Family Farm 215-249-3145 306 Elephant Perkasie 18944 Farmers http://www.myerovfar Rd Market/ m.com/ Produce Stand New Britain Baptist 215-345-9170 Route 202 & New Britain 18901 Food http://www.newbritai Church Food Larder Tamanend Pantry nbaptistchurch.org/fo Avenue od-larder/ New Hope FM N/A 182 W Bridge New Hope 18938 Farmers http://www.newhopeb St Market/ orough.org/document Produce s/FarmersMarket.html Stand No Longer Bound Bristol 215-788-9511 5723 Watson & Bristol 19007 Food https://pa211.commun Norton Ave Pantry ityos.org/zf/profile/ser vice/id/1582742 None Such Farm Market 215-794-5201 4458 York Buckingham 18912 Farmers http://nonesuchfarms. Road Market/ com/ Produce Stand Penn Vermont Fruit 215-795-0230 831 Rolling Bedminster 18910 Farmers https://www.facebook Farm Hills Road Market/ .com/Penn-Vermont- Produce Fruit-Farm- Stand 107360655976304/ Penn View Farm 215-249-9128 1433 Broad Perkasie 18944 Farmers https://www.facebook Street Market/ .com/PennViewFarm Produce Stand Penndel Food Pantry 215-750-4344 349 Durham Penndel 19047 Food N/A

156

Food Assets- Bucks County Name Phone Address City Zip Type Website Code Road Pantry Perkasie Farmers Market 215-257-5065 7th & Market St Perkasie 18944 Farmers https://www.facebook Market/ .com/PerkasieFarmers Produce Market Stand Playwicki Farm Farmers 215-357-7300 2350 Feasterville 19053 Farmers http://www.playwicki Market Bridgetown Market/ farm.org/ Pike Produce Stand Plumsteadville Grange 215-766-8822 5901 Route 611, Plumstead- 18947 Farmers https://www.facebook Farm Market Easton Road ville Market/ .com/Plumsteadville- Produce Grange-Farm-Market- Stand 202768669745812/ Produce Connection 215-788-6552 851 New Bristol 19007 Farmers N/A Rodgers Road Market/ Produce Stand Quakertown Farmers 215-536-4115 201 Station Quakertown 18951 Farmers http://www.quakerto Market Road Market/ wnfarmersmkt.com/ Produce Stand Quakertown Food Pantry 215-536-0240 50 North 4th Quakertown 18951 Food http://www.quakerto Street Pantry wnfoodpantry.org/ Snipes Farm and 215-295-1139 890 West Morrisville 19067 Farmers http://www.snipesfar Education Center Bridge Street Market/ m.org/ Produce Stand Solebury Orchards 215-297-8079 3325 Creamery New Hope 18938 Farmers http://www.soleburyo Road Market/ rchards.com/ Produce Stand Solly Brothers 215-357-2850 707 Almshouse Ivyland 18974 Farmers http://www.sollyfarm. Rd Market/ com/ Produce Stand Soulful Blessings Bristol 215-788-1440 640 Race Street Bristol 19007 Food http://www.foodpantri Pantry es.org/li/soulful- blessings Styer Orchard Inc 215-712-9633 97 Styers Lane Langhorne 19047 Farmers http://www.styerorcha Market/ rd.com/ Produce Stand Suelke's Roadstand 215-257-7027 1912 Old York Sellersville 18960 Farmers http://suelkesroadstan Route 309 Market/ d.com/ Produce Stand Sunflower Kings Farm 215-872-4777 1455 Benner Trumbauers- 18970 Farmers http://agmap.psu.edu/ School Road ville Market/ Businesses/index.cfm Produce ?fid=1577 Stand Tabora Farm and 215-249-3016 1104 Upper Chalfont 18914 Farmers http://www.taborafar

157

Food Assets- Bucks County Name Phone Address City Zip Type Website Code Orchard Stump Road Market/ mandorchard.com/sto Produce re/ Stand The Lord's Pantry 610-847-2402 4050 Durham Ottsville 18942 Food http://stjohnsottsville. Road Pantry org/food-pantry/ The Market at DelVal 215-230-7170 2100 Lower Doylestown 18901 Farmers http://themarketatdelv University State Road Market/ al.com/ Produce Stand The Market at Styer 215-757-7646 1121 Langhorne 19047 Farmers http://newsite.styersm Orchards Woodbourne Market/ arket.com/ Road Produce Stand Thorpe Farmstand and 215-862-4237 371 Newtown 18940 Farmers N/A Garden Center Stoneybrook Market/ Road Produce Stand Tifereth Israel Food 215-752-3468 2909 Bristol Rd Bensalem 19020 Food N/A Pantry Pantry Traugers FM 610-847-5702 335 Island Rd Kintnersville 18930 Farmers http://www.traugers.c Market/ om/ Produce Stand Wildemore Farm 215-249-3683 977 Upper Chalfont 18914 Farmers N/A Stump Road Market/ Produce Stand Winding Brook Farm 215-343-8880 3014 Bristol Warrington 18976 Farmers http://www.windingbr LLC Road Market/ ookfarm.com/ Produce Stand Windy Springs Farm 215-536-8624 1845 Myers Quakertown 18951 Farmers http://www.windyspri Road Market/ ngsfarm.com/ Produce Stand Wrightstown FM 215-378-3284 2203 Second St Wrightstown 18940 Farmers http://wrightstownfar Pike Market/ mersmarket.org/ Produce Stand

158

Food Assets- Montgomery County Name Phone Address City Zip Type Website Code Ada Mutch Community 610-527-7750 9 S. Bryn Bryn Mawr 19010 Food http://www.elderneto Center Mawr Avenue Pantry nline.org/ada- mutch.html A. G. Farm Market 215-536-8674 2073 Harleysville 19438 Farmers http://www.yelp.com/ Sumneytown Market/ biz/a-g-farm-market- Pike Produce woxall Stand Ardmore Food Pantry, 610-525-3075 36 Ardmore Ardmore 19003 Food http://stmarysardmore St. Mary Episcopal Avenue Pantry .org/content.cfm?id=3 Church 30 Bala Cynwyd FM Belmont Ave Bala 19004 http://balacynwydfar Cynwyd Farmers mersmarket.weebly.c Market/ om/ Produce Stand Bauder Farms 610- 489-948 1151 Collegeville 19426 Farmers http://www.localharv Collegeville Market/ est.org/bauder-farms- Rd Produce M21248 Stand Beth Sholom 215-887-1342 8231 Old Elkins Park 19027 Food http://www.bethsholo Congregation York Road Pantry mcongregation.org/m itzvah-food-pantry Bethel A.M.E. Church 610-326-9171 401 Beech Pottstown 19464 Food http://bethelamesf.org Street Pantry /ministries/food- pantry/ Bethel Community 610-326-1700 575 N. Keim Pottstown 19464 Food http://bccpottstown.c Church of Pottstown Street Pantry om/index.html Boyertown Area Multi- 610-367-6957 301 Spring Boyertown 19512 Food http://www.boyertow Service Street Pantry nareamulti- service.org/communit y-food-pantry.html Bright Hope 484-971-6865 468 W. King Stowe 19464 Food http://www.montcoha St Pantry .org/public_housing_ general_occupancy/d efault.html Bryn Mawr FM 48 N Bryn Bryn Mawr 19010 Farmers http://www.brynmaw Mawr Ave Market/ rfarmersmarket.blogs Produce pot.com/ Stand Calvary Assembly of 215-886-0404 7910 Wyncote 19095 Food http://calvarywyncote God Washington Pantry .com/ Lane Calvary Baptist Soup 610-277-4322 801 W. Norristown 19401 Food http://www.thefigtree. Kitchen Marshall Pantry org/dec09/120109cal Street varysoup.html Catholic Social Services 610-279-7372 353 E. Norristown 19401 Food http://www.cadcom.o Johnson Pantry rg/Montgomery- Highway County-Cupboard- List/58/ Chelten Baptist Church 215-646-5557 1601 N. Dresher 19025 Food https://chelten.org Limekiln Pike Pantry

159

Food Assets- Montgomery County Name Phone Address City Zip Type Website Code Church of the Brethren 215-855-3064 1333 Cowpath Hatfield 19440 Food http://www.hatfieldco Road Pantry b.org Cluster Outreach Center 610-970-5995 137 Walnut Pottstown 19464 Food http://www.pottstown Street Pantry cluster.org Collegeville Farmers 610-454-1050 460 East Main Collegeville 19426 Farmers http://www.collegevil Market Street Market/ lefarmersmarket.org Produce Stand Colonial Neighborhood 610-825-4254 107 E 4th Ave, Conshohock 19428 Farmers https://www.facebook Council en Market/ .com/Colonial- Produce Neighborhood- Stand Council- 114125001943541/ Coordinated Homeless 610-292-9244 1001 Sterigere Norristown 19473 Food http://rhd-choc.org Outreach Center (CHOC) St. Norristown Pantry State Hospital Build. 53 Cooper Creek Farm 610-327-1115 1856 Pottstown 19464 Farmers N/A Market Farmington Market/ Avenue Produce Stand County Line Landscape 215-723-8956 811 Harleysville 19438 http://countylinenurse Nursery Harleysville Farmers ry.net Pike Market/ Produce Stand Creekside Coop Market 215-557-4480 7909 High Elkins Park 19117 Farmers http://creekside.coop School Rd Market/ Produce Stand Daily Bread Community 610-287-0325 845 Gravel Collegeville 19473 Food http://dailybreadcom Food Pantry Pike Pantry munityfoodpantry.org Daniel's Produce and 610-908-2758 219 East High Pottstown 19464 Farmers https://www.facebook Dairy Street Market/ .com/DanielsProduce Produce AndDairy/ Stand Dull's Farm 215-654-0344 1001 Limekiln Ambler 19002 Farmers N/A Pike Market/ Produce Stand Emmanual EC Church 215-855-2540 100 S. Main St Hatfield 19440 Food http://www.emmanue Pantry lecchurch.org Frankenfield Farm 215-721-1084 98 Allentown Souderton 18964 http://agmap.psu.edu/ Market Road Farmers Businesses/index.cfm Market/ ?fid=1374 Produce Stand Freddy Hill Farms 215.855.1205 1440 Lansdale 19446 Farmers http://www.freddyhill Sumneytown Market/ .com Pike Produce Stand

160

Food Assets- Montgomery County Name Phone Address City Zip Type Website Code Freed's Produce 215 -723- 175 Morwood Harleysville 19438 Farmers https://www.facebook 9588 Rd Market/ .com/freedsproducest Produce and/ Stand Grace Lutheran 610-659-7255 506 Haws Norristown 19401 Food https://www.facebook Norristown Avenue Pantry .com/pages/Grace- Lutheran- Church/11615515174 5711 Glenside Farmers Market (215) 565- Glenside Ave. Glenside 19038 Farmers http://agmap.psu.edu/ 6422 & Easton Rd. Market/ businesses/index.cfm Produce ?fid=4684 Stand Greener Partners 610-584-6580 3215 Stump Collegeville 19426 Farmers http://greenerpartners. Hall Rd Market/ org Produce Stand Hague's Christmas Trees 215-368-4542 755 Forty Hatfield 19440 Farmers http://www.hagueschr Foot Road Market/ istmastrees.com Produce Stand Hatfield Church of the 215-855-3064 1333 Cowpath Hatfield 19440 Food http://www.hatfieldco Brethren Road Pantry b.org Haws Avenue Food 610-275-1283 800 W. Norristown 19401 Food https://www.facebook Cupboard/Soup Kitchen Marshall St Pantry .com/pages/Haws- Haws Avenue Methodist Ave-United- Church Methodist- Church/11606188174 9082 Hickory Run Produce 610-754-7772 2145 Big Gilbertsville 19525 Farmers https://www.facebook Road Market/ .com/pages/Hickory- Produce Run-Farm- Stand Produce/4592352141 05941 Hillside Farms Buffalo (215) 723- 750 Cowpath Telford 18969 Farmers http://www.hillsidefar 8499 Road Market/ ms.biz Produce Stand Hope Valley Community 215-541-4888 501 Graber Red Hill 18073 Food http://www.hopevalle Church Food Pantry Alley Pantry ychurch.org/valley_fo od_pantry House of God 610-279-3580 542 Dekalb Norristown 19401 Food https://www.facebook Street Pantry .com/pages/The- House-of- God/1200782346756 39 Iglesia De Dios Renacer 610-277-0255 310 Manor Plymouth 19462 Food http://www.whitepag Ave Meeting Pantry es.com/business/igles ia-de-dios-renacer- parsonage-plymouth- meeting-pa

161

Food Assets- Montgomery County Name Phone Address City Zip Type Website Code Indian Valley Farmers (215) 723- Main Street Telford 18969 Farmers https://www.facebook Market 6627 and Penn Market/ .com/ivfarm Avenue Produce Stand Indianvale Farm (215) 723- 551 Bergey Telford 18969 Farmers http://agmap.psu.edu/ 5670 Road Market/ Businesses/index.cfm Produce ?fid=4221 Stand Inter-faith Housing 215-659-2642 2086 Parkview Abington 19001 Food http://www.i-fha.org Alliance Avenue Pantry Interfaith at Grace 267-269-4573 503 Haws Norristown 19401 Food http://www.uccchristc Lutheran Church Avenue Pantry hurch.org/html/interfa ith.html Jenkintown Farmers 267-626-0030 Leedom St & Jenkintown 19046 Farmers https://www.facebook Market Greenwood Market/ .com/Jenkintown- Ave Produce Farmers-Market- Stand 111260468909750/ Jenkintown United 215-886-7250 328 Summit Jenkintown 19046 Food N/A Methodist Avenue Pantry Jenkintown Wholefoods 215-481-0800 1575 The Jenkintown 19046 Farmers http://www.wholefoo FM Fairway Market/ dsmarket.com/stores/j Produce enkintown Stand Jerusalem Lutheran (610) 287- 311 Second Schwenksvil 19473 Food http://www.jelc.org Church 7104 Street le Pantry Jett's Produce (215) 257- 87 Ridge Rd Telford 18969 Farmers http://agmap.psu.edu/ 6274 Market/ Businesses/index.cfm Produce ?fid=2569 Stand Jewish Relief Agency 610-660-0190 125 Bala 19001 Food http://www.jewishreli Montgomery Cynwyd Pantry ef.org Avenue Keystone Opportunity 215-723-5430 104 N Main Souderton 18964 Food http://keystoneopport Center Street Pantry unity.org

King Produce & Dairy 610-908-2758 219 East High Pottstown 19464 Farmers https://m.facebook.co St Market/ m/DanielsProduceAn Produce dDairy Stand Kohler Farms 215-646-4941 1262 Limekiln Ambler 19002 Farmers http://www.kohlerfar Pike Market/ ms.net Produce Stand Lamb Foundation, 215-661-8800 499 E. Walnut North Wales 19454 Food http://www.lambfoun Cornucopia Cupboard Street Pantry dationpa.org/cornuco piacupboard.html Lansdale Farmers Market N/A Railroad Ave Lansdale 19446 Farmers http://www.lansdalefa & Main St Market/ rmersmarket.org Produce Stand

162

Food Assets- Montgomery County Name Phone Address City Zip Type Website Code Lehman Methodist 215-675-2110 300 South Hatboro 19040 Food http://www.lehmanu Church York Road Pantry mc.org Longview Center for 610-584-6580 3215 Stump Collegeville 19426 Farmers http://www.localharv Agriculture Hall Rd Market/ est.org/longview- Produce center-for- Stand agriculture-M45028 Loaves and Fishes 215-886-7250 328 Summit Jenkintown 19046 Food http://food.jenkintow Jenkintown United Avenue Pantry n.net Methodist Church Manna on Main Street 215-855-5454 713 W. Main Lansdale 19446 Food http://mannaonmain.o Street Pantry rg Mattie N. Dixon 215-628-3002 150 N. Main Ambler 19002 Food http://community- Community Cupboard Street Pantry cupboard.org Meals of Hope Ministry 1329 Willow Norristown 19401 Food http://www.siloambc. Soup Kitchen Street Pantry org/index.php/ministr ies/mission- outreach/meals-of- hope-ministry Mitzvah Klein Food 215-698-7300 10100 Jamison Philadelphia 19116 Food https://www.jewishph Pantry Avenue Pantry illy.org/programs- services/mitzvah- food-project/about- mitzvah-food-project Narberth Community 610-642-9370 206 Price Ave Narberth 19072 Food http://narberthcommu Food Bank Pantry nityfoodbank.org New Hope Baptist 610-275-5814 204 E. Oak Norristown 19401 Food http://www.newhopef Street Pantry gbc.org New Life Presbyterian 215-576-0892 567 N. Easton Glenside 19038 Food http://www.newlifegl Church-Glenside Road Pantry enside.com NOR-GWYN Food 215-699-9342 125 N. Main North Wales 19454 Food http://www.uccnorth Cupboard, St. Luke's Street Pantry wales.org/outreach- Church of Christ and-service/nor- gwyn-food-cupboard Norristown Salvation 610-275-4183 533 Swede Norristown 19401 Food http://www.cadcom.o Army Cupboard Street Pantry rg/Montgomery- County-Cupboard- List/58/ North Hills Food 215-628-3002 212 Girard North Hills 19038 Food http://nhco.org/get- Cupboard Ave. Pantry help/food-pantry/ Patrician Society 610-272-6316 121 E. Norristown 19401 Food http://patriciansociety Chestnut Pantry .org Street Positive Aging in Lower 610-642-9370 117 Ardmore Ardmore 19003 Food http://www.palmseni Merion (PALM) Avenue Pantry ors.org Pottstown Salvation 610-326-1621 137 King Pottstown 19464 Food http://www.cadcom.o Army Cupboard Street Pantry rg/Montgomery- County-Cupboard- List/58/

163

Food Assets- Montgomery County Name Phone Address City Zip Type Website Code Pottstown Cluster of 610-970-5995 57 N. Franklin Pottstown 19464 Food http://www.pottstown Religious Communities Street Pantry cluster.org Sandy Hill Terrace 610-272-0382 330 Walnut Norristown 19401 Food N/A Street Pantry Shepard's Shelf; Christ 215-256-8739 2211 Mainland Kulpsville 19443 Food http://www.christlc2. Lutheran Church Road Pantry org Shiloh Full Gospel 610-270-9949 610 George Norristown 19401 Food http://shilohfgbc.org Baptist Church Street Pantry Siloam Baptist Church 610-275-8163 1329 Willow Norristown 19401 Food http://www.siloambc. Soup Kitchen Street Pantry org Meals of Hope Ministry Soup Kitchen Sisters of Charity 610-277-5962 DeKalb & Norristown 19401 Food http://sistersofcharity. Chestnut Pantry com Street St. Augustine- Soup 610-279-8890 1208 Green Norristown 19401 Food http://www.episcopal Kitchen Street Pantry church.org/parish/st- augustine-hippo- episcopal-church- norristown-pa St. Catherine of Siena 215-672-2881 321 Widmer Horsham 19044 Food http://www.stcatherin SVdP Road Pantry eschurch.org St. James Episcopal 267-901-4472 3814 Collegeville 19426 Food http://www.stjames- Church Germantown Pantry episcopal.org/default. Pike asp?sec_id=14000712 5 St. John's Episcopal 610-272-4090 23 E. Airy Norristown 19401 Food http://www.stjohnsno Church Soup Kitchen Street Pantry rristown.org St. Stanislaus Roman 215-368-1670 51 Lansdale Lansdale 19446 Food http://www.ststanisla Catholic Church Avenue (at Pantry us.com Main St) The Hospitality Center 610-277-1321 530 Church Norristown 19401 Food Street Pantry The Lamb Foundation 499 E. Walnut North Wales 19454 Food http://www.lambfoun St. Pantry dationpa.org The Open Door 610-948-4818 350 Main Royersford 19468 Food http://www.opendoor Street Pantry ministry.info The Open Link 215-679-4112 452 Penn Pennsburg 18023 Food http://www.theopenli Street Pantry nk.org Trinity United Church of 610-489-4223 532 E. Main Collegeville 19426 Food http://www.trinityucc Christ Street Pantry collegeville.org Willow Grove SDA 215-657-8364 1556 Fairview Willow 19090 Food http://willowgroveadv Church Avenue Grove Pantry entist.org

164

Appendix E- Other Assets Listing

Other Assets- Bucks and Montgomery Counties Name Phone Address City Zip Type Website Code Abington – Jefferson 215-481-2000 1200 Old York Abington 19001 Other http://www.jefferson. Health Clinics Road edu/abington Information Advanced Living 215-234-4022 1292 Allentown Lansdale 19438 Other http://www.advancedl Road ivingcommunities.org Aiding Our Neighbors 215-968-6208 188 S Canal St Yardley 19067 Clothing http://www.uwbucks. org/resources/aiding- our-neighbors/ Alzheimer's Association, 800-272-3900 620 Freedom King of 19046 Other http://www.alz.org/de Delaware Valley Chapter BLVD., Sute Prussia lval/ 101 Apple Child Care (215) 348- 70 W. Oakland Doylestown 18901 Children www.buckschildcare. Services, Inc. Bucks 1283 Avenue, Suite Services com County CCIS 102 Bethany Christian 215-376-6200 7827 Old York Elkins Park 19027 Children https://www.bethany. Services of the Greater Road Services org/philadelphia Delaware Valley Bridge of Hope BuxMont (267) 932- 121 East Souderton 18964 Other http://buxmont.bridge 8368 Chestnut Street, ofhopeinc.org/contact Suite 205 -us/general-contact- information/ Bucks County (215) 968- 400 Freedom Newtown 18940 Clothing http://www.bucksblin Association for the Blind 2010 Drive d.org/index.php?optio And Visually Impaired – n=com_content&vie Thrift Shop w=article&id=47&Ite mid=57 Bucks County Children (800) 282- 2325 Heritage Furlong 18925 Bridge http://www.buckscou & Youth 5785 Center Drive Housing nty.org Program Bucks County Health 215-348-6000 55 East Court Doylestown 18901 Other http://www.buckscou Department Street nty.org/government/h ealthservices/HealthD epartment Bucks County (800) 770- 705 Shady Doylestown 18901 Bridge http://www3.bucksiu. Intermediate Unit #22 4822 Retreat Road Housing org/site/default.aspx? Program PageID=1 Care & Share Thrift (215) 723- 783 Route 113 Souderton 18964 Clothing http://www.careandsh Shoppes, Inc. 0315 areshoppes.org Catalyst Center for (215) 345- 936 Easton Rd Warrington 18976 Other http://catalystnonprofi Nonprofit Mangement 2727 t.com/ Child, Home & (215) 348- 204 N. West St., Doylestown 18901 Children www.chicinfo.org Community, Inc. 9770 Suite 101 Services Community Connection- 610-278-3522 Human Services 19401 Other http://www.montcopa Navicate Center Norristown .org/index.aspx?NID 1st Floor =1586 1430 DeKalb Street Emilie United Methodist (215) 945- 7300 New Falls Fairless Hills 19030 Clothing http://emilieumc.com Church 5502 Rd

165

Other Assets- Bucks and Montgomery Counties Name Phone Address City Zip Type Website Code Family Service 215-757-6916 4 Cornerstone Langhorne 19047 Children http://www.fsabc.org Association of Bucks Drive Services County Full Circle Thrift Shop, (215) 340- Town Center at New Britain 18901 Clothing http://awomansplace. (A Woman's Place) 0120 Route 202 org/shop/in_full_swin g/what_is_in_full_sw ing.html Grace’s Closet, Grace (215) 723- Reliance Rd. & Telford 18969 Clothing http://gracemethodist. United Methodist Church 2144 South Main net Street Indian Valley Boys and 215-723-2402 115 Washington Souderton 18964 Other http://www.bgca.org/ Girls Club Ave Pages/index.aspx Indian Valley Chamber (215) 723- 211 E. Broad St Souderton 18946 Other http://indianvalleycha of Commerce 9472 mber.com/ Lutheran Children and (215) 881- 1256 Easton Roslyn 19001 Children http://www.lcfsinpa.o Family Service 6800 Road Services rg MCC, Inc. (Maternal (267) 525- 800 Clarmont Bensalem 19020 Children http://www.warwickf Child Consortium) & 7000 Avenue Services amilyservices.com Warwick Family Services

Montgomery County 610-278-5117 1430 DeKalb Norristown 19404 Other http://www.montcopa Health Department Street .org/index.aspx?nid= PO Box 311 513

New Clothing Outreach (215) 355- 21 Beechwood Huntingdon 19006 Clothing http://www.jlc.org/res Ministry 9529 Drive @ County Valley ources/county- c/o Evangelical Line Rd. resource- Fellowship Chapel guide/bucks/new- clothing-outreach- ministry North Penn Community (215) 716- 2506 N. Broad Colmar 18915 Other https://npchf.org/ Health Foundation 5400 St Suite 206 North Penn School (215) 368- 401 E. Hancock Lansdale 19446 Other http://www.npenn.org District 3960 St /site/default.aspx?Pag eID=1 North Penn Valley Boys 215-855-7791 16 Susquehanna Lansdale 19446 Other http://www.npvclub.o and Girls Club Ave rg NOVA Thriftstore (215) 249- Rt. 313 (1628 Fountainville 18923 Clothing http://www.novabuck 8000 Swamp Road) s.org/thriftshop/ One House at a Time (215) 346- 411 Ambler 19002 Other http://www.ohaat.org/ 6427 Susquehanna Rd Pennridge FISH (215) 257- 306 N. 5th Perkasie 18944 Clothing http://pennridgefish.o 7616 Street, Bldg. 3 rg Pennsuburban Chamber (215) 362- 229 S. Broad Lansdale 19446 Other https://pennsuburban. of Commerce 9200 Street org/ Pennsylvania Department (717) 798- P.O. Box 2675 Harrisburg 17105 Other http://www.dhs.pa.go of Human Services 9019 v/Feedback/index.ht m#.VmG4HtCwOec Personal Navigator (215) 572- 1421 Highland Abington 19001 Other http://www.vnacs.org

166

Other Assets- Bucks and Montgomery Counties Name Phone Address City Zip Type Website Code Program of VNA 7880 Avenue /index.php?page=pers onal-navigator- program Quality Child Care (215) 806- 705 Shady Doylestown 18901 Children http://www.bucksqcc Coalition of Bucks Co. 2802 Retreat Road Services c.org Roslyn Boys & Girls (215)-572- 2818 Hammond Roslyn 19001 Other http://www.rbgclub.o Club 1520 Plaza rg Souderton Area School (215) 723- 760 Lower Rd Souderton 18964 Other http://www.souderton District 6061 sd.org/ Successful Steps (215) 781- 1230 New Bristol 19007 Children N/A 8829 Rodgers Road, Services Suite F-3 Suited For Success (215) 781- 1230 Norton Bristol 19007 Clothing N/A 0200 Avenue Sunday Breakfast Rescue (215)741-1010 71 Bellevue Penndel 19040 Clothing http://www.sundaybr Mission Avenue eakfast.org Tabor Children's Service 215-348-4071 601 New Doylestown 18901 Children http://www.tabor.org Britain Road Services Teen Center 215-757-7823 Oxford Valley Langhorne 19047 Children https://www.fsabc.org Mall (between Services /program/teen-center/ JC Penney and Macy’s) 2300 East Lincoln Highway The Baby Bureau (215) 688- 225 Newton Warminster 18974 Clothing http://thebabybureau. 0538 Road org/ The Housing Link (800)-810- 275 Market St Nationwide 19001 Housing http://www.housingli 4434 #509 nk.org The Partnership TMA of (215) 997- 595 Bethlehem Montgomery- 18936 Other http://www.ptma- Montgomery County 9100 Pike ville mc.org/ Valley Youth House (215) 442- 800 N. York Warminster 18974 Children http://www.valleyyou (Bucks County) 9760 Road, Bldg. #22 Services thhouse.org Wiassahickon School (215) 619- 521 Houston Rd Ambler 19012 Other http://www.wsdweb.o District 8112 rg/ Wissahickon Valley (215) 646- 209 Race St Ambler 19012 Other http://www.wvpl.org/ Public Library 1072 Your Way Home (877) 646- 1 Montgomery Norristown 19404 Other http://yourwayhome.o 6306 Plaza, Suite 411 rg

167

References

1 An Integrated Framework for Assessing the Value of Community- Based Prevention – Institute of Medicine 2012 2 Principles of Community Engagement: Edition 2. Clinical and Translational Science Awards Consortium Community Engagement Key Function Committee Task Force on the Principles of Community Engagement. 2011; 11-7782. 3 Adapted From: Barr, V., Robinson, S.,Marin-Link, B., Underhill, L., Dotts, A., Ravensdale, D., & Salivaras, S. (2003). The Expanded Chronic Care Model: An Integration of Concepts and Strategies from Population Health Promotion and the Chronic Care Model. Hospital Quarterly, 7(1), 73-82. 4 hsc.unm.edu/community/toolkit/docs3/CMMI%20Diagram.pdf accessed May 4, 2013 5 Corrigan J, Fisher E, Heiser S. Hospital Community Benefit Programs: Increasing Benefits to Communities. JAMA.2015;313(12):1211-1212. doi:10.1001/jama.2015.0609 6 http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF - accessed 11/12/15 7 www.healthypeople.gov/ - accessed 3/1/13 8 http://www.countyhealthrankings.org/app/pennsylvania/2015/rankings/outcomes/overall / - accessed 11/10/15 9 http://cni.chw-interactive.org - accessed 11/10/15 10 http://health.gov/communication/literacy/quickguide/factsbasic.htm - accessed 11/10/15 11 http://aspe.hhs.gov/2015-poverty-guidelines#threshholds - accessed 11/10/15 12 http://pathwayspa.org.mytempweb.com/wp-content/uploads/2014/01/Overlooked-and- Undercounted-2012.pdf - accessed 11-21-15 13 http://www.countyhealthrankings.org/app/pennsylvania/2015/measure/factors/24/data - accessed November 10, 2015 14 http://www.countyhealthrankings.org/app/pennsylvania/2015/measure/factors/82/data 15 http://www.feedingamerica.org/hunger-in-america/our-research/map-the-meal- gap/2013/PA_AllCounties_CDs_MMG_2013.pdf 16 http://maps.communitycommons.org accessed 2-2-16 17 http://www.apa.org/pi/ses/resources/indicator/2012/06/household-food-insecurities.aspx - accessed 11/12/15 18 http://www.communitycommons.org/2015/11/how-food-insecurity-is-adding-to-our-health-care- costs/ - accessed 11/12/15 19 http://www.ncbi.nlm.nih.gov/pubmed/19272731 accessed 12-2-15 20 http://dnwssx4l7gl7s.cloudfront.net/phillyhunger/default/page/- /StateOfHunger_PA2013_FINAL.pdf - accessed 11-21-15 21 http://www.fns.usda.gov/pd/wic-program - accessed 11/12/15 22 http://www.countyhealthrankings.org/app/pennsylvania/2015/measure/additional/65/data -- accessed 11/10/15 23 North Penn United Way October 2015 eNewsletter. 24 http://www.dhs.pa.gov/cs/groups/webcontent/documents/document/c_213880.pdf - accessed 11/12/15 25 http://www.hungercoalition.org/food-stamp-statistics - accessed 11/12/15 26 http://www.montcopa.org/DocumentCenter/View/7719, page 53 - accessed 11/12/15

168

27 http://www.bls.gov/regions/mid-atlantic/news-release/unemployment_philadelphia.htm - accessed 11/12/15 28 http://beta.bls.gov/maps/cew/US?period=2015- Q1&industry=10&geo_id=US000&chartData=6&distribution=Quantiles&pos_color=blue&neg_colo r=orange&showHideChart=show&ownerType=0 - accessed 11/12/15. 29 Controlling the Cost and Impact of Absenteeism: Why Businesses Should Take a Closer Look at Outsourcing Absence Management, www.nationwidebetterhealth.com...outsourcing- absencemgmt.pdf - accessed on 10/10/10; no longer available 30 Health Affairs (Cohen, Gabriel, and Terrell). 2002 Sep-Oct; 21(5):90-102. 31 http://www.cdc.gov/dhdsp/docs/chw_brief.pdf accessed 12-21-2015 32 http://www.countyhealthrankings.org/app/pennsylvania/2015/measure/factors/43/data - accessed 11-12-15 33 Executive Summary, Crime in Pennsylvania, 2013 Annual Uniform Crime Report. 34 Takiff, Jonathan. "Penn traces the paths of young vicitms" Philadelphia Inquirer South Jersey edition, December 7, 2015, page B1. 35 http://www.countyhealthrankings.org/our-approach/health-factors/family-and-social-support - accessed 11-29-15 36 Branas, Cheney, McDonald, Tam, Ten Have, and Jackson, A difference-in-differences analysis of Health, Safety, and Greening Vacant Urban Space, American Journal of Epidemiology, November 2011. 37 Watson, DB, Moore H., Community Gardening and obesity, Perspectives in Public Health, special issue on obesity, Royal Society for Public Health vision, voice and Practice, July 2011, 131 (4): 163- 164. 38 http://www.uphs.upenn.edu/news/news_releases/2012/08/vacant/ - accessed 11-15-13 39 http://www.asla.org/2011awards/610.html – accessed 11-13-15 40 http://www.montcopa.org/DocumentCenter/View/7719 41 http://www.montcopa.org/DocumentCenter/View/7800 accessed 12-22-2015 42 https://www.enrollamerica.org/ accessed 12-10-15 43 https://s3.amazonaws.com/assets.enrollamerica.org/wp-content/uploads/2015/10/PA-State- Snapshot-2015-10-30.pdf accessed 12-10-15 44 Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, Mockbee J, Hale FA. Quick Assessment of Literacy in Primary Care: The Newest Vital Sign Ann Fam Med. 2006 January; 4(1): 83. 45 Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health Literacy and Mortality Among Elderly Persons - Arch Intern Med. 2007;167(14):1503-1509. 46 Bennett IM, Chen J, Soroui JS, White S, The Contribution of Health Literacy to Disparities in Self-Rated Health Status and Preventive Health Behaviors in Older Adults. Ann Fam Med. 2009 May; 7(3): 204–211. 47 https://nces.ed.gov/naal/kf_demographics.asp- accessed 11-13-15 48 www.iom.edu/Activities/PublicHealth/RtblHealthLiteracy.aspx - accessed March 5, 2013. 49 http://www.jointcommission.org/facts_about_patient-centered_communications/ - accessed 11-13- 15 50 Bass PF III, Wilson JF, Griffith CH, Barnett DR. Residents’ ability to identify patients with poor literacy skills. Academic Medicine. 77(10):1039-1041, October 2002.

169

51 Braddock CH, III, Fihn SD, Levinson W, et al. How doctors and patients discuss routine clinical decisions. Informed decision making in the outpatient setting. Journal of General Internal Medicine. 1997;12:33. 52 Williams MV1, Davis T, Parker RM, Weiss BD. The role of health literacy in patient-physician communication. Fam Med. 2002 May;34(5):383-9. http://www.ncbi.nlm.nih.gov/pubmed/12038721 53 Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio R. Using pictographs to enhance recall of spoken medical instructions. Patient Education and Counseling. Volume 35, Issue 2, 1 October 1998, pages 83–88. http://www.ncbi.nlm.nih.gov/pubmed/10026551 54 http://www.mhsoac.ca.gov/meetings/docs/Meetings/2010/June/CLCC_Tab_4_Towards_Culturally_C ompetent_System.pdf accessed 12-9-15 55 http://www.countyhealthrankings.org/rankings/data/PA accessed 11-17-15 56 https://apps.health.pa.gov/EpiQMS/asp/ChooseDataset.asp accessed 12-9-15 57 http://wwwn.cdc.gov/CommunityHealth/profile/currentprofile/PA/Montgomery/ accessed 12-21- 2015 58 http://wwwn.cdc.gov/CommunityHealth/profile/currentprofile/PA/Montgomery/ accessed 12-21- 2015 59 https://apps.health.pa.gov/EpiQMS/asp/SelectParams_Table_InfantDeath.asp accessed 12-9-15 60 http://www.statistics.health.pa.gov/HealthStatistics/VitalStatistics/FamilyHealthStatistics/Documents/ Family_Health_Statistics_Topic_Area_MICH_Cnty.pdf accessed 12-15-15 61 http://www.cdc.gov/asthma/brfss/2013/tableC1.htm accessed 11-18-15 62 http://www.cdc.gov/asthma/stateprofiles/Asthma_in_PA.pdf accessed 11-18-15 63 http://www.cdc.gov/nchs/pressroom/states/PA_2015.pdf accessed 11-18-15 64 http://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html accessed 11-18-15 65 http://www.cdc.gov/diabetes/atlas/countydata/County_ListofIndicators.html 66 http://www.diabetes.org/diabetes-basics/statistics/ accessed 11-19-15 67 http://www.philly.com/philly/health/20151201_ap_77806d38fea14df5ae0df5c260150898.html accessed 12-10-15 68 http://saveyoursolescampaign.com/pa-diabetes-map/ accessed 12-21-2015 69 http://www.ncbi.nlm.nih.gov/pubmed/22482843 accessed 12-20-15 70 http://www.cdc.gov/obesity/data/index.html accessed 11-19-15 71 http://stateofobesity.org/states/pa/ accessed 12-10-15 72 http://www.statistics.health.pa.gov/HealthStatistics/VitalStatistics/FamilyHealthStatistics/Documents/ Family_Health_Statistics_Topic_Area_MICH_Cnty.pdf page 22 accessed 12-9-15 73 http://www.americashealthrankings.org/PA/Suicide accessed 1-11-16 74 http://www.worldlifeexpectancy.com/usa/pennsylvania-suicide accessed 1-11-16 75 http://www.health.pa.gov/My%20Health/Diseases%20and%20Conditions/E- H/HIV%20And%20AIDS%20Epidemiology/Documents/2014%20Annual%20HIV%20Surveillance %20Summary%20Report.pdf Tables 5 and 9 accessed 1-12-16 76 http://kff.org/hivaids/state-indicator/hiv-testing-rate-ever-tested/ accessed 1-13-16 77 http://www.montcopa.org/AgendaCenter/ViewFile/Minutes/05202015-501 accessed 12-10-15 78 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for- service program. N Engl J Med. 2009 Apr 2; 360(14):1418-28. doi: 10.1056/NEJMsa0803563.

170

79 http://www.phc4.org/reports/readmissions/samecondition/14/docs/full-report.pdf 80 Pulse Check, Abington Hospital, FY 2015 81 http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics accessed 11- 25-15 82 http://www.statistics.health.pa.gov/HealthStatistics/CancerStatistics/CancerTables/Documents/Cance rDeaths_23SitesAgeSexRaceHispOrig_PA_2012.pdf accessed 11-25-15 83 Montgomery County Health Department 2014 Annual Health Statistics Report, Table D-11 84 http://www.cdc.gov/dhdsp/docs/gis_training_highlights_v5.pdf accessed 12-19-15 85 http://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/ accessed 11-25-15 86 http://www.philly.com/philly/health/20151226_Health_official__Holiday_hospital_shift__reminds_y ou_of_your_humanity_.html accessed 12-27-15 87 Sapatkin, Don. "Pa. young men's overdose deaths lead U.S. Philadelphia Inquirer. November 20, 2015. 88 Taylor, Daniel and Engster, Stacey. "Youths' higher use of marijuana." Philadelphia Inquirer. 11- 22-2015 p G3. 89 http://www.cdc.gov/healthyyouth/data/yrbs/index.htm - accessed 11-28-15. 90 http://www.cdc.gov/media/releases/2015/p0416-e-cigarette-use.html 91 http://www.buckscounty.org/docs/human-services-documents/2012-16fouryearplan.pdf?sfvrsn=2 accessed 11-29-15 92 http://www.montcopa.org/DocumentCenter/View/4347 - accessed 11-29-15 93 https://www.nia.nih.gov/alzheimers/publication/alzheimers-disease-fact-sheet accessed 1-4-16 94 http://aspe.hhs.gov/2015-poverty-guidelines#threshholds - accessed 11/10/15 95 https://npchf.org/sites/npchf.org/files/attachments/dual_eligible_report_final_2014_10.pdf accessed 12-2-15 96 http://www.feedingamerica.org/hunger-in-america/our-research/senior-hunger-research/or- spotlight-on-senior-health-executive-summary.pdf accessed 12-2-15 97 http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk accessed 12-18-15 98 http://yourwayhome.org/ywh-data accessed 12-19-15 99 https://www.dropbox.com/s/ugx2fsrj0s69isn/YWH%20Community%20Impact%20Report%202014- 15.pdf?dl=0 accessed 12-15-19 100 http://www.montcopa.org/documentcenter/view/5445 accessed 12-19-15

171

Abington Hospital Abington – Lansdale Hospital 1200 Old York Road 100 Medical Campus Drive Abington, PA 19001 Lansdale, PA 19446

Jeﬀerson.edu/Abington

Created March, 2016