Community Health Needs Assessment 2018 TABLE of CONTENTS

Sinai Hospital of Baltimore • Northwest Hospital • Levindale Hebrew Geriatric Center and Hospital

Community Health Needs Assessment 2018 TABLE OF CONTENTS

Executive Summary...... 3 LifeBridge Health Overview...... 4 The CHNA Process...... 6 Sinai Hospital of Baltimore ...... 12 Levindale Hebrew Geriatric Center and Hospital...... 27 Northwest Hospital...... 41 Appendix...... 56 Appendix A2 - Overall Survey Results...... 59 Appendix A3 - Sinai Hospital Survey Results...... 72 Appendix A4 - Levindale Survey Results...... 90 Appendix A5 - Northwest Survey Results ...... 106 Appendix B1 - Focus Group - LGBTQ...... 123 Appendix B2 - Focus Group - Disabilities ...... 125 Appendix B3 - Focus Group - Older Adults 1 ...... 126 Appendix B4 - Focus Group - Older Adults 2 ...... 127 Appendix B5 - Focus Group - Single Parents...... 128 Appendix B6 - Focus Group - Spanish Speaking...... 130 Appendix B7 - Focus Group - Currently Homeless Men and Women...... 132 Appendix B8 - Focus Group - Homeless Men in Temporary Housing at the Helping Up Mission (#1 of 2) . . . . 134 Appendix B9 - Focus Group - Homeless Men in Overnight Shelter Services at the Helping Up Mission (#2 of 2). . . 135 Appendix B10 - Focus Group - Cancer...... 136 Appendix B11 - Focus Group - Population Health Clients...... 137 Appendix C1 - Focus Group - Key Community Stakeholders...... 139 Appendix C2a - Sinai/Levindale Community Stakeholder Interviews...... 143 Appendix C2b - Northwest Community Stakeholder Interviews ...... 145 Appendix D1 - Sinai Public Health Data Summary ...... 149 Appendix D2 - CHNA Sinai Mortality Map ...... 153 Appendix D3 - CHNA Sinai Drug Alcohol Mortality Map...... 154 Appendix D4 - CHNA Sinai Family Poverty Map...... 155 Appendix D5 - CHNA Sinai Life Expectancy Map ...... 156 Appendix E1 - Kujichagulia Center Progress Report Sinai Program...... 156 Appendix E2 - Community Health Education Progress Report Sinai-Levindale-Northwest Program...... 157 Appendix E3 - Changing Hearts Program Progress Report Sinai-Levindale-Northwest Program...... 158 Appendix E4 - SAFE Program Progress Report Levindale Program...... 159 EXECUTIVE SUMMARY

Sinai Hospital of Baltimore, Levindale Hebrew Geriatric Center and Hospital, and Northwest Hospital conducted their Community Health Needs Assessments (CHNA) in fiscal year 2018 (July 1, 2017 – June 30, 2018). The CHNA complies with the Internal Revenue Service (IRS) mandated requirement that all not-for-profit 501(c)(3) hospitals conduct a CHNA every three years. The CHNA was conducted just two years after the prior CHNA to align with other area hospitals, enabling joint data collection and potential shared implementation projects. Involvement of residents, stakeholders, and community partners was an essential component of the CHNA process for the three hospitals.

The process used to identify the health needs of communities in the LifeBridge Health (LBH) service areas included analyzing primary and secondary health data at the hospital and community level, and involving public health experts, community members and key community groups in further identification of priority concerns and needs. In partnership with other Baltimore City hospitals, 4,755 public surveys were collected, including 1,678 from zip codes in the Primary Service Areas of the three LBH hospitals (Sinai, 1,283; Northwest, 756; Levindale, 409 with overlap among the service areas). Concurrently, a series of focus groups were conducted with residents that were either underrepresented or had higher need. Group meetings of regional leaders and private interviews with stakeholders from the neighborhoods served by the hospitals were also conducted.

The information was synthesized and presented to LifeBridge Health’s Community Mission Committee for evaluation to determine the LBH approach to address the priority needs. The prioritized needs correspond to the three major areas of inquiry from within the survey: 1) health concerns, 2) social/environmental concerns, and 3) reasons for lack of access to health care. The identified priorities are: behavioral health, chronic disease, job opportunities, access to doctors’ offices, health education/literacy, and insurance signups.

The Department of Population Health performed an assessment of hospitals’ resources, expertise and capacity to determine implementation plans to address these prioritized needs. The implementation plans address the priority needs in the three major areas of inquiry mentioned above for Sinai, Northwest and Levindale.

The Board of LifeBridge Health, Inc., approved the prioritized needs and implementation plans as recommended by the Community Mission Committee on March 15, 2018.

3 Community Health Needs Assessment LIFEBRIDGE HEALTH OVERVIEW Sinai Hospital of Baltimore Founded in 1866 as the Hebrew Hospital and Asylum, Sinai Hospital has evolved into a Jewish-sponsored health care organization providing care for all people. Today, Sinai Hospital is a 505-bed community teaching hospital that provides patient care in a variety of settings including inpatient, surgical, outpatient, trauma center (Level II designation), high risk Neonatal Unit, state-of-the-art Emergency Department, and responsive community outreach provided by M. Peter Moser Community Initiatives Department (Community Initiatives), an integral part of the Population Health Department. Sinai Hospital has 16 specialized clinical Centers of Excellence, including the Alvin & Lois Lapidus Cancer Institute, Sandra and Malcolm Berman Brain & Spine Institute, the Rubin Institute for Advanced Orthopedics, and the Krieger Eye Institute, and the Herman & Walter Samuelson Children’s Hospital.

Sinai Hospital is the most comprehensive and largest community hospital in Maryland and is the state’s third largest teaching hospital. Community teaching hospitals such as Sinai find one of their greatest strengths is their clinicians’ commitment to direct patient care. The residents and medical students who train at Sinai have chosen a community-teaching setting over a classic academic medical center setting. Sinai provides medical education and training to 2,000 medical students, residents, fellows, nursing students, and other health professionals each year from the Johns Hopkins University, University of Maryland, and other teaching institutions in the Baltimore/ Washington/ Southern Pennsylvania region.

Sinai Hospital is a member of the LifeBridge Health system, which was formed in 1998 by the merger between Sinai Health System, Inc., that included Sinai and Levindale Hebrew Geriatric Center and Hospital, and Northwest Health System, Inc. A fourth hospital, Carroll County Health Services Corporation, joined the LifeBridge Health system in April 2015.

Sinai Hospital completed its formal community health needs assessment as required and defined by the Patient Protection and Affordable Care Act and Section 501(r)(3) of the Internal Revenue Code during fiscal year 2018 (FY18).

Levindale Hebrew Geriatric Center and Hospital Levindale Hebrew Geriatric Center and Hospital was founded in Baltimore City in 1890 as the Hebrew Friendly Inn and Aged Home, giving temporary shelter to the waves of incoming Jewish immigrants fleeing persecution in Europe.

In 1927, the residents of the Hebrew Friendly Inn and Aged Home moved to a 22-acre lot at Greenspring and Belvedere Avenues in Baltimore, the former home of the Jewish Children’s Society orphanage. The facility was renamed Levindale, in honor of Louis Levin, secretary of the Children’s Society and first Executive Director of the Associated Jewish Charities.

Today, Levindale has evolved into a 330- licensed-bed facility. Levindale’s geriatric center includes 126 comprehensive care (long-term care) beds, 35 sub-acute beds, 28 dementia care beds and a 21-bed respiratory care unit. The Specialty Hospital at Levindale consists of a 40-bed high intensity care unit and an 80-bed behavioral health unit. Levindale also has two adult medical day centers; an outpatient mental health clinic and a geriatric partial day hospital program. As a multi-denominational geriatric hospital and long-term care facility, Levindale offers a complete range of quality health care programs for the elderly and disabled. In 2000, Levindale became the first registered Eden Alternative facility in Maryland. The Eden Alternative philosophy focuses on the joys of life for the elders who live

4 Overview here and the employees who work here. The goal is to eliminate loneliness, helplessness and boredom from the daily lives of Levindale residents through special programming incorporating gardening, pet visits and activities with area children.

Levindale is a member of LifeBridge Health – a Baltimore-based health system composed of Sinai Hospital of Baltimore, Northwest Hospital, Carroll County Health Services Corporation, and Levindale Hebrew Geriatric Center and Hospital – and is a constituent agency of The ASSOCIATED: Jewish Community Federation of Baltimore.

Levindale has completed a formal community health needs assessment as required and defined by the Patient Protection and Affordable Care Act and Section 501(r)(3) of the Internal Revenue Code during fiscal year 2018 (FY18).

Northwest Hospital

Northwest Hospital is an acute care, 238-bed community hospital located in Randallstown, Maryland. It has 164 medical/surgical beds, 37 psychiatric beds, and 39 subacute care beds. The hospital was originally established in 1962 as the Liberty Court Rehabilitation Center. A year later, the center changed its name to the Baltimore County General Hospital, and in 1993, made a final change to Northwest Hospital. The merger of Sinai Health System, Inc. and Northwest Health System, Inc. formed LifeBridge Health System, its parent corporation, in October 1998.

Today, Northwest Hospital maintains its mission to improve the well-being of the community by nurturing relationships between the hospital, medical staff and patients while providing the highest quality of care in a patient-centered environment. In keeping with Northwest Hospital’s philosophy of patient-centered care, its facilities have been designed around the Friesen concept, with nurse alcoves outside each patient room that enable nurses to spend more time with their patients. The Friesen-design hospital functions differently from the traditional hospital in that it creates an environment conducive to direct patient care through smaller 20-bed units; private patient rooms; elimination of nursing stations; and placing supplies, medications, and charts in close proximity to patients. Northwest delivers a broad array of inpatient, emergency and outpatient services to residents throughout the northwest corridor of the state, including Baltimore County, southern and eastern Carroll County, Baltimore City, and northern Howard County.

As a community-focused hospital center, Northwest’s services respond to a broad continuum of health care needs and serves patients either directly, through joint programs with other providers and health related agencies, or as an advocate for alternate sources of care. Northwest operates 10 Centers of Excellence including the Sandra and Malcolm Berman Brain & Spine Institute and the Herman & Walter Samuelson Breast Care Center. In 2010, Northwest received the Silver Plus Award from the American Heart Association and the Primary Stroke designation from the American Stroke Association. In 2011, the hospital’s subacute unit was named a U.S. News and World Report “Best Nursing Home.”

Northwest Hospital completed its formal community health needs assessment as required and defined by the Patient Protection and Affordable Care Act and Section 501(r)(3) of the Internal Revenue Code during fiscal year 2016 (FY16).

5 Community Health Needs Assessment THE CHNA PROCESS Internal CHNA team The following LifeBridge Health staff supported the CHNA process:

Employee Name Department Title Ademola Ekulona M. Peter Moser Community Initiatives Program Supervisor Alexis Harrison M. Peter Moser Community Initiatives Community Health Worker Andre Spell M. Peter Moser Community Initiatives Community Health Worker Belinda Haynie Care Coordination RN Navigator Beth Huber M. Peter Moser Community Initiatives Program Manager Brenda White Care Coordination Community Health Worker Darleen Won Population Health Assistant Vice President Garrick Williams M. Peter Moser Community Initiatives Community Outreach Worker Greg Matvey Population Health Senior Data Analyst Haley Deutsch Development Grants Manager Israel Patoka Government Relations and Community Development Director of Community Development Karen Adams Government Relations and Community Development Administrative Assistant Kashay Webb Population Health Student Intern Lane Levine Population Health Project Manager Livia Kessler Population Health Director of Business Intelligence Mae Hinnant Development Director of Grants Administration Marsha Green Office of Community Health Improvement Community Health Worker

Martha Nathanson Government Relations and Community Development Vice President Nymisha Nimmagadda Population Health Senior Operations Coordinator Rachael Taylor Development Grants Coordinator Rachel Roemer Marketing Community Coordinator Reverend Domanic Smith Office of Community Health Improvement Pastoral Outreach Coordinator Sharon Demarest Government Relations and Community Development Coordinator Sue Westgate Care Coordination Director of Community Care Coordination Terrie Dashiell Office of Community Health Improvement Program Manager Yolanda Marzouk Office of Community Health Improvement Program Development Coordinator

Information gathering Sinai Hospital of Baltimore, Levindale Hebrew Geriatric Center and Hospital, and Northwest Hospital conducted the CHNAs one year early in the three-year cycle. This allowed the hospitals to align with Carroll Hospital, also part of the LifeBridge Health system; and it also allowed an alignment of Sinai Hospital in a joint process with other hospitals in Baltimore City. Through shared tool development and information gathering, the joint process benefited Sinai as well as Levindale and Northwest.

6 The CHNA Process

Citywide collaboration Recognizing the potential benefits from aligning CHNA processes, Sinai agreed to shift the CHNA schedule by one year and collaborate with other Baltimore City-based hospitals in executing major aspects of the CHNA process. A Steering Committee governed this collaboration, which was largely executed by a Project Team. The activities within this collaboration included:

PROCESS PLANNING Public survey tool – the hospitals collaborated to develop a brief survey tool that would engage community members on the most important information related to their health . As a collaborative, it was decided to focus most of the questions on respondents’ opinions about community health needs, rather than respondents’ personal experiences of having those needs . See Appendix A1 for the survey tool . Collaboration in identifying public health informational needs from Baltimore City Health Department (BCHD) – the hospitals joined together with the Baltimore City Health Department to align the CHNA process with BCHD’s accreditation process . An agreement was set up whereby they would provide key public health data for hospitals’ Primary Service Areas, and the hospitals would share qualitative survey data with them . Members of the collaborative also participated in BCHD-led Local Health Improvement Coalition meetings to support their own process of identifying priority needs . Ultimately, the city hospitals came to an agreement about the data elements they wanted to receive from BCHD . Mutual technical support on best practices for hospital-specific CHNA processes – the Project Team and the overarching Steering Committee met on a regular basis and advised each other on best practices in implementing CHNAs . In many cases, the entire collaborative adopted an individual hospitals’ practice for the shared process; and LifeBridge Health hospitals adopted other hospitals’ practices for some of the internal processes . Prioritization and implementation – Community health leaders developed inventories of current and potential programming, convened experts and achieved agreement on direction for a shared strategy . The strategy and tactics will continue to be refined and defined through the Baltimore City hospital collaborative .

DATA COLLECTION Distribution of survey tool – all hospitals within the collaborative utilized individualized methods for reaching community members to respond to the public surveys . The overall effort resulted in the collection of 4,755 surveys from every zip code in Baltimore City, and some overlapping zip codes in Baltimore County (including those relevant to Northwest Hospital) . Facilitation of affinity-based focus groups – the hospitals reached out to their respective communities for organizational sponsors and focus group participants . While some hospitals organized certain focus groups exclusively to gather information from their own populations, such as participants from programs that a particular hospital administered, the majority of the focus groups involved participants from across the city and were co-facilitated by representatives from multiple hospitals . As a result, the hospitals agreed to share the results of these focus groups . This activity resulted in the completion of 10 shared focus groups, including many populations previously not surveyed . Hospitals either cross-promoted, shared contacts with host organizations, co-facilitated, co-sponsored or shared information from relevant groups with each other . Facilitation of stakeholder interviews – the hospitals collaborated in compiling invite lists for two meetings of leaders of organizations who are major partners in health care delivery . All the hospitals co-facilitated these meetings, bringing together 25 leaders to share their input about community health needs .

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DATA COLLECTION PROCESS Public survey tool University of Maryland Medical System hosted an internet-based tool on SurveyMonkey to accommodate the survey and record all responses . This allowed for online respondents to enter their responses directly . For Sinai, Northwest and Levindale, LifeBridge Health adopted the public survey tool created through the collaborative efforts of the city hospitals . A team was convened across various departments at LifeBridge Health, and the majority of two key staff members’ time for one month was dedicated to collecting surveys in-person . LifeBridge Health team members utilized a variety of methods to collect responses for the survey: -Distribution at community events -Distribution to individual clients and patients of LifeBridge Health programs -Dissemination to email lists of partner organizations -Dissemination to LifeBridge Health employee email lists -Collection of surveys from religious congregations Volunteers recruited by Sinai Hospital’s Patient Experience Department entered the data from paper responses into the SurveyMonkey tool . Focus groups Incorporating input from community-facing program staff, community health leadership at LifeBridge Health, and citywide partner hospitals, a listing of the various groupings of population was developed to attain a better understanding of community needs . These groups were identified either because they might represent a small portion of the population but have needs or a perspective that needed to be heard; or they represent a key population in the hospital service area . From these criteria, the collaborative identified nine groups and worked with partner organizations to recruit participants for the focus groups . In some cases, multiple groups were facilitated for one identity category . In the focus groups, the conversations were guided based on the same questions that were asked in the second half of the survey – focusing on key health and environmental/social concerns in the community, problems with access to health care, and general ideas that the participants had for community improvement . The priority concerns for each area of inquiry were summarized based on the amount of time spent on topics and the number of people expressing opinions about the issues . See the table below for a summary of the focus groups conducted by LifeBridge Health and the other hospitals in Baltimore City . See appendix B for notes from the focus groups .

Number of Focus Group Participants Host Organization Lead Hospital Homeless Residents (1) 5 Banner Neighborhoods Community Center Johns Hopkins Homeless Residents (2) 12 Helping Up Mission Johns Hopkins Homeless Residents (3) 12 Helping Up Mission Johns Hopkins LGBTQ (Lesbian, Gay, Bisexual, Transgender and Queer) 5 Chase Brexton Health Center Sinai LifeBridge Health Cancer Patients 3 LifeBridge Health Sinai/ Northwest LifeBridge Health Population Health Clients 2 LifeBridge Health Sinai/ Northwest Older Adults (1) 12 Zeta Healthy Aging Partnership Sinai/ St. Agnes Older Adults (2) 12 Mary Harvin Senior Center Johns Hopkins People with Disabilities 5 League for People with Disabilities Sinai Single Parents 8 Center for Urban Families Sinai Spanish Speaking Residents 7 East Baltimore Medical Center (Johns Hopkins) Johns Hopkins Transition-age Youth 20 Youth Opportunities Sinai/ St. Agnes

8 The CHNA Process

Stakeholder meetings In prior years, hospitals within the citywide collaborative have either reached a limited number of key stakeholders or have all approached the same stakeholders repeatedly . The first phenomenon led to insufficient data collection, and the second led to the inconveniencing of key partners . This year, community partners were pleased to learn that the hospitals planned to survey them together . The citywide collaborative identified the partner organizations that were important stakeholders in addressing community health needs . The task of inviting the organizations to group meetings was divided based on the hospital facilitating the meetings . Two meetings were held, which attracted a total of 25 leaders from partner organizations . As with the focus groups, the questions from the public survey were used to guide the discussions among the stakeholders . Leaders from the participating hospitals led breakout groups during the stakeholder meetings and facilitated dialogues with the support of note takers . The top concerns were determined based on the most prominent themes in the discussions .

Please see the following table for a listing of the participating key stakeholder organizations and staff who represented them.

Stakeholder Organization Staff Title American Diabetes Association, Tracy Newsome Director, Community Health Strategies Maryland Area American Heart Association, Rhonda Chatmon Vice President, Multi-Cultural Markets Mid-Atlantic Affiliate American Heart Association, Kimberly Mays Senior Director, Community Impact Mid-Atlantic Affiliate American Heart Association, Amanda Davani Quality and Systems Improvement Director Mid-Atlantic Affiliate Baltimore City Health Department Heang Tan Deputy Commissioner, Division on Aging and CARE Services Baltimore Medical System, Inc. Liz Kaylor VP of Development and Community Relations CHANA Jacke Schroeder Director, SAFE: Stop Abuse of Elders Chase Brexton Health Care Nate Sweeney Executive Director, LGBT Health Resource Center Comprehensive Housing Mitchell Posner Executive Director Assistance, Inc. Disability Rights Maryland Leslie Margolis Managing Attorney Green and Healthy Homes Initiative Michael McKnight Vice President of Policy and Innovation Jewish Community Services Karen Nettler Director, Community Connections Johns Hopkins University Elizabeth Tanner Director of Interprofessional Education, Community Public Health Nursing MedStar Center for Successful Adrienne Kilby Geriatric Social Worker Aging MedStar Center for Successful Margi Lenz Geriatric Social Worker Aging MedStar Total Elder Care Marina Nellius Community Social Worker Promise Heights Bronwyn Mayden Executive Director Sinai Hospital Vocational Services Mira Appleby Manager, Program Development Program University of Maryland Reba Cornman Director, Geriatrics and Gerontology Education and Research Program University of Maryland Kathryn Lothschuetz Montgomery Associate Professor and Chair, Department of Partnerships, Professional Education, and Practice University of Maryland Wendy Lane Director, Preventive Medicine Residency Program

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Stakeholder interviews In addition to the meetings with citywide stakeholders, one-on-one interviews were also conducted with stakeholders from the three LBH hospitals’ service areas . The following table illustrates the stakeholders that were interviewed individually outside of the collaborative meetings .

Hospital Service Area Organization Interviewee (s) Title Northwest Stevenswood Improvement Aaron Plymouth President Association Northwest Liberty Road Business Association Kelly Carter Executive Director Northwest Oakwood Village Community Vivian Paysour President Association Northwest Baltimore County Health Department Della Leister; Deputy Health Officer; Program Director, Laura Culbertson Baltimore County Home Health Sinai Park Heights Renaissance Tony Bridges Director of Human Services and Operations Sinai/ Levindale Park Heights Community Health Willie Flowers Executive Director Alliance Sinai/ Levindale Pimlico Elementary/Middle School LaJuan Alston; Principal; Community School Coordinator Malkia Pippin

Public health data The collaborative of city hospitals worked together with the Baltimore City Health Department to identify the relevant statistics for describing the communities surrounding each hospital . This supported identification of key public health measures for the Sinai and Levindale populations . Please see Appendix D for this information . Since the hospitals’ Primary Service Areas experience many problems, any priority chosen would be reflected in public health data thereby justifying the focus . Therefore, public health data was not used as a primary driver to guide the decisions on community priorities . However, publicly available data that illustrates the extent of the prioritized problems was included .

Prioritization process The prioritization of needs involved the following steps:

1. IDENTIFICATION OF PRIORITIES FROM EACH DATA SOURCE Public survey summarization – the Business Intelligence Team in LifeBridge Health’s Population Health Department used the data from all 4,755 public surveys collected to provide summaries of information from the respondents overall, as well as summaries breaking down the responses for the service areas of participating LBH hospitals . The summaries identified the top five responses to each of the three major questions in the survey . These served as an indication of the priorities of the general population . Focus groups – for each group, priorities were identified based on themes or priorities explicitly identified during the conversations . In several cases, the priorities that arose from focus groups were different from those of the general population – sometimes so different that they had not even been mentioned as an option in the survey . Stakeholder meetings and interviews – a similar method was used to identify priorities from the stakeholder meetings and interviews . Some priorities emerged that had not been listed as options in the public survey during these meetings as well .

10 The CHNA Process

2. GROUP DISCUSSION AND VOTING EXERCISE The compiled prioritized needs were presented to LifeBridge Health’s Community Mission Committee, an official committee that includes board members, executives from each hospital, staff with community-related responsibilities, and members-at-large from partnering community organizations . For ease of discussion, the groups were broken down into two subgroups . Using NACCHO guidelines1, facilitators from the Department of Population Health led freeform discussions that provided an opportunity to consider root causes and connections between community needs, and potential solutions . Each group decided on 1-2 priorities for each of the questions from the survey (health; environmental/social; and access) . The subgroups reported back to the whole group at the end, and 1-3 priorities were selected per survey question for each hospital . These priorities were regarded as the final decision for all three hospitals .

Implementation plan development Once the priorities were received from the Community Mission Committee, the Population Health Department engaged in a multi-stepped development and approval process to establish an implementation plan. Using a framework borrowed from MedStar Health, another collaborative partner, three potential types of implementation were identified: “Sponsor,” which would involve taking full ownership of an intervention or program; “Partner,” which would involve a referral relationship or other agreement to collaborate to provide services; or “Advocate,” which would involve working on policies and advocating for resources that would address the problems we had prioritized.

1. ORGANIZATIONAL SCAN The Population Health Department collaborated with the Development Department to discuss the priorities generated from the Community Mission Committee . A comprehensive understanding of the potential areas for expansion, growth through grant funding, or other means of development throughout the LBH system was achieved . Criteria used to determine the plans included: hospital’s ability to effect change, resource availability, alignment with current internal or external efforts, evidence-based strategy, and extent to which the strategy addresses the prioritized need .

2. PLAN REVIEW Program ideas were shared with managers within Population Health and other departments who are responsible for implementation of the solutions identified . These managers provided recommendations and feedback to the suggested plan . All staff involved in these discussions had previously collaborated with Population Health either as part of the Population Health Management Team, a system-wide quarterly collaboration meeting among programs addressing violence, or a similar system-wide regular meeting about various approaches to schools in the community .

3. PLAN APPROVAL The resulting implementation plan was presented to LifeBridge Health’s Community Mission Committee for final review . The Committee voted unanimously to recommend the plan for approval to the Board of LifeBridge Health . Finally, the chairperson of the Community Mission Committee presented the priorities and implementation plan to the LifeBridge Health Board, where they voted unanimously in approval .

1 National Association for County and City Health Officials, 2016 . White Paper: Community Health Status Assessment Core Health Indicators List

11 Community Health Needs Assessment SINAI HOSPITAL OF BALTIMORE

Sinai Hospital is located within the red and purple primary service areas.

Sinai Hospital is located in the northwest quadrant of Baltimore City, serving both its immediate neighbors and others throughout the Baltimore City and Baltimore County. The community served by Sinai Hospital can be defined by its Primary Service Area (PSA) and geographically represents the zip codes immediately surrounding Sinai Hospital.

The PSA is comprised of zip codes from which the top 60% of patient discharges originate. Listed in order from largest to smallest number of discharges for fiscal year 2014, Sinai Hospital’s PSA includes the following zip codes: 21215, 21207, 21208, 21209, 21117 and 21216 represented by the red and purple areas above.

12 Sinai Hospital of Baltimore

Community Demographics Although respondents in the sample size (n=1,283) were more likely to be older, female and African American compared to the general age distribution across the community, active steps were taken to hear from all parts of the community by conducting focus groups with populations that may have been underrepresented in the surveys.

General Population Survey Respondents Sinai Hospital Source: American Community Survey2 Source: Baltimore Citywide CHNA survey 2017

2010 Census: 253,870 Population 2016 Estimate: 261,160 1,283 2020 Projection: 264,365

0-17 yr: 0 (0%) 0-17 yr: 64,461 (24.7%) 18-64 yr: 851 (66.3%) Age 18-64 yr: 154,198 (59.0%) 65 yrs. and older: 409 (31.9%) 65 yrs. and older: 42,501 (16.3%) Prefer not to answer/no response: 23 (1.8%)

Income Income less than $15,000 (below FPL): 13,302 (13.3%) (Avg. Household Size: Income between $15,000 to $34,999: 18,027 (18%) 2.46; Income between $35,000 to $74,999: 31,165 (31.2%) Not asked in survey Est. Median Household Income between $75,000 to $99,999: 12,562 (12.6%) income: $62,467) Income over $100,000 or more: 24,961 (24.9%)

Male: 313 (24.4%) Male: 119,810 (45.9%) Female: 961 (74.9%) Gender Female: 141,350 (54.1%) Transgender: 2 (0.2%) Prefer not to answer/no response: 7 (0.5%)

White Alone: 83,761 (32.1%) White Alone: 269 (21.0%) Black or African American Alone: 160,871(61.6%) Black or African American Alone: 915 (71.3%) American Indian and Alaska Native Alone: American Indian and Alaska Native: 12 (0.9%) Race 455 (0.2%) Asian Alone: 10 (0.8%) Asian Alone: 8,815 (3.3%) Native Hawaiian or Other Pacific Islander: 6 (0.5%) Some Other Race Alone: 1,904 (0.7%) Other/multiple races: 130 (10.1%) Two or More Races: 5,354 (2.1%) Prefer not to answer: 36 (2.8%)

Hispanic or Latino: 42 (3.3%) Hispanic or Latino: 9,042 (3.5%) Ethnicity Not Hispanic or Latino: 1125 (87.7%) Not Hispanic or Latino: 252,118 (96.5%) Prefer not to answer/don’t know/no response: 116 (9.0%)

Less than 9th grade: 5,566 (2.7%) Some High School, no diploma: 17,039 (8.4%) High School Graduate (or GED): 55,630 (27.5%) Education Not asked in survey Some College, no degree: 45,791 (22.6%) College Degree: 50,375 (24.9%) Master’s Degree or above: 28,087 (13.9%)

2 https://factfinder .census .gov/faces/nav/jsf/pages/index .xhtml

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Prioritized Needs and Supporting Data The following prioritized needs were identified for the community served by Sinai Hospital:

HEALTH CONCERNS Behavioral health Survey evidence:

CHNA Number of Survey Responses X

In the surveys, mental health and substance abuse were provided as two distinct categories . Of all survey respondents, these two categories were the first and second most frequently identified health concerns . Among respondents from the Sinai service area, these categories were the first and third most frequently identified health concerns . The causes and solutions for mental health and substance abuse are often intertwined . Therefore, they were grouped together as “behavioral health” to address the needs in an appropriate way . Further, the survey

14 Sinai Hospital of Baltimore asked participants about their own experience of mental wellness . Among Sinai respondents, 22 .3% reported experiencing one or more days of mental health problems in the previous month .

Stakeholder feedback: In the stakeholder meetings, participants spoke about the effects of drug addiction on communities and how it impacts physical health, leading to chronic disease . Stakeholders also noted stigma and silence around mental health, the lack of treatment resources and the disproportionately high availability of liquor stores . Additionally, stakeholders in the Sinai service area identified behavioral health as a top priority and discussed the importance of schools as a site for addressing childhood trauma .

Focus group feedback: • The disabilities focus group identified drug abuse and mental health as top concerns . They discussed the high consumption of alcohol/drugs or food as a coping mechanism for dealing with the hardships of their disabilities . Similar to stakeholders, the group also linked these behaviors to additional physical health complications such as chronic disease . • The LGBTQ focus group identified drug/alcohol abuse and mental health as two of the most important health concerns . They see mental health as stigmatized and noted that Ryan White funding is the only way to access covered mental health services . • In the Single Parents focus group, participants noted the high prevalence of people with addictions on the streets of their neighborhoods . They stated that obtaining opioids was too easy; some of them had used or sold drugs themselves in the past – and some had been jailed for these offenses . • Similarly, the Transition-Age Youth focus group noted the high prevalence of drug use in their neighborhoods and spoke of family members who were active drug users . This group also noted that people do not generally receive the mental health support that they need . • The Spanish-speaking focus group noted the prevalence of drugs on the street, which they see as having risen in the last two years . • In the three focus groups with homeless people, drug abuse and mental health were conveyed as not only the most important problems, but the essential and defining problems for participants . One participant mentioned the use of drugs to cope with their difficult life as a homeless person . Another participant stated that mental health treatment was the only true priority/need, as it would reduce drug use and thus the consequence of homelessness . All participants in the homeless focus groups identified themselves as having been diagnosed with a mental health or substance abuse problems . • Sinai’s Population Health programs focused group also prioritized behavioral health . They spoke about trauma as a central source of mental health problems, and they spoke about the high density of liquor stores in their neighborhoods as a risk factor for alcoholism . • The cancer patient focus group mentioned mental health as it relates to the isolation that they see in themselves and their community members .

Public health data: • 18 percent of adults in Baltimore City report binge or heavy drinking (County Health Rankings 2018) • The age adjusted average number of mentally unhealthy days reported in past 30 days by adults was 4 .1 for Baltimore City (County Health Rankings 2018) • In 2017, the Baltimore City Health Department reported that although Baltimore City residents made up about 11 percent of Maryland’s total population, they have consistently represented 30 percent of all statewide inpatient hospital discharges for individuals with mental illness (White Paper 2017) .

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Chronic Disease Survey evidence:

30 participants did not provide information on Health Problems in their community.

Stakeholder feedback: In the Stakeholder meetings, participants touched on their observations of rising COPD rates, high prevalence of diabetes, and how the lifestyle in Baltimore causes and encourages obesity through the lack of healthy food and exercise options . All stakeholders from the Sinai service area mentioned some aspect of chronic disease – whether it was heart disease, obesity, or high blood pressure .

16 Sinai Hospital of Baltimore

• LGBTQ focus group participants spoke about HIV as a chronic disease . HIV does not fall under the same cluster as the other chronic diseases included, but some of the context for concern about HIV parallels the context for the concern about other chronic diseases . These include poverty and lack of adequate housing causing patients to deprioritize disease self-management, as well as the stigma and depression that accompany HIV . Since both themes are consistent with other chronic diseases, an approach to chronic disease could also take HIV into account . • Although the older adult focus groups did not touch on chronic disease as a top priority for the community, they did note certain behavioral factors associated closely with chronic disease management such as smoking and healthy food access . • The single parents focus group prioritized diabetes and spoke specifically about healthy food access as a related concern . • One of the homeless focus groups prioritized high blood pressure as a top concern . • The Population Health program participants identified smoking as a top health concern, a factor in chronic disease management . • The cancer focus group mentioned issues related to chronic disease management such as smoking and healthy eating . They also identified cancer as a top concern .

Public health data: The top causes of death in the CHNA area: cardiovascular disease, cancer (lung cancer is most common), stroke, and homicide (Baltimore City Health Department 2017) .

Mt.Washington/Coldspring Pimlico/Arlington/Hilltop Southern Park Heights Cross Country/Cheswolde Age-adjusted % of Total Age-adjusted % of Total Age-adjusted % of Total Age-adjusted % of Total Mortality Rate Deaths Mortality Rate Deaths Mortality Rate Deaths Mortality Rate Deaths (Deaths per (Deaths per (Deaths per (Deaths per 10,000) 10,000) 10,000) 10,000) Cardiovascular Disease 24.0 25.5 34.3 23.9 29.4 21.7 11.5 28.4 Cancer (all kinds) 17.1 18.0 27.2 19.5 29.1 21.9 11.5 23.0 Lung Cancer 3.8 3.8 7.8 5.5 10.1 7.7 2.7 5.4 Stroke 5.0 5.4 6.2 4.4 7.9 5.6 2.2 5.0 Homicide 0.6 0.4 9.3 5.3 5.6 4.3 0.3 0.4

Dorchester/Ashburton Howard Park/West Arlington Glen-Falstaff Age-adjusted % of Total Age-adjusted % of Total Age-adjusted % of Total Mortality Rate Deaths Mortality Rate Deaths Mortality Rate Deaths (Deaths per (Deaths per (Deaths per 10,000) 10,000) 10,000)

Cardiovascular Disease 22.8 23.6 29.0 24.9 19.6 28.0

Cancer (all kinds) 19.9 20.9 23.4 19.9 13.7 19.7 Lung Cancer 4.5 4.7 6.8 5.9 2.8 3.8 Stroke 4.3 4.5 8.9 7.6 4.0 5.5 Homicide 5.6 4.1 1.9 1.6 2.7 2.3

17 Community Health Needs Assessment

ENVIRONMENTAL/SOCIAL PROBLEMS

Job opportunities Survey evidence:

From the overall responses and Sinai hospital service area responses, the most commonly identified environmental/ social concern was neighborhood safety/violence . However, the second most commonly identified concern was lack of job opportunities . In the overall survey there was a difference of 10 votes between these neighborhood safety/violence and lack of job opportunities (1445 vs . 1435); for Sinai there was a difference of only one vote between these categories (419 vs . 418) . Reviewing this information, the Community Mission Committee cited two reasons for choosing job opportunities over neighborhood safety as a priority: 1) Sinai Hospital has already prioritized neighborhood safety/violence in the last two CHNAs (2012 and 2015) with the creation of Kujichagulia Center/ Street Violence Intervention Program (see appendix E1 for progress report) . This is an active program that will continue to expand 2) Community Mission Committee members discussed the importance of addressing underlying causes for the social concerns that are identified in the communities . They recognized that violence (as well as many behavioral health problems) could be tied back to lack of job opportunities as a common underlying cause .

Stakeholder feedback: The Stakeholder meetings did not prioritize job opportunities as the top environmental/social concerns . However, they did speak about the many aspects and manifestations of poverty in the community and identified the lack of employment opportunities as a direct cause of poverty . The Community Mission Committee took this connection into account in their decision to prioritize job opportunities . Some of the stakeholders in the Sinai service area prioritized or mentioned job opportunities and spoke about the need for workforce training and other support for employment, such as better transportation .

18 Sinai Hospital of Baltimore

• The single parents focus group specifically talked about the job readiness training program that the Center for Urban Families facilitates . Employment was the top priority, but the group saw themselves as responsible parties for rising to the challenge of employment – rather than identifying employment as an issue to be solved by hospitals or other organizations . They spoke about the difficult context in which they are attempting to launch their careers – including transportation and child care challenges . • The transition-age youth focus group also identified job opportunities as their top priority in the environmental/ social concerns category . They noted the connection between joblessness and violence/ drug use, positing that a lack of jobs leads young people to spend more time on the streets . Participants expressed the need for more job training in growing fields of opportunity, such as technology . • One of the three homeless focus groups (the group with homeless men in overnight shelter services) prioritized jobs/ unemployment as their top environmental/ social concern . Some participants noted that the lack of proper mental health and education services make it impossible for their population to maintain a steady job or a home . They also expressed a general need for job readiness training . • The focus group with Population Health participants also included job opportunities as one of their priorities . They spoke about the need for technology training, and the risk of unemployed community members resorting to selling drugs .

Public health data: Unemployment rate was 15% in the CHNA area (Baltimore City Health Department 2017). • Mt . Washington/Coldspring population (16 years of age and older): 4 .5% • Pimlico/Arlington/Hilltop population (16 years of age and older): 17 .1% • Southern Park Heights population (16 years of age and older): 23 .6% • Dorchester/Ashburton population (16 years of age and older): 21 .9% • Howard Park/West Arlington population (16 years of age and older): 12 .9% • Glen-Falstaff population (16 years of age and older): 16 .2% • Cross Country/Cheswolde (16 years of age and older): 6 .5% The family poverty rate was 27% for the CHNA area (Baltimore City Health Department 2017) • Mt . Washington/Coldspring (percentage of families with children under 18 years): 9 .6% • Pimlico/Arlington/Hilltop (percentage of families with children under 18 years): 28 .4% • Southern Park Heights (percentage of families with children under 18 years): 46 .4% • Dorchester/Ashburton (percentage of families with children under 18 years): 31 .6% • Howard Park/West Arlington (percentage of families with children under 18 years): 35 .1% • Glen-Falstaff (percentage of families with children under 18 years): 23 .9% • Cross Country/Cheswolde (percentage of families with children under 18 years): 10 .5% *Data from BCHD Neighborhood Health Profile Reports 2017.

19 Community Health Needs Assessment

ACCESS TO HEALTH CARE

Health Education/ Lack of knowledge about available resources Survey evidence:

55 participants did not provide information on Reasons For No Health Care in their community.

20 Sinai Hospital of Baltimore

Health education was not listed as an option in the survey under the question about why people do not get health care . Majority of freeform responses to the final question, “What ideas or suggestions do you have to improve the health in your community?” could be categorized as ideas about health education and health literacy . Please see Appendix A3 for a summary of the comments . In the future, health literacy and health education will be included as options under this question . Other topics that ranked high in the survey were areas in which LifeBridge is already implementing improvements (transportation access and reducing wait times) .

Stakeholder feedback: The participants in the meeting of key citywide stakeholders prioritized health education . Specifically, they spoke about patients’ problems understanding their benefits . Most of the stakeholders in the Sinai service area also prioritized health education and spoke about the low insurance sign-up rates due to lack of awareness and understanding about it .

Focus group feedback: • The older adults focus groups identified a desire to be better informed about the health care offerings available to them . • The Spanish-speaking focus group identified health education as a priority . Specifically, they felt uninformed about the safety of submitting certain documents in order to obtain health care, for fear of immigration enforcement . They also spoke of the need for more education about available community health resources and clinics where they can receive good care and be safe . They suggested that hospitals must conduct more awareness campaigns about their offerings . The group also spoke of the importance of following doctors’ orders, taking medication, and other activities of health maintenance . • The transition-age youth focus group identified lack of awareness about available resources as a top priority . They mentioned the importance of hospital employees working directly in the community, ensuring people understand what is available to them . • The homeless focus groups did not prioritize health education, but they mentioned the difficulty with navigating health care systems, a general lack of information, and a need for more information about services such as available screenings . • The Population Health program participants did not prioritize health education, but they spoke of the need for more advertising of available health services and programs . • The cancer focus group identified lack of knowledge about the health system as a priority – specifically the lack of knowledge about navigation .

Public health data: Neighborhoods in the CHNA catchment score in the lowest quartile for health literacy in Baltimore city with scores ranging from mid-fiftieth to low-sixtieth percentiles for basic or below basic percentiles (University of North Carolina Chapel Hill Health Literacy Data Map 2014) .

21 Community Health Needs Assessment

INSURANCE SIGNUPS

Survey evidence:

55 participants did not provide information on Reasons For No Health Care in their community.

The topic that ranked high on the survey, which the Community Mission Committee felt LifeBridge could influence, was “no insurance .” This topic ranked second for the overall survey (with 2719 votes) as well as for Sinai (760 votes) .

Stakeholder feedback: This topic did not come up as a theme in the Stakeholder meetings . Some of the stakeholders in the Sinai service area mentioned lack of insurance as a problem .

Focus group feedback: • The LGBTQ focus group identified lack of insurance as a priority linked with poverty and unemployment/ underemployment . • The Spanish-speaking focus group cited the importance of having health insurance – or some alternative to health insurance – as vital to the health of the community .

Public health data: Percentage of Residents with No Health Insurance

Mt. Washington Pimlico/Arlington Southern Dorchester/ Howard Park/ Cross Country/ /Coldspring /Hilltop Park Heights Ashburton West Arlington Glen-Falstaff Cheswolde Adults 18 years 5.2% 13.7% 16.8% 14.5% 9.8% 15.5% 7.4% and older Adults under 3.63% 10.1% 4.2% 2.0% 3.0% 3.7% 5.5% 18 years

*Data from BCHD Neighborhood Health Profile Reports 2017.

22 Sinai Hospital of Baltimore

Implementation Strategies

The table below illustrates the full list of priorities and implementation strategies for Sinai Hospital.

Health Education/

SINAI IMPLEMENTATION STRATEGY: Category: Health Concerns; Prioritized Need: Behavioral Health

Action to address the need: Implement SBIRT in the Emergency Department and Sinai Community Care, Sinai’s outpatient primary care clinic. Through a statewide grant, Sinai Hospital will be implementing the SBIRT or “Screening-Brief Intervention-Referral to Treatment” protocol in the Emergency Department and Sinai Community Care. This protocol is designed to work with patients who may have substance abuse problems and provide some level of support and navigation for them before they leave the facility. Programs and resources Planned collaboration with Anticipated impact Plan to evaluate impact to be used other facilities or organizations Patients in these The SBIRT implementation team will Using state grant funds, Sinai will work with Mosaic settings who are provide monthly reports on a variety Sinai employed Mosaic to to provide the training for experiencing drug of measures: train support workers, who the support workers in the addiction will be will provide the intervention. Emergency Department. The referred to proper • Number of unique patients seen hospital is also simultaneously treatment. • Number of patient encounters working with other facilities of LifeBridge Health, including Sinai • Number of SBIRT screens completed Community Care, the Northwest • Number of brief interventions Hospital Emergency Department, and the Carroll Hospital Emergency • Number of suspected overdoses Department, to implement these • Number of referrals to community programs. recovery coaches • Number of referrals to treatment • Number of Linkages to treatment

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Action to address the need: Partner, implement and advocate for a citywide behavioral health/housing strategy. In collaboration with other city hospitals, Sinai determined that a consistent and troubling problem is the lack of housing options for patients who are discharged from the Emergency Department and Inpatient setting. The hospitals brought together a citywide meeting of leaders and service providers in the field of housing and homelessness and decided that a Permanent Supportive Housing model would be an effective and sustainable initiative for patients across the city. The collaborative plans to work together over the next three years to create a strategy and funding source for this type of program, and begin implementation. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations Patients identified as expe- Sinai will collaborate Community Health Collaboration with other Baltimore riencing homelessness and with other Baltimore City leadership and the City hospitals, the Baltimore City behavioral health diagnoses hospitals to establish Development Department Mayor’s Office of Homelessness will be housed and provided goals and metrics for will continue participating Services, Health Care for the supportive services, which this intervention during in strategic conversations Homeless, and other organizations will lead to improved health the process of securing to fund these types of who share the goal of developing and decreased utilization of funding. initiatives. permanent supportive housing for high-cost hospital services. homeless patients.

SINAI IMPLEMENTATION STRATEGY: Category: Health Concerns; Prioritized Need: Chronic Disease Action to address the need: : Implement Diabetes Wellness Series. To complement the array of disease management programs and services that Sinai offers, the Hospital recognized the need to begin assisting people who are at risk of developing chronic diseases, in addition to those who live with chronic disease already. A four-part wellness series targeted towards pre-diabetic and diabetic people will be implemented. The curriculum focuses on healthy eating, exercise and stress reduction. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations Participants will lose The program involves This program will be imple- The curriculum and program design weight and increase their weekly weigh-ins and mented through the collab- provided by the Center for Disease levels of physical activity. self-reports of physical oration of the Community Control will be used. Sinai will also be Overall, the rates of onset activity. Diabetic health Health Education Team, the reaching out to partner organizations of diabetes amongst indicators including A1C Diabetes Resource Center, in the community to facilitate their own participants who are and glucose levels will and the Department of programs in partnership with LifeBridge diagnosed as prediabetic also be monitored. Employee Wellness. Health. will decrease.

Action to address the need: Continue to implement Changing Hearts Program. The program is focused on risk identification and prevention of heart disease within the Primary Service Area. Staff provides Live Heart Risk Assessments in the community to identify pre-hypertensive patients (assessment includes cholesterol, glucose, blood pressure and body composition analysis). Based on the assessment, health education counseling is provided by a registered nurse. Patients receive on-going support from staff to facilitate lifestyle changes. This includes follow-up calls and/or home visits by a CHW with a focus on individualized care plans developed with patients, lifestyle classes to maintain a long-term change, and educational material and resources to improve health. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations Program aims to maintain This program employs This program will be The program collaborates with many and improve behavioral nursing staff who check implemented by staff of community partners, including American and biometric outcomes, the identified measures the Office for Community Heart Association, Baltimore City Health such as blood pressure, on a regular basis. Health Improvement, Department Cardiovascular Disparities Task blood sugar, BMI, HDL, A Population Health which is a LifeBridge Force, Baltimore City Department of Aging, LDL, quality of life, smoking dashboard updates the Health system-wide American Stroke Association, Sandra and cessation, physical activity team with progress on office within the Malcolm Berman Brain and Spine Institute and healthy eating. these measures. Population Health Stroke Programs at LifeBridge Health, Department. ShopRite Howard Park, and Park Heights Community Health Alliance, and assorted community churches and businesses.

24 Sinai Hospital of Baltimore

SINAI IMPLEMENTATION STRATEGY: Category: Social/Environmental Concerns; Prioritized Need: Job Opportunities Action to address the need: Implement workforce readiness trainings for existing Population Health programs’ clients. Sinai’s workforce development program, VSP, provides workforce readiness training for people throughout Baltimore City. The target population for these services are people with disabilities and other qualifications to which funding sources are attached. A need was recognized among the hundreds of clients already served by the programs within Sinai’s Community Initiatives Department to receive the same kind of support as VSP clients. For instance, victims of domestic violence who are served by the Family Violence Program often have economic constraints that prevent them from leaving their abusive relationships, and they could benefit from workforce training and job counseling. Participants of Kujichagulia Center/ Street Violence Intervention Program already receive some level of workforce development, but they could benefit greatly from more support in being linked to hiring opportunities inside and outside of the organization. Sinai will seek funding to provide these services to willing clients from programs within the Community Initiatives Department. Programs and resources Planned collaboration with Anticipated impact Plan to evaluate impact to be used other facilities or organizations More clients of The number of VSP clients being referred The workforce development VSP works with a variety Population Health from Population Health programs, the and job placement resources of employers all over the programs will get success in completing job training, of VSP will be utilized for this metropolitan area for job jobs. entering the workforce and maintaining intervention. placements for its clients. employment will be tracked.

SINAI IMPLEMENTATION STRATEGY: Category: Access to Health Care; Prioritized Need: Health Education/ Knowledge of Available Resources Action to address the need: Add Pastoral Outreach Coordinator and Community Educator to Community Health Education Team. The Community Health Education Team has grown in past years in response to past needs highlighted in the Community Health Needs Assessment. Recognizing the many different approaches required to reach community members, positions were added and moved to provide more outreach to faith communities and offer new educational topics such as sexual health for teens. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations More people will be The number of people reached These two staff are The Community Health Education reached through health at each event has been tracked supervised by the Manager team collaborates with many fairs, educational through sign-in sheets. When of the Office of Community local partners, from churches to workshops and events. workshops or other programs Health Improvement. schools to the American Heart are conducted, the knowledge or Association and many more. health improvement among individuals in the program is evaluated.

SINAI IMPLEMENTATION STRATEGY: Category: Access to Health Care; Prioritized Need: Insurance Signups Action to address the need: Continue training application counselors who can assist patients with insurance signups. Through the Maryland Health Benefit Exchange, Sinai is certified as an ACSE – Application Counselor Sponsoring Entity. This allows the hospital to offer training and administrative support to any employee to assist patients or clients in signing up for insurance. Community Health Workers and Social Workers in the outpatient clinic and Population Health programs have been trained to provide these signups. This offer will be expanded to Medical Assistants and workers in other facilities. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations More patients will have A quarterly report with Client/patient-facing staff Sinai will collaborate with the insurance, which will lead to the number of people will add this intervention to Maryland Health Benefit Exchange more consistent treatment for assisted is provided. the services they are already to receive training and certification. patients who need it. providing.

Action to address the need: Encourage use of community organizations offering insurance signups. In addition to Sinai’s trained counselors, staff will be equipped with knowledge of organizations that provide full assistance for patients to sign up for insurance and refer or accompany patients to those organizations. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations More patients will have A quarterly report with the Client/patient-facing staff Sinai will collaborate with insurance, which will lead to number of people assisted is will add this intervention to the Maryland Health Benefit more consistent treatment for provided. the services they are already Exchange to receive training patients who need it. providing. and certification.

25 Community Health Needs Assessment Needs not addressed within implementation strategy Many of the following needs were identified either as top priorities by populations or conversations, but ultimately were not chosen by the Community Mission Committee as priority for implementation.

Neighborhood safety/violence: This was the top environmental/social concerns however, it was not prioritized this year since the Street Violence Intervention Program (SVIP) is a robust program actively working with victims of street violence . Sinai’s Kujichagulia Center hosts SVIP and partners with Baltimore City’s Safe Streets program to address conflicts as they arise . See Appendix E1 for the progress report about the Kujichagulia Center, which was an outgrowth of the 2012 CHNA and was expanded as a response to the 2015 CHNA . Housing/homelessness: Housing/ homelessness came up in several focus groups but did not arise as one of the most commonly identified priorities in the survey responses . This concern will be addressed through a collaborative with other city hospitals, which is committed to developing a housing strategy for behavioral health patients . Lack of transportation: Lack of transportation arose in the surveys as an important reason for why people do not get health care . Through the Care Management Department and other programs that work with people in the community, transportation funding is provided for many patients who need help in getting to their doctors’ appointments . Since patients and clients are served well by these resources, this concern was not prioritized as a target for further investment . Insurance too expensive: As a reason for why people do not get health care, this need received top scores across all zip codes . However, this is not within the purview of the hospital . Insurance not accepted: This reason ranked fourth on the public survey, but it was not addressed since Sinai Hospital accepts all forms of insurance . It was concluded that this problem would be best addressed by physician offices . Limited access to healthy foods: : Healthy food access came up in several surveys and discussions . There is a lot of interest throughout Baltimore City in addressing the problem of food desserts, but overall the need was not expressed as a top priority among community members . Poverty: Poverty came up as the fifth-highest priority in the Sinai and overall surveys, and as the number one priority among people with disabilities and LGBTQ group . However, since this need was determined to be a concern with various underlying factors, Sinai focused on addressing the underlying problems (including job readiness, transportation) leading to poverty . School dropout/poor schools: The focus groups with participants in younger demographics spoke about school- related problems . While LifeBridge Health is engaged in various ways with schools, these efforts are not geared towards improving overall school quality . Kujichagulia Center currently implements a mentorship program for middle schoolers focused on addressing bullying and violence in the African American/Black community . Wait is too long for care: : This problem surfaced as a commonly-identified need . A system-wide effort is being undertaken to address throughput in various hospital settings . This would not be taken on as a community benefit project but rather through quality leadership at the hospital . Broader problems, such as wait times for other health care services such as mental health therapy appointments in the community, are beyond the scope of the hospital . Stigma/discrimination: Stigma and discrimination showed up in some of the focus groups that were conducted . Although it was not prioritized as a central focus for the next three years, the concerns were shared with other parts of the system . The Clinically Integrated Network has begun addressing stigma and discrimination by instituting an LGBTQ-friendly Provider Network . Sinai Hospital’s Patient Experience Department has also hired a Patient Liaison for the LGBTQ community . Physicians not trustworthy: A few people mentioned this concern in focus groups . Addressing this issue was beyond the scope of community benefit .

26 Levindale Hebrew Geriatric Center and Hospital LEVINDALE HEBREW GERIATRIC CENTER AND HOSPITAL

Levindale Hebrew Geriatric Center and Hospital is located within the yellow primary service areas on the map.

Levindale Hebrew Geriatric Center and Hospital (“Levindale”) is located in the northwest quadrant of Baltimore City, serving both its immediate neighbors and others across the state of Maryland. Levindale primarily serves the elderly, frail, and ill in need of skilled long-term nursing, respite, dementia, respiratory, and comfort/hospice care. Due to the nature of the services provided and the lack of availability across the state, the population served by Levindale is not geographically representative of the community surrounding the hospital. SInce Levindale’s patients’ zip codes vary widely, the CHNA team focused primarily on 21215, the zip code in which Levindale’s community health improvement projects are targeted.

For attribution purposes of the CHNA survey respondents, the CHNA team utilized the HSCRC’s identified community benefit service area for Sinai Hospital of Baltimore, but focused on the respondents within that service area aged 65 and older.

27 Community Health Needs Assessment

Community demographics Although respondents in the sample size (n=409) were more likely to be female and African American compared to the general age distribution across the community, we took active steps to hear from all parts of the community by conducting focus groups with populations that may have been underrepresented in the surveys.

Levindale Demographics

General Population Survey Respondents Source: American Community Survey Source: Baltimore Citywide CHNA survey 2017

Population 2016 Estimate: 42,501 409

Income less than $15,000 (below FPL): 4,907 (17.7%) Income between $15,000 to $34,999: 7,066 (25.5%) Income Income between $35,000 to $74,999: 8,216 (29.8%) Not gathered in survey

Income between $75,000 to $99,999: 2,312 (8.4%) Income over $100,000 or more: 5,155 (18.6%)

Male: 91 (22.2%) Male: 16,980 (40%) Female: 318 (77.8%) Gender Female: 25,521 (60%) Transgender: 0 (0.0%) No response: 0 (0.0%)

White Alone: 97 (23.7%) White Alone: 18,041 (42.5%) Black or African American Alone: 287 (70.2%) Black or African American Alone: 22,775 (53.7%) American Indian and Alaska Native: 6 (1.5%) American Indian and Alaska Native Alone: 60 (0.1%) Race Asian Alone: 0 (0.0%) Asian Alone: 1,057 (2.5%) Native Hawaiian or Other Pacific Islander: 0 (0.0%) Some Other Race Alone: 144 (0.3%) Other/multiple races: 24 (5.9%) Two or More Races: 371 (0.9%) Prefer not to answer/don’t know: 10 (2.4%)

Hispanic or Latino: 4 (1.0%) Hispanic or Latino: 476 (1.1%) Ethnicity Not Hispanic or Latino: 352 (86.1%) Not Hispanic or Latino: 41,972 (98.9%) Prefer not to answer/no response: 53 (13.0%)

Less than 9th grade: 392 (6.2%) Some High School, no diploma: 429 (6.8%) High School Graduate (or GED): 1,258 (20%) Education Not gathered in survey Some College, no degree: 1,266 (20.1%) College Degree: 1,692 (26.8%) Master’s Degree or above: 1,271 (20.1%)

28 Levindale Hebrew Geriatric Center and Hospital

Prioritized Needs and Supporting Data The process identified the following prioritized needs for the community served by Levindale Hebrew and Geriatric Center. The responses from individuals living in the Sinai Primary Service Area who were over 65 were identified to represent the Levindale population.

HEALTH CONCERNS Behavioral health Survey evidence:

CHNA Number of Survey Responses X

Respondents to the survey who were categorized as Levindale community members (Sinai service area, age 65+) identified alcohol/drug addiction as the top priority . They did not identify mental health within the top five health priorities . Further, the survey asked participants about their own experience of mental wellness . Among Levindale respondents, 15 .9% of respondents reported experiencing one or more days of mental health problems in the previous month .

29 Community Health Needs Assessment

Stakeholder feedback: In the stakeholder meetings, participants spoke about the effects of drug addiction on communities and how it impacts physical health, leading to chronic disease . Stakeholders also noted stigma and silence around mental health, the lack of treatment resources and the disproportionately high availability of liquor stores . Additionally, stakeholders in the Levindale service area identified behavioral health as a top priority and discussed the importance of schools as a site for addressing childhood trauma .

30 Levindale Hebrew Geriatric Center and Hospital

Chronic Disease Survey evidence:

12 participants did not provide information on Health Problems in their community.

Respondents to the survey, who were categorized as Levindale community members, identified three of the options that have been bundled together as chronic disease (diabetes/ high blood sugar, heart disease/ blood pressure, and overweight/ obesity) as the second, third and fourth priorities .

Stakeholder feedback: In the Stakeholder meetings, participants touched on their observations of rising COPD rates, high prevalence of diabetes, and how the lifestyle in Baltimore causes and encourages obesity through the lack of healthy food and exercise options . All stakeholders from the Sinai/Levindale service area mentioned some aspect of chronic disease – whether it was heart disease, obesity, or high blood pressure .

Focus group feedback: • The disabilities focus group did not prioritize chronic disease, but they did speak about challenges with chronic disease management . They discussed the challenges with healthy eating due to financial constraints and their lack of agency when it comes to deciding which foods are prepared for them by caregivers . They also agreed as a group that disability can lead to depression, which can lead to sedentary living and neglect of healthy behaviors, resulting in chronic disease . • LGBTQ focus group participants spoke about HIV as a chronic disease . HIV does not fall under the same cluster as the other chronic diseases included, but some of the context for concern about HIV parallels the context for the concern about other chronic diseases . These include poverty and lack of adequate housing, causing patients to deprioritize disease self-management, as well as the stigma and depression that accompany HIV . Since both of these themes are consistent with other chronic diseases, an approach to chronic disease could also take HIV into account .

31 Community Health Needs Assessment

• Although the older adult focus groups did not touch on chronic disease as a top priority for the community, they did note certain behavioral factors associated closely with chronic disease management such as smoking and healthy food access . • The single parents focus group prioritized diabetes and spoke specifically about healthy food access as a related concern . • One of the homeless focus groups prioritized high blood pressure as a top concern . • The Population Health program participants identified smoking as a top health concern, a factor in chronic disease management . • The cancer focus group mentioned issues related to chronic disease management such as smoking and healthy eating . They also identified cancer as a top concern .

Public health data:

Cardiovascular Disease 24.0 25.5 34.3 23.9 29.4 21.7 11.5 28.4 Cancer (All kinds) 17.1 18.0 27.2 19.5 29.1 21.9 11.5 23.0 Lung Cancer 3.8 3.8 7.8 5.5 10.1 7.7 2.7 5.4 Stroke 5.0 5.4 6.2 4.4 7.9 5.6 2.2 5.0 Homicide 0.6 0.4 9.3 5.3 5.6 4.3 0.3 0.4

Cardiovascular Disease 22.8 23.6 29.0 24.9 19.6 28.0 Cancer (All kinds) 19.9 20.9 23.4 19.9 13.7 19.7 Lung Cancer 4.5 4.7 6.8 5.9 2.8 3.8 Stroke 4.3 4.5 8.9 7.6 4.0 5.5 Homicide 5.6 4.1 1.9 1.6 2.7 2.3

32 Levindale Hebrew Geriatric Center and Hospital

ENVIRONMENTAL/SOCIAL PROBLEMS Job opportunities Survey evidence:

From the overall response and the responses that were categorized as Levindale community members (Sinai service area, age 65+), the most commonly identified environmental/social concern was neighborhood safety/ violence . However, the second most commonly identified concern was lack of job opportunities . In the overall survey there was a difference of 10 votes between these categories (1445 vs . 1435); for Levindale there was a difference of 62 votes (425 vs . 363) . Reviewing this information, the Community Mission Committee cited two reasons for choosing job opportunities over neighborhood safety as a priority: 1) Levindale Hospital has the Stop Abuse of Elders (SAFE) program that is focused on treatment and prevention of elder abuse (see appendix E4 or progress report) . The greater impact of the SAFE program has been assessed at the statewide level, resulting in legislative action under the Maryland Health Care Decisions Act of 2017 . Several unique cases in the SAFE program shed light on inconsistencies in legal definitions of support allowed by surrogate decision makers . Specific examples of overarching ethical implications related to protective orders designed to aid victims with limited decision-making capacity, undermined by current surrogate decision maker guidelines have been identified .

2) Community Mission Committee members discussed the importance of addressing underlying causes for the social concerns that are identified in the communities . They felt that violence (as well as many behavioral health problems) could be tied back to lack of job opportunities as a common underlying cause . Although many Levindale community members are of retirement age, the changing economy requires increasing numbers of seniors to keep working or go back to work . The respondents may have been answering based on their assessment of the needs of their communities, and they may have also been speaking of their own situations .

Stakeholder feedback: The Stakeholder meetings did not prioritize job opportunities as the top environmental/social concerns . However, they discussed the various aspects and manifestations of poverty in the community and identified the lack of employment opportunities as a direct cause of poverty . The Community Mission Committee took this connection into account in their decision to prioritize job opportunities . Some of the stakeholders in the Sinai/Levindale service area prioritized job opportunities and mentioned about the need for workforce training and other support for employment, such as better transportation .

33 Community Health Needs Assessment

Focus group feedback: • The LGBTQ focus group identified poverty as a top social/ environmental concern . In keeping with the analysis about underlying causes, the group mentioned that employment is a crucial priority in attempting to address poverty . Additionally, they mentioned that many LGBTQ people are unemployed or employed in low-wage service jobs without health insurance, which leads to poverty and inability to manage their health . • The single parents focus group specifically talked about the job readiness training program that the Center for Urban Families facilitates . Employment was the top priority, but the group saw themselves as responsible parties for rising to the challenge of employment – rather than identifying employment as an issue to be solved by hospitals or other organizations . They spoke about the difficult context in which they are attempting to launch their careers – including transportation and child care challenges . • The transition-age youth focus group also identified job opportunities as their top priority in the environmental/ social concerns category . They noted the connection between joblessness and violence/ drug use, positing that a lack of jobs leads young people to spend more time on the streets . Participants expressed the need for more job training in growing fields of opportunity, such as technology . • One of the three homeless focus groups (the group with homeless men in overnight shelter services) prioritized jobs/ unemployment as their top environmental/ social concern . Some participants noted that the lack of proper mental health and education services make it impossible for their population to maintain a steady job or a home . They also expressed a general need for job readiness training . • The focus group with Population Health participants also included job opportunities as one of their priorities . They spoke about the need for technology training, and the risk of unemployed community members resorting to selling drugs .

PUBLIC HEALTH DATA Unemployment rate was 15% in the CHNA area (Baltimore City Health Department 2017). • Mt . Washington/Coldspring population (16 years of age and older): 4 .5% • Pimlico/Arlington/Hilltop population (16 years of age and older): 17 .1% • Southern Park Heights population (16 years of age and older): 23 .6% • Dorchester/Ashburton population (16 years of age and older): 21 .9% • Howard Park/West Arlington population (16 years of age and older): 12 .9% • Glen-Falstaff population (16 years of age and older): 16 .2% • Cross-Country/Cheswolde (16 years of age and older): 6 .5% The family poverty rate was 27% for the CHNA area (Baltimore City Health Department 2017) • Mt . Washington/Coldspring (percentage of families with children under 18 years): 9 .6% • Pimlico/Arlington/Hilltop (percentage of families with children under 18 years): 28 .4% • Southern Park Heights (percentage of families with children under 18 years): 46 .4% • Dorchester/Ashburton (percentage of families with children under 18 years): 31 .6% • Howard Park/West Arlington (percentage of families with children under 18 years): 35 .1% • Glen-Falstaff (percentage of families with children under 18 years): 23 .9% • Cross-Country/Cheswolde (percentage of families with children under 18 years): 10 .5% Data from BCHD Neighborhood Health Profile Reports 2017.

34 Levindale Hebrew Geriatric Center and Hospital

ACCESS TO HEALTH CARE Health Education/Lack of knowledge about available resources. Survey evidence:

Health education was not listed as an option in the survey under the question about why people do not get health care . Majority of freeform responses to the final question, “What ideas or suggestions do you have to improve the health in your community?” could be categorized as ideas about health education and health literacy . Please see Appendix A4 for a summary of the comments . In the future, health literacy and health education will be included as options under this question . Other topics that ranked high in the survey were areas in which LifeBridge is already implementing improvements (transportation access and reducing wait times) .

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area also prioritized health education and spoke about the low insurance sign-up rates due to lack of awareness and understanding about it . A general need for more education all around was also mentioned .

Insurance signups

Survey evidence:

36 Levindale Hebrew Geriatric Center and Hospital

The topic that ranked high on the survey, which the Community Mission Committee felt LifeBridge Health could influence, was “no insurance .” This topic ranked second for the overall survey (with 2719 votes) as well as for Levindale (210 votes) .

Stakeholder feedback: This topic did not come up as a theme in the Stakeholder meetings . Some of the stakeholders in the Sinai service area mentioned lack of insurance as a problem .

Public health data: Percentage of Residents with No Health Insurance

Mt. Washington/ Pimlico/Arlington Southern Dorchester/ Howard Park/ Cross Country/ Coldspring /Hilltop Park Heights Ashburton West Arlington Glen-Falstaff Cheswolde

Adults 18 years and 5.2% 13.7% 16.8% 14.5% 9.8% 15.5% 7.4% older

Adults under 18 3.63% 10.1% 4.2% 2.0% 3.0% 3.7% 5.5% years Data from BCHD Neighborhood Health Profile Reports 2017.

Implementation Strategies We identified the following implementation plan to address the prioritized needs for the Levindale community.

Health Education/ Knowledge of available resources

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LEVINDALE IMPLEMENTATION STRATEGY: Category: Health Concerns; Prioritized Need: Behavioral Health

Action to address the need: Partner, implement and advocate for a citywide behavioral health/housing strategy. In collaboration with other city hospitals, Levindale determined that a consistent and troubling problem is the lack of housing options for patients who are discharged from the Emergency Department and Inpatient setting. The hospitals brought together a citywide meeting of leaders and service providers in the field of housing and homelessness and decided that a Permanent Supportive Housing model would be an effective and sustainable initiative for patients across the city. The collaborative plans to work together over the next three years to create a strategy and funding source for this type of program, and begin implementation. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations Patients identified as expe- Levindale will collaborate with Community Health Collaboration with other Baltimore riencing homelessness and other Baltimore City hospitals leadership and the City hospitals, the Baltimore City behavioral health diagnoses to establish goals and metrics Development Department Mayor’s Office of Homelessness will be housed and provided for this intervention during the will continue participating Services, Health Care for the supportive services, which process of securing funding. in strategic conversations Homeless, and other organizations will lead to improved health to fund these types of who share the goal of developing and decreased utilization of initiatives. permanent supportive housing for high-cost hospital services. homeless patients.

LEVINDALE IMPLEMENTATION STRATEGY: Category: Health Concerns; Prioritized Need: Chronic Disease

Action to address the need: Implement Diabetes Wellness Series. To complement the array of disease management programs and services, Levindale recognized the need to begin addressing people who are at risk of developing chronic diseases, in addition to those who live with chronic disease already. A four-part wellness series targeted towards pre-diabetic and diabetic members will be implemented. The curriculum focuses on healthy eating, exercise and stress reduction. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations Participants will lose weight The program involves weekly This program will be The curriculum and program design and increase their levels of weigh-ins and self-reports of implemented through provided by the Center for Disease physical activity. Overall, the physical activity. Diabetic health the collaboration of the Control will be used. Sinai will also rates of onset of diabetes indicators including A1C and Community Health be reaching out to partner amongst participants who glucose levels will also be Education Team, the organizations in the community are diagnosed as prediabetic monitored. Diabetes Resource Center, to facilitate their own programs in will decrease. and the Department of partnership with LifeBridge Health. Employee Wellness.

LEVINDALE IMPLEMENTATION STRATEGY: Category: Health Concerns; Prioritized Need: Chronic Disease

Action to address the need: Continue to implement Changing Hearts Program. The program is focused on risk identification and prevention of heart disease within the Primary Service Area. Staff provides Live Heart Risk Assessments in the community to identify pre-hypertensive patients (assessment includes cholesterol, glucose, blood pressure and body composition analysis). Based on the assessment, health education counseling is provided by a registered nurse. Patients receive on-going support from staff to facilitate lifestyle changes. This includes follow-up calls and/or home visits by a CHW with a focus on individualized care plans developed with patients, lifestyle classes to maintain a long-term change, and educational material and resources to improve health. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations Program aims to maintain This program employs This program will be The program collaborates with many and improve behavioral nursing staff who check the implemented by staff of the community partners, including and biometric outcomes, identified measures on a Office for Community Health American Heart Association, Baltimore such as blood pressure, regular basis. A Population Improvement, which is a City Health Department Cardiovascular blood sugar, BMI, HDL, Health dashboard updates LifeBridge Health Disparities Task Force, Baltimore City LDL, quality of life, smoking the team with progress on system-wide office within Department of Aging, American Stroke cessation, physical activity these measures. the Population Health Association, Sandra and Malcolm and healthy eating. Department. Berman Brain and Spine Institute Stroke Programs at LifeBridge Health, ShopRite Howard Park, and Park Heights Community Health Alliance, and assorted community churches and businesses.

38 Levindale Hebrew Geriatric Center and Hospital

LEVINDALE IMPLEMENTATION STRATEGY: Category: Social/Environmental Concerns; Prioritized Need: Job opportunities Action to address the need: Implement workforce readiness trainings for existing Population Health programs’ clients. Sinai’s workforce development program, VSP, provides workforce readiness training for people throughout Baltimore City. The target populations for these services are people with disabilities and other qualifications to which funding sources are attached. A need was recognized among the hundreds of clients already served by the programs within Sinai’s Community Initiatives Department to receive the same kind of support as VSP clients. For instance, victims of domestic violence who are served by the Family Violence Program often have economic constraints that prevent them from leaving their abusive relationships, and they could benefit from workforce training and job counseling. Participants of Kujichagulia Center/ Street Violence Intervention Program already receive some level of workforce development, but they could benefit greatly from more support in being linked to hiring opportunities inside and outside of the organization. LifeBridge Health will seek funding to provide these services to willing clients from programs within the Community Initiatives Department. Programs and resources Planned collaboration with Anticipated impact Plan to evaluate impact to be used other facilities or organizations More clients of The number of VSP clients being re- The workforce development VSP works with a variety Population Health ferred from Population Health programs, and job placement resources of employers all over the programs will get the success in completing job training, of VSP will be utilized for this metropolitan area for job jobs. entering the workforce and maintaining intervention. placements for its clients. employment will be tracked.

LEVINDALE IMPLEMENTATION STRATEGY: Category: Access to Health Care; Prioritized Need: Health Education/ Knowledge of Available Resources Action to address the need: Add Pastoral Outreach Coordinator and Community Educator to Community Health Education Team. The Community Health Education Team has grown in past years in response to past needs highlighted in the Community Health Needs Assessment. Recognizing the many different approaches required to reach community members, positions were added and moved to provide more outreach to faith communities and offer new educational topics such as sexual health for teens. Programs and resources to Planned collaboration with other Anticipated impact Plan to evaluate impact be used facilities or organizations More people will be reached The number of people reached at These two staff are The Community Health Education through health fairs, each event has been tracked supervised by the Manager team collaborates with many local educational workshops through sign-in sheets. When of the Office of Community partners, from churches to schools and events. workshops or other programs are Health Improvement. to the American Heart Association conducted, the knowledge or health and many more. improvement among individuals in the program is evaluated.

LEVINDALE IMPLEMENTATION STRATEGY: Category: Access to Health Care; Prioritized Need: Insurance Signups Action to address the need: Continue training application counselors who can assist patients with insurance signups. Through the Maryland Health Benefit Exchange, Sinai is certified as an ACSE – Application Counselor Sponsoring Entity. This allows the hospital to offer training and administrative support to any employee to assist patients or clients in signing up for insurance. Community Health Workers and Social Workers in the outpatient clinic and Population Health programs have been trained to provide these signups. This offer will be expanded to Medical Assistants and workers in other facilities. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations More patients will have A quarterly report with the Client/patient-facing staff LifeBridge Health will collaborate insurance, which will lead to number of people assisted will add this intervention to with the Maryland Health Benefit more consistent treatment for is provided. the services they are already Exchange to receive training and patients who need it. providing. certification.

Action to address the need: Encourage use of community organizations offering insurance signups. In addition to Sinai’s trained counselors, staff will be equipped with knowledge of organizations that provide full assistance for patients to sign up for insurance and refer or accompany patients to those organizations. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations More patients will have A quarterly report with the Client/patient-facing staff LifeBridge Health will collaborate insurance, which will lead to number of people assisted will add this intervention to with the Maryland Health Benefit more consistent treatment for is provided. the services they are already Exchange to receive training and patients who need it. providing. certification.

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Needs Not Addressed within Implementation Strategy Many of the following needs were identified either as top priorities by populations or conversations, but ultimately were not chosen by the Community Mission Committee as priority for implementation. Neighborhood Safety/Violence: This was the top environmental/social concerns however, it was not prioritized this year since the Street Violence Intervention Program (SVIP) is a robust program actively working with victims of street violence . Sinai’s Kujichagulia Center hosts SVIP and partners with Baltimore City’s Safe Streets program to address conflicts as they arise . See Appendix E1 for the progress report about the Kujichagulia Center, which was an outgrowth of the 2012 CHNA and was expanded as a response to the 2015 CHNA . Housing/Homelessness: Housing/homelessness came up in several focus groups but did not arise as one of the most commonly identified priorities in the survey responses . This concern will be addressed through a collaborative with other city hospitals, which is committed to developing a housing strategy for behavioral health patients . Lack of transportation: Lack of transportation arose in the surveys as an important reason for why people do not get health care . Through the Care Management Department and other programs that work with people in the community, transportation funding is provided for many patients who need help in getting to their doctors’ appointments . Since patients and clients are served well by these resources, this concern was not prioritized as a target for further investment . Insurance too expensive: As a reason for why people do not get health care, this need received top scores across all zip codes . However, this is not within the purview of the hospital . Insurance not accepted: This reason ranked fourth on the public survey, but it was not addressed since Sinai Hospital accepts all forms of insurance . It was concluded that this problem would be best addressed by physician offices . Limited access to healthy foods: Healthy food access came up in several surveys and discussions . There is a lot of interest throughout Baltimore City in addressing the problem of food desserts, but overall the need was not expressed as a top priority among community members . Poverty: Poverty came up as the fifth-highest priority in the Levindale and overall surveys, and as the number one priority among people with disabilities and LGBTQ group . However, since this need was determined to be a concern with various underlying factors, Levindale focused on addressing the underlying problems (including job readiness, transportation) leading to poverty . School dropout/poor schools: The focus groups with participants in younger demographics spoke about school-related problems . While LifeBridge Health is engaged in various ways with schools, these efforts are not geared towards improving overall school quality . Kujichagulia Center currently implements a mentorship program for middle schoolers focused on addressing bullying and violence in the African American/Black community . Wait is too long for care: This problem surfaced as a commonly- identified need . A system-wide effort is being undertaken to address throughput in various hospital settings . This would not be taken on as a community benefit project but rather through quality leadership at the hospital . Broader problems, such as wait times for other health care services such as mental health therapy appointments in the community, are beyond the scope of the hospital . Stigma/discrimination: Stigma and discrimination showed up in some of the focus groups that were conducted . Although it was not prioritized as a central focus for the next three years, the concerns were shared with other parts of the system . The Clinically Integrated Network has begun addressing stigma and discrimination by instituting an LGBTQ-friendly Provider Network . Physicians not trustworthy: A few people mentioned this concern in focus groups . Addressing this issue was beyond the scope of community benefit .

40 Northwest Hospital NORTHWEST HOSPITAL

Northwest Hospital is located within the blue and purple primary service areas on the map.

Northwest Hospital is located in the northwest quadrant of Baltimore, in the Randallstown community of Baltimore County, serving patients throughout the Baltimore City and Baltimore County regions. The community served by Northwest Hospital can be defined by Northwest Hospital’s PSA, represented as the zip codes immediately surrounding Northwest Hospital.

The PSA is comprised of zip codes from which the top 60% of patient discharges from the hospital originate. Listed in order from largest to smallest number of discharges for fiscal year 2014, Northwest Hospital’s PSA includes the following zip codes: 21117, 21133, 21136, 21207, 21208, and 21244 represented by the blue and purple areas above.

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Community Demographics Although respondents in the sample size (n=756) were more likely to be older, female and African American compared to the general age distribution across the community, we took active steps to hear from all parts of the community by conducting focus groups with populations that may have been underrepresented in the surveys.

Northwest Hospital Primary Service Area General Population Survey Respondents Source: American Community Survey Source: Baltimore Citywide CHNA survey 2017 2010 Census: 231,908 Population 2016 Estimate: 246,902 756 2020 Projection: 250,445 0-17 yr: 0 (0%) 0-17 yr: 55,515 (22.5%) 18-64 yr: 531 (70.2%) Age 18-64 yr: 154,825 (62.7%) 65 yrs. and older: 214 (28.3%) 65 yrs. and older: 36,562 (14.8%) Prefer not to answer/no response: 11 (1.5%) Income less than $15,000 (below FPL): 7,909 (8.4%) Income between $15,000 to $34,999: 12,771 (13.6%) Income Income between $35,000 to $74,999: 30,790 (32.9%) Not gathered in survey

Income between $75,000 to $99,999: 13,175 (14.1%) Income over $100,000 or more: 29,047 (31%) Male: 172 (22.8%) Male: 114,008 (46.2%) Female: 578 (76.5%) Gender Female: 132,894 (53.8%) Transgender: 1 (0.1%) Prefer not to answer/no response: 5 (0.7%) White Alone: 84,034 (34%) White Alone: 216 (28.6%) Black or African American Alone: 142,727(57.8%) Black or African American Alone: 469 (62.0%) American Indian and Alaska Native Alone: 462 (0.2%) American Indian and Alaska Native: 12 (1.6%) Race Asian Alone: 12,000 (4.9%) Asian Alone: 9 (1.2%) Some Other Race Alone: 2,210 (0.9%) Other/multiple races: 31 (4.1%) Two or More Races: 5,469 (2.2%) Prefer not to answer: 36 (4.8%) Hispanic or Latino: 25 (3.3%) Hispanic or Latino: 12,322 (5%) Ethnicity Not Hispanic or Latino: 669 (88.5%) Not Hispanic or Latino: 234,580 (95%) Prefer not to answer/don’t know/no response: 62 (8.2%) Less than 9th grade: 6,581 (3.7%) Some High School, no diploma: 8,852 (4.8%) High School Graduate (or GED): 41,695 (22.6%) Education Not gathered in survey Some College, no degree: 45,189 (24.5%) College Degree: 55,164 (29.9%) Master’s Degree or above: 26,806 (14.5%)

42 Northwest Hospital

Prioritized Needs and Supporting Data

The following prioritized needs were identified for the community served by Northwest Hospital:

HEALTH CONCERNS Behavioral health Survey evidence:

CHNA Number of Survey Responses X

In the surveys, mental health and substance abuse were provided as two distinct categories . Of all survey respondents, these two categories were the first and second most frequently identified health concerns . Among respondents from the Northwest service area, these categories were the second and fourth most frequently identified health concerns . The causes and solutions for mental health and substance abuse are often intertwined . Therefore, they were grouped together as “behavioral” health to address the needs in an appropriate way . Further, the survey asked participants about their own experience of mental wellness . Among Northwest respondents, 21 .6% reported experiencing one or more days of mental health problems in the previous month .

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Stakeholder feedback: In the stakeholder’s meetings, participants spoke about the effects of drug addiction on communities and how it impacts physical health, leading to chronic disease . Stakeholders also noted stigma and silence around mental health, the lack of treatment resources and the disproportionately high availability of liquor stores . Most of the stakeholders in the Northwest service area identified behavioral health as a top priority . Additionally, the Baltimore County Health Department officials noted the presence of opioid crisis in the community and the lack of treatment for mental health disorders .

Public health data: • 16 percent of adults in Baltimore County report binge or heavy drinking (County Health Rankings 2018) • The age adjusted average number of mentally unhealthy days reported in past 30 days by adults was 3 .7 for Baltimore County (County Health Rankings 2018) .

44 Northwest Hospital

Chronic Disease Survey evidence:

20 participants did not provide information on Health Problems in their community.

The surveys had several options that respondents prioritized relatively similarly, all of which are interrelated and can be categorized as chronic disease . Overall survey respondents identified diabetes/ high blood sugar, overweight/ obesity, and heart disease/ high blood pressure as the third, fourth and fifth most important health concerns for the community . Respondents in the Northwest service area responded similarly, listing overweight/ obesity, diabetes/ high blood sugar and heart disease/ high blood pressure as the first, third and fifth most important concerns . As a result of this clustering and an understanding of the interrelatedness of these problems, chronic disease was prioritized as a health concern . Stakeholder feedback: In the Stakeholder meetings, all participants voiced concerns about chronic disease, whether it was heart disease, obesity, or high blood pressure . Stakeholders spoke of the visible preponderance of obesity in the community, as well as their personal knowledge of many people who live with, or have died from, heart problems . In addition, stakeholders noted rising COPD rates and the high prevalence of diabetes in their communities . In response to these concerns, Baltimore County Public Health officials plan to create more exercise opportunities for families and have embarked on a county-wide initiative to implement a Diabetes Prevention Program . Focus group feedback: • The disabilities focus group did not prioritize chronic disease, but they did speak about challenges with chronic disease management . They discussed the challenges with healthy eating due to financial constraints and their lack of agency when it comes to deciding which foods are prepared for them by caregivers . They also agreed as a group that disability can lead to depression, which can lead to sedentary living and neglect of healthy behaviors, resulting in chronic disease . • LGBTQ focus group participants spoke about HIV as a chronic disease . HIV does not fall under the same cluster as the other chronic diseases included, but some of the context for concern about HIV parallels the context for the concern about other chronic diseases . These include poverty and lack of adequate housing, causing patients to deprioritize disease self-management, as well as the stigma and depression that accompany HIV . Since both themes are consistent with other chronic diseases, an approach to chronic disease could also take HIV into account .

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• Although the older adult focus groups did not touch on chronic disease as top priorities for the community, they did note certain behavioral factors associated closely with chronic disease management such as smoking and healthy food access . • The single parents focus group prioritized diabetes and spoke specifically about healthy food access as a related concern . • One of the homeless focus groups prioritized high blood pressure as a top concern . • The cancer focus group mentioned issues related to chronic disease management such as smoking and healthy eating . They also identified cancer as a top concern .

Public health data: The top causes of death in the CHNA area: cardiovascular disease, cancer, stroke, and chronic respiratory disease (Baltimore County CHNA 2015) .

ENVIRONMENTAL/SOCIAL PROBLEMS Job opportunities Survey evidence:

From the overall response to the survey, the most commonly identified environmental/social concern was neighborhood safety/violence . Among the responses specific to respondents in the Northwest Hospital service area, the most commonly identified environmental/social concern was Availability/Access to insurance . However, the second most commonly identified concern was lack of job opportunities . In the overall survey there was a difference of 10 votes between neighborhood safety/violence and lack of job opportunities (1445 vs . 1435); for Northwest there was a difference of only six votes between availability/access to insurance and lack of job opportunities (194 vs . 188) . The selection of job opportunities over neighborhood safety or availability/access to insurance was based on addressing the underlying causes for the social concerns that are identified in the communities . Violence, behavioral health problems (such as depression and drug use), and lack of insurance, can all be traced back to lack of job opportunities as a common underlying cause .

46 Northwest Hospital

Stakeholder feedback: The Stakeholder meetings did not prioritize job opportunities as the top environmental/social concerns . However, they did speak about the many aspects and manifestations of poverty in the community and identified the lack of employment opportunities as a direct cause of poverty . The prioritization of job opportunities is a result of the feedback and recognizing the need to address underlying causes to affect change .

Public health data: The unemployment rate was 4 .5% in Baltimore County for ages 16 and older (County Health Rankings 2018) .

*The PSA unemployment rate is greater than the overall Baltimore County unemployment rate.

47 Community Health Needs Assessment

ACCESS TO HEALTH CARE Access to Doctor’s Office: Survey evidence:

Survey evidence: While access to a doctor’s office did not appear as one of the top five ranked problems on the survey, many comments in the freeform section spoke about access to health care, and specifically about appointment wait times and lack of available physician offices .

48 Northwest Hospital

Stakeholder feedback:

The Baltimore County Health Department identified doctors’ office access as one of the most important issues . They felt that the dearth of primary care clinics in the county was a major source of lack of access for the many residents in the area .

Focus group feedback:

• The LGBTQ focus group spoke of the stigma and discrimination that they experience as a factor that prevents them from seeking medical care . • The disabilities focus group spoke of the lack of physically accessible spaces and equipment in doctors’ offices, which prevents them from receiving routine or specialty services .

Public health data: In Baltimore County, there is a ratio of 990 residents to every primary care physician and a ratio of 1,114 residents to every primary care provider other than physicians (nurse practitioners (NP), physician assistants (PA), and clinical nurse specialists) (County Health Rankings 2018) .

Health education/lack of knowledge about available resources Survey evidence:

49 Community Health Needs Assessment

Health education was not listed as an option on the survey under the question about why people do not get health care . Majority of freeform responses to the final question, “What ideas or suggestions do you have to improve the health in your community?” could be categorized as ideas about health education and health literacy . Please see Appendix A5 for a summary of the comments . In the future, we will include health literacy and health education as options under this question . Other topics that ranked high in the survey were areas in which LifeBridge is already implementing improvements (transportation access and reducing wait times) .

Focus group feedback: • The older adults focus groups identified a desire to be better informed about the health care offerings available to them . • The Spanish-speaking focus group identified health education as a priority . Specifically they felt uninformed about the safety of submitting certain documents in order to obtain health care, for fear of immigration enforcement . They also spoke of the need for more education about available community health resources and clinics where they can receive good care and be safe . They suggested that hospitals must conduct more awareness campaigns about their offerings . The group also spoke of the importance of following doctors’ orders, taking medication, and other activities of health maintenance . • The transition-age youth focus group identified lack of awareness about available resources as a top priority . They mentioned the importance of hospital employees working directly in the community, ensuring people understand what is available to them . • The homeless focus groups did not prioritize health education, but they mentioned the difficulty with navigating health care systems, a general lack of information, and a need for more information about services such as available screenings . • The Population Health program participants did not prioritize health education, but they spoke of the need for more advertising of available health services and programs . • The cancer focus group identified lack of knowledge about the health system as a priority – specifically the lack of knowledge about navigation .

50 Northwest Hospital

Public health data: Baltimore County scored from the lowest quartile to the third quartile in health literacy, with scores ranging from the 40th percentile to the 60th percentile (University of North Carolina Chapel Hill Health Literacy Data Map 2014) .

Insurance signups Survey evidence:

Stakeholder feedback: The participants in the stakeholder meeting prioritized health education . Specifically, they spoke about patients’ problems understanding their benefits . Most of the stakeholders in the Northwest service area also prioritized health education, noting the need for advertising of available resources, including nutrition education . The topic that ranked high on the survey, and was also a concern that LifeBridge could influence, was “no insurance .” This topic ranked second for the overall survey (with 2719 votes), as well as for Northwest Focus group feedback: (407 votes) . • The older adults focus groups identified a desire to be better informed about the health care offerings available to them . Stakeholder feedback: • The Spanish-speaking focus group identified health education as a priority . Specifically they felt uninformed This topic did not come up as a theme in the Stakeholder meetings, however, some of the stakeholders in the about the safety of submitting certain documents in order to obtain health care, for fear of immigration Northwest service area mentioned lack of insurance as a problem . enforcement . They also spoke of the need for more education about available community health resources and clinics where they can receive good care and be safe . They suggested that hospitals must conduct more awareness Focus group feedback: campaigns about their offerings . The group also spoke of the importance of following doctors’ orders, taking medication, and other activities of health maintenance . • The LGBTQ focus group identified the lack of insurance as a priority linked with poverty and unemployment/ underemployment . • The transition-age youth focus group identified lack of awareness about available resources as a top priority . They mentioned the importance of hospital employees working directly in the community, ensuring people • The Spanish-speaking focus group cited the importance of having health insurance – or some alternative to understand what is available to them . health insurance – as vital to the health of the community . • The homeless focus groups did not prioritize health education, but they mentioned the difficulty with navigating Public health data: health care systems, a general lack of information, and a need for more information about services such as The percentage of Baltimore County residents under the age of 65 without health insurance is 7% (University of available screenings . North Carolina Chapel Hill Health Literacy Data Map 2014) . • The Population Health program participants did not prioritize health education, but they spoke of the need for more advertising of available health services and programs . • The cancer focus group identified lack of knowledge about the health system as a priority – specifically the lack of knowledge about navigation .

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Implementation strategies We identified the following implementation plan to address the prioritized needs for the Northwest community.

Health Education/ Knowledge of available resources

NORTHWEST IMPLEMENTATION STRATEGY: Category: Health Concerns; Prioritized Need: Behavioral Health

Action to address the need: Implement SBIRT in the Emergency Department. Through a statewide grant, Northwest Hospital will be implementing the SBIRT or “Screening-Brief Intervention-Referral to Treatment” protocol in the Emergency Department. This protocol is designed to work with patients who may have substance abuse problems, and to provide some level of support and navigation for them before they leave the facility. Programs and resources Planned collaboration with Anticipated impact Plan to evaluate impact to be used other facilities or organizations Patients in the The SBIRT implementation team will provide Using state grant funds, Northwest will work with Mosaic Emergency Department monthly reports on a variety of measures: we employed Mosaic to to provide the training for the who are experiencing • Number of unique patients seen train support workers, and support workers in the Emergency drug addiction will • Number of patient encounters these support workers will Department. The hospital is be referred to proper • Number of SBIRT screens completed provide the intervention. also simultaneously working treatment. with other facilities of LifeBridge • Number of brief interventions Health, including Sinai Community • Number of suspected overdoses Care, the Sinai Hospital • Number of referrals to community Emergency Department, and recovery coaches the Carroll Hospital Emergency • Number of referrals to treatment Department, to implement these • Number of Linkages to treatment programs simultaneously.

NORTHWEST IMPLEMENTATION STRATEGY: Category: Health Concerns; Prioritized Need: Chronic Disease

Action to address the need: Partner to administer Diabetes Prevention Program. To complement the array of disease management programs and services that LifeBridge Health offers, the need to expand at-risk chronic disease programming was recognized. By partnering with the Baltimore County Health Department, Northwest patients will be referred to their Diabetes Prevention Program. The curriculum for this year-long group-based lifestyle coaching program focuses on healthy eating, exercise, and stress reduction.

Programs and resources Planned collaboration with Anticipated impact Plan to evaluate impact to be used other facilities or organizations Participants will lose The program involves weekly weigh- The communication Partner with the Baltimore weight and increase their ins and self-reports of physical channels of Community County Health Department’s levels of physical activity. activity. Diabetic health indicators Health Education team and program in order to meet Overall, the rates of including A1C and glucose levels Clinically Integrated Network this goal. onset of diabetes amongst will also be monitored. Since – LifeBridge Health’s network participants who are Northwest will not be implementing of employed and affiliated diagnosed as prediabetic the program directly, we will rely on physician offices will be will decrease. general indicators of success from utilized to provide referrals to the county, such as overall program the program. attendance.

52 Northwest Hospital

Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations Program aims to maintain This program employs This program will be The program collaborates with many and improve behavioral nursing staff who check the implemented by staff of community partners, including American and biometric outcomes, identified measures on a the Office for Community Heart Association, Baltimore City Health such as blood pressure, regular basis. A Population Health Improvement, which Department Cardiovascular Disparities blood sugar, BMI, HDL, Health dashboard updates is a LifeBridge Health Task Force, Baltimore City Department LDL, quality of life, smoking the team with progress on system-wide office within of Aging, American Stroke Association, cessation, physical activity these measures. the Population Health Sandra and Malcolm Berman Brain and and healthy eating. Department. Spine Institute Stroke Programs at LifeBridge Health, ShopRite Howard Park, and Park Heights Community Health Alliance, and assorted community churches and businesses.

NORTHWEST IMPLEMENTATION STRATEGY: Category: Social/Environmental Concerns; Prioritized Need: Job Opportunities

Action to address the need: Advocate for internships for Randallstown High School students. Northwest Hospital has developed a partnership with Northwest Academy Middle School and Randallstown High School to provide tours, career exposure, and internships for students. The program started with a middle school rollout and currently, a 5-week rotational internship will be created for students of the high school. Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations Youth in the Northwest The number of students LifeBridge Health’s Center for This program will involve a close Hospital area will choose in the internship program Leadership and Professional collaboration with Northwest health care careers after and the number of those Development will lead this Academy and Randallstown High they graduate. students who indicate partnership, with the support of School. interest in a career in health staff throughout the organization care after graduation will be that will host the internships. tracked.

NORTHWEST IMPLEMENTATION STRATEGY: Category: Social/Environmental Concerns; Prioritized Need: Access to Doctors’ Offices

Action to address the need: Strengthen relationship with Chase Brexton as Primary Care Provider. Chase Brexton Health Services currently provides a nurse from their staff to Northwest Hospital in order to provide linkages to primary care for patients in the Inpatient setting. A plan to re-engage Northwest staff to not only utilize this nurse but to expand referrals for other patients to seek their primary care services at Chase Brexton will be created.

Programs and resources to be Planned collaboration with other Anticipated impact Plan to evaluate impact used facilities or organizations Decrease in Northwest The referrals by hospital Northwest Hospital’s Inpatient Continue partnership with patients who lack a Primary units, and insurance status nursing and Care Management Chase Brexton Health Services Care Provider. of referred patients will Departments will work with in Randallstown. continue to be tracked. Chase Brexton staff to ensure smooth operation of the program. Chase Brexton staff will maintain data and produce monthly reports to assist in program evaluations and program calibration.

53 Community Health Needs Assessment

NORTHWEST IMPLEMENTATION STRATEGY: Category: Access to Health Care; Prioritized Need: Health Education/ Knowledge of Available Resources

Action to address the need: Add Pastoral Outreach Coordinator and Community Educator to Community Health Education Team. The Community Health Education Team has grown in past years in response to past needs highlight ed in the Community Health Needs Assessment. Recognizing the many different approaches required to reach community members, positions were added and moved to provide more outreach to faith communities and offer new educational topics such as sexual health for teens.

Programs and resources to Planned collaboration with other Anticipated impact Plan to evaluate impact be used facilities or organizations More people will be The number of people These two staff are The Community Health Education team reached through health reached at each event supervised by the Manager collaborates with many local partners, fairs, educational has been tracked through of the Office of Community from churches to schools to the workshops and events. sign-in sheets. When Health Improvement. American Heart Association and workshops or other many more. programs are conducted, the knowledge or health improvement among individuals in the program is evaluated.

NORTHWEST IMPLEMENTATION STRATEGY: Category: Access to Health Care; Prioritized Need: Insurance Signups

Action to address the need: Continue training application counselors who can assist patients with insurance signups. Through the Maryland Health Benefit Exchange, Sinai is certified as an ACSE – Application Counselor Sponsoring Entity. This allows the hospital to offer training and administrative support to any employee to assist patients or clients in signing up for insurance. Community Health Workers and Social Workers in the outpatient clinic and Population Health programs have been trained to provide these signups. This offer will be expanded to Medical Assistants and workers in other facilities. Programs and resources Planned collaboration with Anticipated impact Plan to evaluate impact to be used other facilities or organizations More patients will have A quarterly report with the Client/patient-facing staff LifeBridge Health will collaborate with insurance, which will lead to number of people assisted will add this intervention the Maryland Health Benefit Exchange more consistent treatment for is provided. to the services they are to receive training and certification. patients who need it. already providing.

Programs and resources Planned collaboration with other Anticipated impact Plan to evaluate impact to be used facilities or organizations More patients will have A quarterly report with the Client/patient-facing staff LifeBridge Health will collaborate with insurance, which will lead to number of people assisted will add this intervention to the Maryland Health Benefit Exchange more consistent treatment is provided. the services they are already to receive training and certification. for patients who need it. providing.

54 Northwest Hospital

Neighborhood Safety/ Violence: This was the top environmental/social concerns however, it was not prioritized this year since the Street Violence Intervention Program (SVIP) is a robust program actively working with victims of street violence . Sinai’s Kujichagulia Center hosts SVIP and partners with Baltimore City’s Safe Streets program to address conflicts as they arise . See Appendix E1 for the progress report about the Kujichagulia Center, which was an outgrowth of the 2012 CHNA and was expanded as a response to the 2015 CHNA . Housing/Homelessness: Housing/ homelessness came up in several focus groups but did not arise as one of the most commonly identified priorities in the survey responses . This concern will be addressed through a collaborative with other city hospitals, which is committed to developing a housing strategy for behavioral health patients . Lack of Transportation: Lack of transportation arose in the surveys as an important reason for why people do not get health care . Through the Care Management Department and other programs that work with people in the community, transportation funding is provided for many patients who need help in getting to their doctors’ appointments . Since patients and clients are served well by these resources, this concern was not prioritized as a target for further investment . Insurance too expensive: As a reason for why people do not get health care, this need received top scores across all zip codes . However, this is not within the purview of the hospital . Insurance not accepted: This reason ranked fourth on the public survey, but it was not addressed since Sinai Hospital accepts all forms of insurance . It was concluded that this problem would be best addressed by physician offices . Limited access to healthy foods: Healthy food access came up in several surveys and discussions . There is a lot of interest throughout Baltimore City in addressing the problem of food desserts, but overall the need was not expressed as a top priority among community members . Poverty: Poverty came up as the fifth-highest priority in the Northwest and overall surveys, and as the number one priority among people with disabilities and LGBTQ group . However, since this need was determined to be a concern with various underlying factors, Northwest focused on addressing the underlying problems (including job readiness, transportation) leading to poverty . School dropout/poor schools: The focus groups with participants in younger demographics spoke about school- related problems . While LifeBridge Health is engaged in various ways with schools, these efforts are not geared towards improving overall school quality . Kujichagulia Center currently implements a mentorship program for middle schoolers focused on addressing bullying and violence in the African American/Black community . Wait is too long for care: This problem surfaced as a commonly-identified need . A system-wide effort is being undertaken to address throughput in various hospital settings . This would not be taken on as a community benefit project but rather through quality leadership at the hospital . Broader problems, such as wait times for other health care services such as mental health therapy appointments in the community, are beyond the scope of the hospital . Stigma/discrimination: Stigma and discrimination showed up in some of the focus groups that were conducted . Although it was not prioritized as a central focus for the next three years, the concerns were shared with other parts of the system . The Clinically Integrated Network has begun addressing stigma and discrimination by instituting an LGBTQ-friendly Provider Network . Physicians not trustworthy: A few people mentioned this concern in focus groups . Addressing this issue was beyond the scope of community benefit .

55 Community Health Needs Assessment APPENDIX

A. Survey Results 1. Survey Tool 2. Overall Survey Results 3. Sinai Hospital Survey Results 4. Levindale Survey Results 5. Northwest Hospital Survey Results B. Focus Group Notes 1. LGBTQ 2. Disabilities 3. Older Adults 1 4. Older Adults 2 5. Single Parents 6. Spanish Speaking 7. Currently Homeless Men and Women 8. Homeless Men in Temporary Housing 9. Homeless Men in Overnight Shelters Services 10. LifeBridge Health Cancer Patients 11. LifeBridge Health Population Health Clients C. Key Community Stakeholders Meeting and Interview Notes 1. Stakeholder Focus Groups 2. Community Stakeholder Interviews a. Sinai/Levindale Community b. Northwest Community D. Baltimore City/Sinai Hospital Public Health Data 1. CHNA Sinai Public Health Data Summary 2. CHNA Sinai Mortality Map 3. CHNA Sinai Drug Alcohol Mortality Map 4. CHNA Sinai Family Poverty Map 5. CHNA Sinai Life Expectancy Map E. Progress Reports from 2015 CHNA Implementation Strategies 1. Kujichagulia Center – Sinai 2. Community Health Education – Sinai, Levindale and Northwest 3. Changing Hearts Program – Sinai, Levindale and Northwest 4. SAFE Program – Levindale F. References: https://factfinder .census .gov/faces/nav/jsf/pages/index .xhtml https://factfinder .census .gov/faces/tableservices/jsf/pages/productview .xhtml?pid=ACS_16_5YR_DP05&src=pt

56 Appendix

2017 Baltimore Health Needs Survey

Your responses to this optional survey are anonymous and will inform how hospitals and agencies work to improve health in Baltimore City. Thank you!

Instructions: You must be 18 years or older to complete this survey. Please answer all questions and return the survey as indicated. For questions about this survey, contact 667-234-2102 or 1-800-492-5538.

1. What is your ZIP code? Please write 5-digit ZIP code. ______

2. What is your sex? Please check one. ☐ Male ☐ Female ☐ Transgender ☐ Other specify______☐ Don’t know ☐ Prefer not to answer

3. What is your age group (years)? Please check one. ☐ 18-29 ☐ 40-49 ☐ 65-74 ☐ 75+ ☐ 30-39 ☐ 50-64 ☐ Don’t know ☐ Prefer not to answer

4. Which one of the following is your race? Please check all that apply. ☐ Black or African American ☐ White ☐ Asian ☐ Native Hawaiian or Other Pacific Islander ☐ American Indian or Alaska Native ☐ Other/more than one race specify______☐ Don’t know ☐ Prefer not to answer

5. Are you Hispanic or Latino/a? Please check one. ☐ Yes ☐ No ☐ Don’t know ☐ Prefer not to answer

6. On how many days during the past 30 days was your mental health not good? Mental health includes stress, depression, and problems with emotions. Please write number of days.

_____ days ☐ Zero days ☐ Don’t know ☐ Prefer not to answer

PLEASE TURN OVER FOR NEXT PAGE

2017 Baltimore Health Needs Survey 57 Community Health Needs Assessment

7. What are the three most important health problems that affect the health of your community? Please check only three. ☐ Alcohol/drug addiction ☐ Alzheimer’s/dementia ☐ Mental health (depression, anxiety) ☐ Cancer ☐ Diabetes/high blood sugar ☐ Heart disease/blood pressure ☐ HIV/AIDS ☐ Infant death ☐ Lung disease/asthma/COPD ☐ Stroke ☐ Smoking/tobacco use ☐ Overweight/obesity ☐ Don’t know ☐ Prefer not to answer

8. What are the three most important social/environmental problems that affect the health of your community? Please check only three. ☐ Availability/access to doctor’s office ☐ Child abuse/neglect ☐ Availability/access to insurance ☐ Lack of affordable child care ☐ Domestic violence ☐ Housing/homelessness ☐ Limited access to healthy foods ☐ Neighborhood safety/violence ☐ School dropout/poor schools ☐ Poverty ☐ Lack of job opportunities ☐ Limited places to exercise ☐ Race/ethnicity discrimination ☐ Transportation problems ☐ Don’t know ☐ Prefer not to answer

9. What are the three most important reasons people in your community do not get health care? Please check only three. ☐ Cost – too expensive/can’t pay ☐ Wait is too long ☐ No insurance ☐ No doctor nearby ☐ Lack of transportation ☐ Insurance not accepted ☐ Language barrier ☐ Cultural/religious beliefs ☐ Don’t know ☐ Prefer not to answer

10. What ideas or suggestions do you have to improve health in your community? ______☐ Don’t know ☐ Prefer not to answer

Thank you for completing the survey!

58 2017 Baltimore Health Needs Survey Appendix

APPENDIXCommunity A2 Health - OVERALLNeeds Assessment SURVEY RESULTS 1.15.17

Baltimore City/Baltimore County results are based on the complete set of CHNA survey results N= 4755 surveys completed (82 Respondents (1.7% of total) did not provide Zip Code information).

Q1: What is your Zip Code? (Free Response Data)

CHNA Number of Surveys X Zip Codes (Baltimore City/Baltimore County--at least 20 respondents)

21215 634 21224 346 21213 229 21218 220 21207 181 21208 180 21216 153 21133 153 21117 148 21229 146 21202 144 21217 140 21209 135 21228 131 21206 123 21222 109 21223 99 21205 99 21244 94 21239 93 21201 90 21227 77 21225 77 21212 70 21230 63 21231 56 21136 48 21234 45 21214 39 21043 31 21211 29 21157 24 21784 21 21122 21 21221 20 0 100 200 300 400 500 600 700 In addition to the zip codes represented above, 405 respondents had zip code data from 98 additional zip codes (median number of respondents for those zip codes = 2 responses)

1 59 Community Health Needs Assessment Community Health Needs Assessment 1.15.17

Q2: What is your age?

(Responses: 18-29 years, 30-39 years, 40-49 years, 50-64 years, 75+, Prefer Not to Answer)

CHNA Number of Surveys X Age (Baltimore City/Baltimore County) 1600 1433 1400 1200 876 1000 704 800 621 564 600 477 400 55 200 25 0 18-29 years 30-39 years 40-49 years 50-64 years 65-74 years 75+ Prefer Not to No response Answer

Number of % of Total Survey Responses 18-29 years 564 11.9% 30-39 years 704 14.8% 40-49 years 621 13.1% 50-64 years 1433 30.1% 65-74 years 876 18.4% 75+ 477 10.0% Prefer Not to 25 <1% Answer No Response 55 1.2%

60 Appendix Community Health Needs Assessment 1.15.17

Q3: What is your sex? (Responses: Male, Female, Transgender, Prefer Not to Answer)

CHNA Number of Surveys X Gender (Baltimore City/Baltimore County) 4000 3399 3500 3000 2500 2000 1500 1304 1000 500 10 14 28 0 Female Male Transgender Prefer Not to Answer No Response

Number of % of Total Survey Responses Female 3399 71.5% Male 1304 27.4% Transgender 10 <1% Prefer Not to Answer 14 <1% No Response 28 <1%

61 Community Health Needs Assessment Community Health Needs Assessment 1.15.17

Q4: Which one of the following is your race? (Please check all that apply) (Responses: Black or African American, White, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, Don't Know, Prefer Not to Answer, Other /More than one race (please specify)

For the purposes of an initial summary, responses of Other/More Than One Race were NOT recategorized into other categories if applicable (e.g., “Chinese” to “Asian”); as participants were able to select multiple responses, table and chart values do not add up to the number of total surveys.

CHNA Number of Survey Responses X Race (Baltimore City/Baltimore County) 3000 2677 2500

2000 1509 1500

1000

500 253 117 83 70 20 9 0 Black or African White Other/ More than Prefer Not to Asian American Indian Native Hawaiian Don't Know American one Race Answer or Alaska Native or Other Pacific Islander

126 participants did not provide information on Race

Number % of Total Race of Race Responses Responses Black or African 2677 59.7% American White 1509 33.6% Other/ More Than 253 2.5% One Race Prefer Not to 117 1.8% Answer Asian 83 1.5% American Indian or 70 <1% Alaska Native Native Hawaiian or 20 <1% Other Pacific Islander Don't Know 9 <1%

62 Appendix Community Health Needs Assessment 1.15.17

Q5: Are you Hispanic or Latino/a? (Please check one) (Responses: Yes, No, Prefer Not to Answer, Don’t Know)—referred to as “Ethnicity” in Charts and Tables below

CHNA Number of Surveys X Ethnicity (Baltimore City/Baltimore County) 4500 4020 4000 3500 3000 2500 2000 1500 1000 324 103 283 500 25 0 Not Hispanic Hispanic Prefer Not to Answer Don't Know No response

Number % of Total of Survey Responses Not Hispanic (“No”) 4020 84.5% Hispanic (“Yes”) 324 6.8% Prefer Not to Answer 103 2.2% Don't Know 25 <1% No response 283 6.0%

63 Community Health Needs Assessment Community Health Needs Assessment 1.15.17

: n how any days drin the past days was yor ental health not ood (ental health incldes stress, depression, and probles with eotions) (esponses: ero days, ree Entry for Number of Days Not Good, Prefer Not to Answer, Don’t Know)

CNA Nber of reys: Days Eperiencin ental ealth Probles (altiore Cityaltiore Conty) 2500 2242

2000

1500

1000 615 500 234 167 74 0 0 Days 1-7 Days 8-15 Days 16-21 Days 22-30+ Days

Nber of Total of rey esponses Days 2242 47.2% Days 615 12.9% Days 234 4.9% Days 167 3.5% Days 74 1.6% Dont now 445 9.4% Prefer Not to Answer 240 5.0% nclear Answer 23 <1% No esponse 715 15.0%

64 Appendix Community Health Needs Assessment 1.15.17

at are te tree most mortant eat robems tat affet te eat of your ommunty Pease e ony tree esonses AooDru Addton, enta eat DeressonAnety), Dabetes ood uar, AD, un DseaseAstmaPD, monobao se, AemersDementa, aner, eart Dseaseood Pressure, nfant Deat, troe, erwetbesty, Dont Know, Prefer Not to Answer)

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed eat Probems o ) atmore tyatmore ounty) 3000 2743 2500

2000 1720 1715 1600 1500 1321

1000

500

0 Alcohol/Drug Mental Health Diabetes/High Blood Overweight/Obesity Heart Disease/Blood Addiction (Depression/Anxiety) Sugar Pressure

155 participants did not provide information on Health Problems in their Community Number of urey of ota esonses esonses AooDru Addton 2743 20.8% enta eat DeressonAnety) 1720 13.0% Dabetes ood uar 1715 13.0% erwetbesty 1600 12.1% eart Dseaseood Pressure 1321 10.0% monobao se 1265 9.6% aner 989 7.5% AD 465 3.5% AemersDementa 393 3.0% un DseaseAstmaPD 280 2.1% troe 233 1.8% nfant Deat 32 <1% Dont Know 384 2.9% Prefer Not to Answer 78 <1%

65 Community Health Needs Assessment Community Health Needs Assessment 1.15.17

at are te tree most mortant soaenronmenta robems tat affet te eat of your ommunty Pease e ony tree esonses AaabtyAess to Dotors ffe, AaabtyAess to nsurane, Domest oene, mted Aess to eaty oods, oo DrooutPoor oos, a of ob ortuntes, aetnty Dsrmnaton, d AbuseNeet, a of Affordabe d are, ousnomeessness, Neborood afetyoene, Poerty, mted Paes to erse, ransortaton Probems, Dont Know, Prefer Not to Answer)

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed oanronmenta Probems o )atmore tyatmore ounty) 1600 1445 1435 1400 1178 1200 1065 1000 870 800 600 400 200 0 Neighborhood Lack of Job Opportunities Housing/Homelessness Availability/Access to Poverty Safety/Violence Insurance

251 participants did not provide information on Social/Environmental Problems in their community Number of urey of ota oan esonses esonses Neborood afetyoene 1445 11.8% a of ob ortuntes 1435 11.7% ousnomeessness 1178 9.6% AaabtyAess to nsurane 1065 8.7% Poerty 870 7.1% mted Aess to eaty oods 868 7.1% oo DrooutPoor oos 812 6.6% AaabtyAess to Dotors ffe 667 5.5% ransortaton Probems 651 5.3% aetnty Dsrmnaton 646 5.3% Domest oene 606 5.0% a of Affordabe d are 554 4.5% mted Paes to erse 379 3.1% d AbuseNeet 300 2.5% Dont Know 637 5.2% Prefer Not to Answer 123 1.0%

66 Appendix Community Health Needs Assessment 1.15.17

at are te tree most mortant reasons eoe n your ommunty do not et eat are Pease e ony tree esonses ost oo enseant Pay, No nsurane, a of ransortaton, anuae arrer, at s oo on, No Dotor Nearby, nsurane Not Aeted, uturaeous eefs, Dont Know, Prefer Not to Answer)

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed easons for No eat are o ) atmore tyatmore ounty) 3500 3203 3000 2719 2500

2000 1319 1500 1263 891 1000

500

0 Cost - Too No Insurance Insurance Not Accepted Lack of Transportation Wait is Too Long Expensive/Can't Pay

223 participants did not provide information on Reasons for No Health Care in their community Number of ota of urey esonses esonses

ost oo enseant Pay 3203 28.6% No nsurane 2719 24.2% nsurane Not Aeted 1319 11.8% a of ransortaton 1263 11.3% at s oo on 891 7.9% No Dotor Nearby 389 3.5% anuae arrer 347 3.1% uturaeous eefs 244 2.2% Dont Know 714 6.4% Prefer Not to Answer 127 1.1%

67 Community Health Needs Assessment Community Health Needs Assessment 1.15.17

at deas or suestons do you ae to mroe te eat n your ommunty enended resonse)

2822 survey participants responded to Q10. Responses from 960 participants were removed from further analysis due to lack of information in the response (e.g., “No”, “None at this time”, “can’t think of any”, “I don’t know”, etc.). The remaining responses from 1862 survey participants (39.2% of all participants) were then categorized on the basis of content with 2075 ideas identified from survey participants (i.e., at least some responses contained multiple ideas). The top 10 content areas in terms of response frequency are presented followed by selected examples from some of those content areas.

ontent Area Number of ureys etter Aess to eat are 235 ore Affordabe eat are 220 etter duaton About eat are 215 ommunty utrea 193 ore Affordabe nsurane 165 mroements to te eat are ystem 119 ore Aess to eaty oods 98 etter ransortaton Aess 97 ommunty mroements 86 obs 44

etter Aess to eat are

Have more clinics in urban area. More clinics available for walk-in purposes. Low cost, low barrier, healthcare clinics that are marketed to community and engage with community to build trust. Build other places/clinics where we can access care and communicate with the community that they are available. More options should be available like more doctors offices, more dental options. There should be a mobile health van or truck that comes around to give people screenings and let them know when its something serious. But they need to be able help people with resources and get them there. May be able to do pregnancy tests, std screenings too. Send out healthcare buses to do health conversations in the community. Put those trucks with doctors in it in the community. Providing a mobile health van to visit the recreation center monthly. More programs that could immediately help without having to wait too long. Access to programs (financial, transportation) Let people know about what is available re disease(HIV). We need more employment at the hospital that people dont have to wait 3 to 4 hours to see a doctor in the ER . Waiting that long is not emergency. that part need more help. Allowing people better access to private doctors and hospital visits where more extensive care is given. Decrease ER wait time, improve care coordination so things don't "fall through the cracks," better mental

68 Appendix ommunity ealth Needs ssessment ..

health and ehaioral health access. ind out what an indiiduals needs are and assign a person to make a call to get them the help andor resources they need. Improe access to health care y proiding specialty care neary or on campus enhance transportation. ring ack home isits from doctors to patients. Improe access to proiders earlier and later in the day for those who work. ore primary care physicians.

ore Affordabe eat are

Make copays in installmentsor time frame. ore affordale insurance plans doctors isits. ree health insurance or make it affordale ffordale healthy food. asier access to health care, more affordale. se a sliding scale that considers monthly epenses and not ust yearly income. educe cost of prescription drugs. More free clinics, addiction aid, help for housing the homeless. ree clinics with resources to get help with insurance and homelessness. ore affordale local health care for preentatie medication.

etter duaton About eat are

Increase awareness of local clinicsopportunities (range of cost) health clinics in schools, for whole family, more access to freeaffordale . Increase awareness and education aout common health prolems facing the community and community memers to get help applying for medicaid insurance. roide education in a casual setting where uestions can e answered and discussions could take place priately or in group setting, ut where people would not feel threatened or udged. ae etter transportation, lower copays, education aout health efore the prolem starts. People need to e educated more aout health cost, options other than emergency isits and proper nutrition. Proide more townhallinformation type seminars to educate the community, proide speakers from hospitals and healthcare agencies to speak to consumers. Need wellness seminars iaetesigh lood sugar eart diseasehigh lood pressure eercise programs for seniors programs inschool and after school to encourage youth. y guess is that people in my community dont realie that their haits today hae a huge impact on their health so Id like to see more awareness around how people can take more responsiility for their health. ake sure when kid gets age where they can go to the doctor their self. help them and reak it down so they can understand what they doctor are saying. ducation aout preention measures nutrition, low cost eercise options. ducation aout healthy life styles. ducation teach the importance of regular check ups to stay out of hospitals. ducate the community aout mental health and addiction to decrease the stigma of the disorders and facilitate people getting help. ental health and addiction treatment parity.

69 Community Health Needs Assessment ommunity ealth Needs ssessment ..

ddress populations y age, and talk aout things usually not addressed death and dying, mental illnesses, hope, despair. Thank you. etter education aout preention of health prolems if the prolem is already present to control. etter education on what symptoms should initiate a doctors isit, especially for high school, college, and young adult ages.

ommunty utrea

ore free health screenings. More free community screenings. ore community info sessions, health screenings. llow patients and families more workshops. ealth fairs, community outreach education. ree health screenings. Interact with community more in an informal setting. ommunity ealth air with other facilities once or twice a year. se liaries or senior center facilities. lace notices in community newsletters. ore community inolement with healthcare professionals such as health fairs. iked the health fair gae opportunities for new topics some people don’t like r office this helps. ealth fairs in community, lirary, supermarket. Train community educators. ngage churches. Health fairs eery few months maye right efore highrisk periods (augustseptemer efore flu season). ommunity health care nurses or practitioners should e aailale. ommunity health adocates need to come to my uilding to talk to people. Need to talk to seniors. ommunitywide information sessions and resource centers with followup procedures. ommunity seminars that are releant to the needs of the surrounding community. If people can go door to door and ask if they hae health care and how they can help them to get needed care. ore community outreach opportunities for education aout community resources for etter health. eed to et people to o door to door ot elt cre nd te ones tt dont e insrnce dont discrd tem ie tem elp witot insrnce. Need more people going door to door to epress this issue. Health fairs are good ut we must get more personal y door to door seniors. Meeting people is the est way. roide education and health serices right in the community, free health fairs, community health programs in churches, synagogues, malls places where people in the community typically go. uild a relationship with the people in the community with home isits. ring proiders into the neighorhood and speak facetoface to the people in the community so they may not feel stigmatied and let them know that someone cares. ommunity fairs, lood pressure screening, access to colonscopymammogram.

ore Aess to eaty oods

ore araers deliering fresh produce. ess corner stores, liuor stores. orner stores selling produce. ore programs that offer low cost or free eggies and fruits, ardening opportunities within the neighorhoods. lasses on nutritional cooking and eating.

70 Appendix ommnit elt eeds ssessment

lit food mrets wit ffordle oods ewer ct rte rs nd corner stores ccess to ntrient dense foods etter ccess to fres food eetle frit. ecent rocer store tt sells fres mets eetles nd frits. e ll food stores inclde elt options een mom pop stores ccess to less epensie eltier foods rocer stores ffordle locl ccess to elt etin options not corner conenience stores. permret wit fres ffordle food.

etter ransortaton Aess

e cre more ccessile improe moilit. e it es for s to et to te doctor nd e ride for free e dont e mone to p. Improed plic trnsporttion. mproe trnsporttion to proider offices. mproin plic trnsport ccess to te commnit cn encore elt lifestle. tin te commnit need etter trnsporttion so te commnit cn et to te doctor. e ood free eltcreset p ccont wit er or ft to elp o et to ppointment. e desinted trnsporttion serice to ssist elderl in lifin for moilit serice. To proide trnsporttion for tese moters to et teir cildren to te doctors. close s stop for tose witot trnsporttion. e trnsporttion to doctors ls etc more ille. ore fndin to ssist wit elpin ptients oercome rriers sc s ospitl sttle tt pics p ptients t lest in te ip code to rin tem to ppointments ree prin for ptients needs to remp s lines e old w d etter ccess for seniors tt se tt trnsporttion.

ommunty mroements

e need to ddress te oercrowdin oo mn of or omes e een trned into mltifmil dwellins o crete more sfe plces to wor ot or pl for cildren nd dlts of ll es. er down cnts nd ild rn frms in teir sted. lic ccess to sfe prs rec centers nd oter spces. roide crete or ild commnit center tts ept clen nd eipped wit indiidls wo re nowledele to ndle commnities needs nd resorces tdoor recretionl re. eed ie wl pt er plces to o lie recs ins to do nd sfet. ore commnit centers. ore ccessile nd clen wter fontins. dditionl prsreen spces ie lnesplic trnsporttion.

71 Community Health Needs Assessment APPENDIXCommunity A3 Health - SINAINeeds Assessment HOSPITAL—Sinai Hospital SURVEY of Baltimore RESULTS 1.19.18

atmore tyatmore ounty results are based on the complete set of CHNA survey results N= surveys completed (82 Respondents (1.7% of total) did not provide Zip Code information)

na osta of atmore ) results are based on respondents in CBSA zip codes: N= surveys completed

at s your ode ree esonse Data)

NA Number of ureys odes atmore tyatmore ountyat east resondents)

1 72 Appendix

—

NA Number of ureys odes na osta)

atmore Number of ureys na Number of ureys ty of urey atmore ty osta of urey na osta atmore esonses atmore ounty) esonses odes) ounty

73 Community Health Needs Assessment —

at s your ae

esonses years, years, years, years, , Prefer Not to Answer)

NA Number of ureys Ae atmore tyatmore ounty)

NA Number of ureys Ae na osta)

atmore ty Number of of ota na osta Number of of ota atmore urey atmore ty urey na osta) ounty esonses atmore ounty) esonses years years years years years years years years years years Prefer Not to Prefer Not to Answer Answer No esonse No esonse

74 — Appendix

at s your se esonses ae, emae, ransender, Prefer Not to Answer)

NA Number of ureys Gender atmore tyatmore ounty)

NA Number of ureys Gender na osta)

atmore ty Number of of ota na Number of of ota atmore ounty urey atmore ty osta urey na osta) esonses atmore ounty) esonses emae emae ae ae ransender ransender Prefer Not to Prefer Not to Answer Answer No esonse No esonse

75 Community Health Needs Assessment —

one of te foown s your rae Pease e a tat ay) Possbe esonses a or Afran Ameran, te, Asan, Nate awaan or ter Paf sander, Ameran ndan or Aasa Nate, Dont Know, Prefer Not to Answer, ter ore tan one rae ease sefy)

For the purposes of an initial summary, responses of Other/More than one race were NOT recategorized into other categories if applicable (e.g., “Chinese” to “Asian”); as participants were able to select multiple responses, table and chart values do not add up to the number of total surveys.

NA Number of urey esonses ae atmore tyatmore ounty)

126 participants did not provide information on Race

NA Number of urey esonses ae na osta)

15 participants did not provide information on Race

76 Appendix —

one of te foown s your rae Pease e a tat ay) ont)

atmore ty Number of of ota ae na Number of of ota ae atmore urey esonses osta urey esonses ounty esonses atmore ty esonses na osta) atmore ounty) a or Afran a or Afran Ameran Ameran te te ter ter uteaes sted ute aes sted Prefer Not to Answer Prefer Not to Answer Asan Ameran ndan or Aasa Nate Ameran ndan or Asan Aasa Nate Nate awaan or Nate awaan ter Paf sander or ter Paf sander Dont Know

77 Community Health Needs Assessment —

Are you san or atnoa Pease e one) Possbe resonses es, No, Prefer Not to Answer, Don’t Know)—referred to as “Ethnicity” in Charts and Tables below

NA Number of ureys tnty atmore tyatmore ounty)

NA Number of ureys tnty na osta)

atmore ty Number of of ota na osta Number of of ota atmore ounty urey atmore ty urey na osta) esonses atmore ounty) esonses Not san Not san san san Prefer Not to Prefer Not to Answer Answer Dont Know Dont Know No resonse No resonse

78 Appendix —

n how any days drin the ast days was yor ental health not ood ental health incldes stress, deression, and robles with eotions.) ossible esonses ero days, ree Entry for Number of Days Not Good, Prefer Not to Answer, Don’t Know)

CA ber of reys Days Eeriencin ental ealth robles altiore Cityaltiore Conty)

CA ber of reys Days Eeriencin ental ealth robles inai osital)

79 Community Health Needs Assessment —

n ow many days durn te ast days was your menta eat not ood enta eat nudes stress, deresson, and robems wt emotons.) ont)

atmore ty Number of of ota na Number of of ota atmore ounty urey atmore ty osta urey na esonses atmore ounty) esonses osta) Days Days Days Days Days Days Days Days Days Days Dont Know Dont Know Prefer Not to Prefer Not to Answer Answer near near Answer Answer No esonse No esonse

80 Appendix —

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed eat Probems o ) atmore tyatmore ounty)

155 participants did not provide information on Health Problems in their Community

NA Number of urey esonses dentfed eat Probems o ) na osta)

30 participants did not provide information on Health Problems in their Community

81 Community Health Needs Assessment —

at are te tree most mortant eat robems tat affet te eat of your ommunty Pease e ony tree ont)

atmore ty Number of of ota na osta Number of of ota atmore ounty urey esonses urey esonses esonses atmore ty esonses na atmore ounty) osta) AooDru AooDru Addton Addton enta eat Deresson Dabetes Anety) ood uar enta eat Dabetes Deresson ood uar Anety) erwet erwet besty besty eart eart Dseaseood Dseaseood Pressure Pressure monobao mon se obao se aner aner AD AD Aemers Aemers Dementa Dementa un Dsease AstmaPD troe un Dsease troe AstmaPD nfant Deat nfant Deat Dont Know Dont Know Prefer Not to Prefer Not to Answer Answer

82 Appendix —

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed oanronmenta Probems o )atmore tyatmore ounty) 251 participants did not provide information on Social/Environmental Problems in their community

NA Number of urey esonses dentfed dentfed oanronmenta Probems Probems o ) na osta) 65 participants did not provide information on Social/Environmental Problems in their community

83 Community Health Needs Assessment —

at are te tree most mortant soaenronmenta robems tat affet te eat of your ommunty Pease e ony tree ont)

atmore ty Number of of ota na osta Number of of ota atmore ounty urey oan urey oan esonses esonses esonses esonses atmore ty na osta) atmore ounty) Neborood Neborood afetyoene afetyoene a of ob a of ob ortuntes ortuntes ousn ousnomeessness omeessness AaabtyAess AaabtyAess to to nsurane nsurane Poerty Poerty mted Aess to mted Aess to eaty oods eaty oods oo DrooutPoor oo DrooutPoor oos oos AaabtyAess AaabtyAess to to Dotors ffe Dotors ffe ransortaton aetnty Probems Dsrmnaton aetnty Dsrmnaton Domest oene ransortaton Domest oene Probems a of Affordabe a of Affordabe d are d are mted Paes to mted Paes to erse erse d AbuseNeet d AbuseNeet Dont Know Dont Know Prefer Not to Answer Prefer Not to Answer

84 Appendix —

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed easons for No eat are o ) atmore tyatmore ounty)

223 participants did not provide information on Reasons for No Health Care in their community

NA Number of urey esonses dentfed easons for No eat are o ) na osta) 55 participants did not provide information on Reasons for No Health Care in their community

85 Community Health Needs Assessment —

at are te tree most mortant reasons eoe n your ommunty do not et eat are Pease e ony tree ont)

atmore ty Number of of ota na osta Number of of ota atmore ounty urey esonses urey esonses esonses atmore ty esonses na osta) atmore ounty) ost oo ost oo enseant Pay enseant Pay No nsurane No nsurane nsurane Not a of Aeted ransortaton a of nsurane Not ransortaton Aeted at s oo on at s oo on No Dotor Nearby No Dotor Nearby anuae arrer uturaeous eefs uturaeous anuae arrer eefs Dont Know Dont Know Prefer Not to Prefer Not to Answer Answer

86 Appendix —

at deas or suestons do you ae to mroe te eat n your ommunty enended resonse)

in the response (e.g., “No”, “None at this time”, “can’t think of any”, “I don’t know”, etc.). The remaining responses fro

ontent Area Number of ureys etter duaton About eat are ommunty utrea etter Aess to eat are ore Affordabe eat are ore Affordabe nsurane mroed eat are ystem ommunty mroements ore Aess to eaty oods obs etter ransortaton Aess

etter duaton About eat are

. . P . . M .

87 Communityommnity Health eath Needs Needs Assessment ssessment—inai ospita of atimore ..

ommunty utrea

More free commnity screenings. eath fairs, commnity screening. ree screenings at commnity eents. oca free screening for , diaetes testing, senior resorces. ae more programs to screen for certain medica diseases sch as diaetes and heart disease. I eiee there shod e a heath fair eery month. Proide speakers from hospitas and heathcare agencies to speak to consmers. tart going door to door to find ot what the peope in the commnity needs are then offer sotions to cre these proems. ore commnity interaction to address persona heath isses. If peope can go door to door and ask if they hae heath care and how they can hep them get needed care. ae staff attend neighorhood association meetings to get the word ot ae a town ha meeting to discss isses. oor to door peope iding a reationship with commnity.

etter Aess to eat are

ore heath cinics. ommnity heath centers. ore options shod e aaiae ike more doctors offices, more denta options. There shod e a moie heath an or trck that comes arond to gie peope screenings and et them know when its something serios. t they need to e ae hep peope with resorces and get them there. ay e ae to do pregnancy tests, std screenings too. aye sppy a an that cod hep those who cant and dont nderstand the wording in the heathcare appications and make the heathcare affordae. ree moie cinics in a heath areas. A diaetes cinic. ors conenient to work schede, affordae medication, awareness programs. ind ot what an indiidas needs are assign a person to make a ca to get them the hep or resorces they need. ind another way to admit on the weekend, other than throgh the ...II to wait hors. ecrease wait time, improe care coordination so things dont fa throgh the cracks, etter menta heath and ehaiora heath access. eope homeond and need someone to check on their needs and they prefer to stay where they hae ied a their ies so need more if possie. I wod ike to see more heath programs roght into or commnity sch as, a nrse, ood pressre checks, and menta heath.

88 Appendix —

ore Affordabe eat are

M . C . .

ore Affordabe nsurane

ommunty mroements

. . . .

ore Aess to eaty oods

. . . . H .

etter ransortaton Aess

. . .

89 Community Health Needs Assessment APPENDIX A4 - LEVINDALE SURVEY RESULTS Community Health Needs Assessment—Levindale Hebrew Geriatric Center and Hospital 1.15.18

atmore tyatmore ounty results are based on the complete set of CHNA survey results for survey participants ae and oder N= surveys completed

endae ebrew Geratr enter and osta G) results are based on respondents in CBSA zip codes: who were ae and oder N= surveys completed

at s your ode ree esonse Data)

NA Number of ureys odes atmore tyatmore ounty Ae at east resondents)

21215 206 21208 79 21213 76 21228 75 21224 58 21218 55 21229 49 21206 49 21207 48 21216 45 21133 44 21222 44 21239 35 21227 33 21209 31 21217 26 21117 23 21201 22 21212 20 21244 20 21223 20

0 50 100 150 200 250

90 1 Appendix

—

NA Number of ureys odes G)

atmore ty Number of ureys G Number of ureys atmore ounty of urey atmore ty of urey G Ae ) esonses atmore ounty esonses odes) Ae )

91 Community Health Needs Assessment —

at s your ae

esonses years, years, years, years, , Prefer Not to Answer)

NA Number of ureys Ae atmore tyatmore ounty Ae )

NA Number of ureys Ae G)

atmore ty Number of of ota G Number of of ota atmore urey atmore ty urey G ounty Ae ) esonses atmore ounty esonses odes) Ae ) years years

92 Appendix —

at s your se esonses ae, emae, ransender, Prefer Not to Answer)

NA Number of ureys Gender atmore tyatmore ounty Ae )

NA Number of ureys Gender G)

atmore ty Number of of ota G Number of of ota atmore ounty urey atmore ty urey G Ae ) esonses atmore ounty esonses odes) Ae ) emae emae ae ae ransender No esonse

93 Community Health Needs Assessment —

or the prposes of an initial sar, responses of therore than one race ere recategorized into other categories if applicable (e.g., “Chinese” to “Asian”) as participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses ae atmore tyatmore ounty Ae ) 16 participants did not provide information on Race

NA Number of urey esonses ae G)

6 participants did not provide information on Race

94 — Appendix

one of te foown s your rae Pease e a tat ay) ont)

atmore ty Number of of ota ae G Number of of ota ae atmore ounty urey esonses urey esonses Ae ) esonses atmore ty esonses G atmore ounty odes) Ae ) a or Afran a or Afran Ameran Ameran te te terute terute aes sted aes sted Prefer Not to Prefer Not to Answer Answer Ameran ndan Ameran ndan or Aasa Nate or Aasa Nate Asan Dont Know Dont Know Nate awaan or ter Paf sander te

95 Community Health Needs Assessment —

Are you san or atnoa Pease e one) Possbe resonses es, No, Prefer Not to Answer, Don’t Know)—referred to as “Ethnicity” in Charts and Tables below

NA Number of ureys tnty atmore tyatmore ounty Ae )

NA Number of ureys tnty G)

atmore ty Number of of ota G Number of of ota atmore ounty urey atmore ty urey G) Ae esonses atmore ounty esonses Ae ) Not san Not san san san Prefer Not to Prefer Not to Answer Answer Dont Know No esonse No esonse

96 Appendix —

n how any days drin the ast days was yor ental health not ood ental health incldes stress, deression, and robles with eotions) ossible esonses ero days, ree Entry for Number of Days Not Good, Prefer Not to Answer, Don’t Know)

CA ber o reys Days Eeriencin ental ealth robles altiore Cityaltiore Conty) Ae

CA ber o reys Days Eeriencin ental ealth robles C)

97 Community Health Needs Assessment —

n ow many days durn te ast days was your menta eat not ood enta eat nudes stress, deresson, and robems wt emotons) ont)

atmore ty Number of of ota G Number of of ota atmore ounty urey atmore ty urey G) Ae esonses atmore ounty esonses Ae ) Days Days Days Days Days Days Days Days Days Days Dont Know Dont Know Prefer Not to Prefer Not to Answer Answer near Answer near Answer No esonse No esonse

98 Appendix —

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed eat Probems o ) atmore tyatmore ounty Ae )

50 participants did not provide information on Health Problems in their Community

NA Number of urey esonses dentfed eat Probems o ) G)

12 participants did not provide information on Health Problems in their Community

99 Community Health Needs Assessment —

at are te tree most mortant eat robems tat affet te eat of your ommunty Pease e ony tree ont)

atmore ty Number of of ota G Number of of ota atmore ounty urey esonses urey esonses Ae esonses atmore ty esonses G) atmore ounty Ae ) Aoo Aoo Dru Addton Dru Addton Dabetes Dabetes ood uar ood uar eart Dsease eart Dsease ood Pressure ood Pressure erwet erwet besty besty aner mon obao se enta eat enta eat Deresson Deresson Anety) Anety) mon aner obao se Aemers Aemers Dementa Dementa troe AD un Dsease troe AstmaPD AD un Dsease AstmaPD nfant Deat nfant Deat Dont Know Dont Know Prefer Not to Prefer Not to Answer Answer

100 Appendix —

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed oanronmenta Probems o ) atmore tyatmore ounty Ae )

102 participants did not provide information on Social/Environmental Problems in their community

NA Number of urey esonses dentfed oanronmenta Probems o ) G)

30 participants did not provide information on Social/Environmental Problems in their community

101 Community Health Needs Assessment —

at are te tree most mortant soaenronmenta robems tat affet te eat of your ommunty Pease e ony tree ont)

atmore ty Number of of ota G Number of of ota atmore ounty urey oan urey oan Ae esonses esonses esonses esonses atmore ty G) atmore ounty Ae ) Neborood Neborood afetyoene afetyoene a of ob a of ob ortuntes ortuntes ousn ousn omeessness omeessness AaabtyAess AaabtyAess to nsurane to nsurane mted Aess to mted Aess to eaty oods eaty oods oo Droout Poerty Poor oos ransortaton oo Droout Probems Poor oos AaabtyAess ransortaton to Dotors ffe Probems Poerty AaabtyAess to Dotors ffe aetnty aetnty Dsrmnaton Dsrmnaton mted Paes to mted Paes to erse erse Domest oene a of Affordabe d are a of Affordabe Domest oene d are d Abuse d Abuse Neet Neet Dont Know Dont Know Prefer Not to Prefer Not to Answer Answer

102 Appendix —

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed easons for No eat are o ) atmore tyatmore ounty Ae )

93 participants did not provide information on Reasons for No Health Care in their community

NA Number of urey esonses dentfed easons for No eat are o ) G)

25 participants did not provide information on Reasons for No Health Care in their community

103 Community Health Needs Assessment —

at are te tree most mortant reasons eoe n your ommunty do not et eat are Pease e ony tree ont)

atmore ty Number of of ota G Number of of ota atmore ounty urey esonses urey esonses Ae esonses atmore ty esonses G) atmore ounty Ae ) ost oo ost oo enseant Pay enseant Pay No nsurane No nsurane nsurane Not a of Aeted ransortaton a of ransortaton nsurane Not Aeted at s oo on at s oo on No Dotor Nearby No Dotor Nearby anuae arrer utura eous eefs utura anuae arrer eous eefs Dont Know Dont Know Prefer Not to Answer Prefer Not to Answer

104 Appendix —

at deas or suestons do you ae to mroe te eat n your ommunty enended resonse)

analysis due to lack of information in the response (e.g., “No”, “None at this time”, “can’t think of any”, “I don’t know”, etc.). The remaining responses from

ontent Area Number of ureys etter duaton About eat are ore Affordabe eat are ore Affordabe nsurane etter Aess to eat are ommunty mroements

etter duaton About eat are

. P . .

etter Aess to eat are

. . P .

105 Community Health Needs Assessment

APPENDIXCommunity A5 Health - NeedsNORTHWEST Assessment—Northwest SURVEY Hospital RESULTS 1.15.18

atmore tyatmore ounty results are based on the complete set of CHNA survey results N= surveys completed (82 Respondents (1.7% of total) did not provide Zip Code information)

Nortwest osta N) results are based on respondents in CBSA zip codes: N= 756 surveys completed

at s your ode ree esonse Data)

NA Number of ureys odes atmore tyatmore ountyat east resondents)

106 1

Appendix

—

NA Number of ureys odes Nortwest osta)

atmore Number of ureys Nortwest Number of ureys ty of urey atmore ty osta of urey Nortwest osta atmore esonses atmore ounty) esonses odes) ounty

107

Community Health Needs Assessment —

at s your ae

esonses years, years, years, years, , Prefer Not to Answer)

NA Number of ureys Ae atmore tyatmore ounty)

NA Number of ureys Ae Nortwest osta)

atmore ty Number of of ota Nortwest Number of of ota atmore ounty urey atmore ty osta urey Nortwest esonses atmore ounty) esonses osta) years years years years years years years years years years Prefer Not to Prefer Not Answer to Answer No esonse No resonse

108 — Appendix

at s your se esonses ae, emae, ransender, Prefer Not to Answer)

NA Number of ureys Gender atmore tyatmore ounty)

NA Number of ureys Ae Nortwest osta)

atmore ty Number of of ota Nortwest Number of of ota atmore ounty urey atmore ty osta urey Nortwest esonses atmore ounty) esonses osta)

109 Community Health Needs Assessment —

NA Number of urey esonses ae atmore tyatmore ounty)

126 participants did not provide information on Race

NA Number of urey esonses ae Nortwest osta) 21 participants did not provide information on Race

110 Appendix —

one of te foown s your rae Pease e a tat ay) ont)

atmore ty Number of of ota ae Nortwest Number of of ota ae atmore urey esonses osta urey esonses ounty esonses atmore ty esonses Nortwest atmore ounty) osta) a or Afran a or Afran Ameran Ameran te te ter Prefer Not to ute aes Answer sted Prefer Not to terute Answer aes sted Asan Asan Ameran ndan Ameran ndan or Aasa Nate or Aasa Nate Nate awaan or ter Paf sander Dont Know

111 Community Health Needs Assessment —

Are you san or atnoa Pease e one) Possbe resonses es, No, Prefer Not to Answer, Don’t Know)—referred to as “Ethnicity” in Charts and Tables below

NA Number of ureys tnty atmore tyatmore ounty)

NA Number of ureys tnty Nortwest osta)

atmore ty Number of of ota Nortwest Number of of ota atmore ounty urey atmore ty osta urey Nortwest esonses atmore ounty) esonses osta) Not san Not san san san Prefer Not to Prefer Not to Answer Answer Dont Know Dont Know No esonse No esonse

112 Appendix —

CA ber of reys Days Eeriencin ental ealth robles altiore Cityaltiore Conty)

CA ber of reys Days Eeriencin ental ealth robles orthwest osital)

113 Community Health Needs Assessment —

n ow many days durn te ast days was your menta eat not ood enta eat nudes stress, deresson, and robems wt emotons) ont)

atmore ty Number of of ota Nortwest Number of of ota atmore ounty urey atmore ty osta urey Nortwest esonses atmore ounty) esonses osta) Days Days Days Days Days Days Days Days Days Days Dont Know Dont Know Prefer Not to Prefer Not to Answer Answer near Answer near Answer No esonse No esonse

114 Appendix —

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed eat Probems o ) atmore tyatmore ounty)

155 participants did not provide information on Health Problems in their Community

NA Number of urey esonses dentfed eat Probems o ) Nortwest osta) 20 participants did not provide information on Health Problems in their Community

115 Community Health Needs Assessment —

at are te tree most mortant eat robems tat affet te eat of your ommunty Pease e ony tree ont)

atmore ty Number of of ota Nortwest Number of of ota atmore ounty urey esonses osta urey esonses esonses atmore ty esonses Nortwest atmore ounty) osta) AooDru erwet Addton besty enta eat Deresson AooDru Anety) Addton Dabetes Dabetes ood uar ood uar enta eat erwet Deresson besty Anety) eart Dsease eart Dsease ood Pressure ood Pressure monobao se aner mon aner obao se Aemers AD Dementa Aemers Dementa AD un Dsease AstmaPD troe un Dsease troe AstmaPD nfant Deat nfant Deat Dont Know Dont Know Prefer Not to Prefer Not to Answer Answer

116 Appendix —

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed oanronmenta Probems o )atmore tyatmore ounty) 251 participants did not provide information on Social/Environmental Problems in their community

NA Number of urey esonses dentfed oanronmenta Probems o ) Nortwest osta)

37 participants did not provide information on Social/Environmental Problems in their community

117 Community Health Needs Assessment —

at are te tree most mortant soaenronmenta robems tat affet te eat of your ommunty Pease e ony tree ont)

atmore ty Number of of ota Nortwest osta Number of of ota atmore ounty urey oan urey oan esonses esonses esonses esonses atmore ty Nortwest atmore ounty) osta) Neborood AaabtyAess afetyoene to nsurane a of ob a of ob ortuntes ortuntes ousn Neborood omeessness afetyoene AaabtyAess mted Aess to to nsurane eaty oods aetnty Poerty Dsrmnaton mted Aess to eaty oods Poerty oo DrooutPoor ousn oos omeessness AaabtyAess to ransortaton Dotors ffe Probems ransortaton AaabtyAess to Probems Dotors ffe aetnty a of Affordabe Dsrmnaton d are oo DrooutPoor Domest oene oos a of Affordabe d are Domest oene mted Paes to mted Paes to erse erse d AbuseNeet d AbuseNeet Dont Know Dont Know Prefer Not to Answer Prefer Not to Answer

118 Appendix —

As participants ere able to select ltiple responses, table and chart ales do not add p to the nber of total sres.

NA Number of urey esonses dentfed easons for No eat are o ) atmore tyatmore ounty)

223 participants did not provide information on Reasons for No Health Care in their community

NA Number of urey esonses dentfed easons for No eat are o ) Nortwest osta)

34 participants did not provide information on Reasons for No Health Care in their community

119 Community Health Needs Assessment —

at are te tree most mortant reasons eoe n your ommunty do not et eat are Pease e ony tree ont)

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120 Appendix —

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121 Community Health Needs Assessment ommunity ealth Needs ssessment—Northwest ospital ..

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122 Appendix APPENDIX B1 - FOCUS GROUP - LGBTQ

Date/Time: 11/13/17, 6 p.m. Location/Host: Chase Brexton Health Care Number of attendees: 5 Attendee profile: Attendees were recruited by Chase Brexton staff, and they were all people from the LGBTQ community; representing African American gay seniors, African American gay young men, people living with HIV, African American women and caregivers.

Facilitator: Lane Levine, Sinai Hospital

IDENTIFIED HEALTH PRIORITIES: Drug/alcohol addiction Mental health Sexual Health

IDENTIFIED SOCIAL/ENVIRONMENTAL PRIORITIES: Poverty Housing

IDENTIFIED ACCESS ISSUE PRIORITIES: Lack of steady employment – therefore not insured or can’t afford copays Stigma/discomfort with care providers unequipped to serve LGBTQ patients

HEALTH PROBLEMS: • Alcohol and drug addiction • HBP • Alcoholism isn’t always noticed because it’s seen as • Hepatitis C part of communal existence . Alcoholism is the worst • Compounding chronic conditions addiction for the community . • Young men develop heart disease due to stress, anxiety • Heroin and opioids are common drugs • HIV positive members might go through 7 different • Mental health is still stigmatized so people won’t medication regimens throughout their lifetime . take care of their problems . There are limited resources – Ryan White funding is sometimes the only way to SOCIAL/ENVIRONMENTAL PROBLEMS: receive support . • Poverty leads to deprioritization of their health since • Sexual health is a problem – people no longer see they must focus on other things . This also applies to HIV as a death sentence, also people see Ryan White addiction . programs to reliable resources . Unprotected sex is becoming more common in the LGBTQ community . • Discrimination • Racial discrimination • Alzheimer’s • Homophobia – HIV is still stigmatized as a gay • Diabetes disease, so people are afraid to seek treatment . In • Cancer less educated communities, people are afraid to disclose their sexual orientation . • STIs

123 Community Health Needs Assessment

• There is a constant state of anxiety since REASONS PEOPLE DO NOT GET HEALTH CARE: the government doesn’t care for the LGBT • Many have service jobs without health insurance community . “We do not feel safe under the • Don’t seek care because they will be treated poorly current administration” . • People still dying of AIDS because they never get • Incarceration tested • Isolation – mental health problems can cause • Underemployment, can’t afford copays and be caused by isolation • People are not living in families • Fear of abuse in nursing homes, hospice IDEAS OR SUGGESTIONS: • With HIV, comes a loss of sense of future • Hospitals should have programs to deal with above • Housing issues, including housing • Long waiting lists for section 8 housing and • We are going to see a lot more ED visits if Medicaid not enough availability shrinks again • Homelessness • Senior homes for LGBTQ people • With limited housing comes lack of life enhancement skills • LGBTQ representation in doctors’ offices, • Mental health keeps people from being able posters, etc . to get housing • Staff have to be able to take a sexual history, • Homelessness makes it hard to adhere to not just enter stuff into EMR medication regimens for people with HIV . • Cultural readiness – understanding external If people don’t have a place to live, they are environment, relatability more likely to drop out of care . • Having LGBTQ friendly medical staff matters – • It is hardest for black trans women to get housing easier to talk about concerns • Even though there are anti-discrimination laws, landlords break laws and tenants don’t stand up • Sex positivity in medical practices for themselves • Fitness for seniors • Domestic Violence • Deal with food deserts • Not represented so hard to identify • Offerings for community members • LGBTQ people don’t know about safe places to go when abused • Cooking classes for seniors, yoga, tai chi • Age-related abuse can go in both directions • Better patient food • Gardens for kids

124 Appendix REASONS PEOPLE DO NOT GET HEALTH CARE: APPENDIX B2 - FOCUS GROUP - DISABILITIES • Many have service jobs without health insurance • Don’t seek care because they will be treated poorly Date/Time: 10/27/17, 12 p.m. • People still dying of AIDS because they never get Location/Host: League for People with Disabilities tested Number of attendees: 5 • Underemployment, can’t afford copays Attendee profile: Attendees were recruited by the League staff, and they were all people in wheelchairs with physical disabilities, not mental disabilities. However, many served representational roles on IDEAS OR SUGGESTIONS: boards and committees, so they felt equipped to speak for other people with disabilities. • Hospitals should have programs to deal with above Facilitator: Lane Levine, Sinai Hospital issues, including housing IDENTIFIED HEALTH PRIORITIES: • We are going to see a lot more ED visits if Medicaid Drug/alcohol addiction shrinks again Mental health • Senior homes for LGBTQ people IDENTIFIED SOCIAL/ENVIRONMENTAL PRIORITIES: • LGBTQ representation in doctors’ offices, Housing posters, etc . Poverty • Staff have to be able to take a sexual history, Transportation not just enter stuff into EMR IDENTIFIED ACCESS ISSUE PRIORITIES: • Cultural readiness – understanding external Accessibility of health care services (such as wheelchair accessible mammograms) environment, relatability Limited awareness among providers about disabilities • Having LGBTQ friendly medical staff matters – easier to talk about concerns HEALTH PROBLEMS: REASONS PEOPLE DO NOT GET HEALTH CARE: • Sex positivity in medical practices • Drug/alcohol addiction • More preventive screening needs to be readily • There was a consensus among the focus group • Fitness for seniors available for those with disabilities . Mammograms and regarding key issues of drug/alcohol addiction stemming PAP screenings are problematic for disabled patients . • Deal with food deserts from mental health and physical health issues . • Many do not get preventive screenings because they • Offerings for community members Participants agreed that many members of the disabled community use drugs, alcohol or food (“emotional feel doctors are too “overloaded”, rushed and “lack • Cooking classes for seniors, yoga, tai chi eating”) as a way of coping with their disability, and the human touch” . They want to be treated as “people • Better patient food these mechanisms lead to chronic disease . first, patients second” .

• Gardens for kids SOCIAL/ENVIRONMENTAL PROBLEMS: IDEAS OR SUGGESTIONS: • Poverty • Coverage for “attended care” and medical • Many people with disabilities live in “poverty” and supplies to be covered by insurance . as a result, lack access to healthy and nutritious food . Many people with disabilities are “at the mercy of • Taking healthcare to the “streets” and to the home- others” and eat what is available to them, or what is less . provided for them because they are unable to cook” . • Creating “bags of hope” to distribute to the homeless Due to a limited fixed monthly income, many choose population . processed foods and fast foods over healthier options . • There needs to be more education, awareness and • Housing proper equipment in “dealing with people and their • Affordable, safe and handicap accessible housing disabilities” . is limited . Many people with disabilities are homeless • More appropriate training for staff, physicians and and have unmet medical needs . first responders on how to safely handle those with • Transportation disabilities . • The need for housing which is accessible to public transportation is a concern .

125 Community Health Needs Assessment APPENDIX B3 - FOCUS GROUP - OLDER ADULTS 1

Date/Time: 11/9/2017, 5:30 p.m. Location/Host: Langston Hughes Community Resource Center Number of attendees: 12 Attendee profile: Attendees were recruited by the Zeta Healthy Aging Partnership (Z-HAP) and they were all African-American older adults who are current participants in the Z-HAP program. Facilitator: Anne Claggett (St. Agnes Hospital)

IDENTIFIED HEALTH PRIORITIES: Drug/alcohol addiction Mental health Smoking

IDENTIFIED SOCIAL/ENVIRONMENTAL PRIORITIES: Access to healthy foods Housing Lack of job opportunities

IDENTIFIED ACCESS ISSUE PRIORITIES: Cost Discrimination, Wait is too long

HEALTH PROBLEMS: REASONS PEOPLE DO NOT GET HEALTH CARE: • Alcohol/drug addiction • Cost is primary cause (including cost of parking) • Mental Health • Insurance • Smoking • No doctor close by • Heart disease • Fear and denial • Overweight/obesity • Staff do not maintain confidentiality • Diabetes • Getting through to someone who can help – • Alzheimer’s/dementia gatekeepers • Wait is too long SOCIAL/ENVIRONMENTAL PROBLEMS: • Discrimination in ER and poor quality of care • ER vs . Urgent Care vs . Doctor • Housing • Jobs IDEAS OR SUGGESTIONS: • Healthy food • Neighborhood violence and safety • Free walk-in clinic for the homeless • Poverty and food deserts • Mass medical clinics and screenings • School dropout • House calls by Specialists • Transportation • Rx delivery with Sheriff • Finding out what programs are offered • Billboard signage on medical programs • Drug treatment center • Use neighborhood organizations like Z-HAP (Zeta Healthy Aging Partnership) • After-school program on health • Train community leaders • Outreach to churches, barber shops, beauty shops, senior buildings, etc . • Hospitals – give back to the community from money made on drug treatment • Dental clinic

126 Appendix APPENDIX B4 - FOCUS GROUP - OLDER ADULTS 2

Date: 11/9/2017 Location: Mary Harvin Senior Center in East Baltimore Number of attendees: 12 Attendee profile: All attendees were residents of an affordable senior housing building in East Baltimore between the ages of 62-83 years. There were 7 African American women and 5 African American men. Facilitator: Adrianna Overdorff

IDENTIFIED SOCIAL/ENVIRONMENTAL PRIORITIES: Access to Healthy Food Public Safety and Violence Prevention

IDENTIFIED ACCESS ISSUE PRIORITIES: Access to Care

SOCIAL/ENVIRONMENTAL PROBLEMS: • Child neglect/engaging children

• Access to healthy food • “Our kids don’t trust anymore . They don’t

• “I think it would be a healthier place if we had know who to run to . That’s sad and at some more available to us, like a fresh market . Unless you point, they will be our future .” have transportation to travel out, you don’t have • “A healthy community is one where kids can access to healthy food .” grow up enjoying themselves . Today they don’t • “There are corner stores around but that’s not have much of anything, not like we had when fresh . The bread is stale, and it costs twice as much .” we were growing up .” • “A healthy community to me is a place where • Neighborhood Safety seniors and the young people mix-in together . • “A healthy community is one where the police walk They meet and come together as groups . Some the streets of Baltimore, and where children get to of us could read stories and some of us could tell know them like we did . A healthy community is stories to them .” where we look out for each other - if we could go • “Could we not volunteer? We don’t need to wait back to when we used to .” for the children to come . We go to them and ask, • “I can tell you what I’m worried about - I’m wor- “Is it okay if I come up here for an hour a week ried about crime waiting to happen in that parking and read you a story? These little kids - they lot (outside the senior apartment building) . I worry haven’t met older people .” about women getting off late at night from doing their marketing, and I see characters walking up and IDEAS OR SUGGESTIONS: down the alleys and there’s no protection at night • The Mary Harvin Senior Center needs a social when women are getting home .” worker to help the seniors in the building • A few years back I was sitting at the bus stop and this mom and child were there and the little girl • A fresh market to buy fruits and vegetables asked me, “Where’s your husband?” And I said, when we need them . “Oh, he went to heaven” and she said, “Somebody • A drug store so seniors don’t have to go too far killed him?” That messed me up . She had no idea to get a prescription . that you can get sick and die because all she knows • Seniors as resources to help kids in the is, murders and killings .” community .

127 Community Health Needs Assessment APPENDIX B5 - FOCUS GROUP - SINGLE PARENTS

Date/Time: 10/31/17, 9:30 a.m. Location/Host: Center for Urban Families Number of attendees: 8 Attendee profile: Attendees were recruited by the Center for Urban Families, and they were all single parents who were participants in the Strive program – focused on building the skills necessary to enter the workforce. Facilitators: Lane Levine & Yolanda Marzouk, Sinai Hospital

IDENTIFIED HEALTH PRIORITIES: Diabetes/high blood pressure Drug/alcohol addiction Mental health

IDENTIFIED SOCIAL/ENVIRONMENTAL PRIORITIES: Lack of job opportunities Limited access to healthy foods Neighborhood safety/violence

IDENTIFIED ACCESS ISSUE PRIORITIES: Physicians not trustworthy

HEALTH PROBLEMS: • Drug/alcohol addiction support and believed that if they had a positive

• All participants communicated frustration with male role model in their lives, their lives would alcohol and drug addiction - “We can’t go anywhere have been different . without seeing alcoholics and drug addicts” . • Domestic violence They stated it was “too easy” to get opioids • Most of the group also expressed having and prescription drugs . Some have used drugs, witnessed domestic violence growing up; half and some have sold drugs in the past . of them had experienced that violence personally • Some participants have also been jailed . at the hands of a parent . All expressed a desire to Participants believe that jail was not a good raise their children with different approaches from solution to drug charges . A heated argument the ones they knew growing up . about marijuana use revealed strong feelings • Access to healthy food on the part of participants who thought marijuana use was destructive, versus those • The group expressed the desire for healthier who felt it was helpful . foods to be available . • They patronize corner stores and grocery stores and expressed interest in seeing more health foods SOCIAL/ENVIRONMENTAL PROBLEMS: in corner stores . • Housing • They had all watched a food-related documentary • Homelessness is an additional concern . together during the course and had made individual • Many came from an unstable or under-resourced commitments to eat more plant-based diets . home environment . All expressed a lack of home However, they noted how difficult it was to carry out these decisions consistently .

128 Appendix

• Participants who had limited custody of their children expressed frustration that they did not have enough control over their children’s environment to feed them healthier foods . • Transportation

• Most participants use public transport . They stated that the buses fill up with school children and it causes adults to be late to their destination .

• This group expressed feelings of personal responsibility for finding work, adhering to commitments, and improving their lives . These feelings came out strongly in a debate about public transportation .

• The group discussed about the most reliable ways to arrive on time and meet their responsibilities . All options were difficult – walking for hours, waiting hours for a bus after already having worked a night shift, etc .

REASONS PEOPLE DO NOT GET HEALTH CARE: • Generally, there was a lack of trust in physicians . They felt doctors weren’t always truthful . But in general, participants understood the importance of going to the doctor on a regular basis, and they had done so their whole lives .

IDEAS OR SUGGESTIONS: • Renovating abandoned homes • Healthy food options - special restaurants, more produce stores, healthy food stores, healthier food served in hospitals . • Separate public buses for kids during school hours

129 Community Health Needs Assessment APPENDIX B6 - FOCUS GROUP - SPANISH SPEAKING

Date: 11/9/2017 Location: East Baltimore Medical Center Number of attendees: 7 Attendee profile: All attendees were Latin immigrants from Central America and Mexico between the ages of 30-51 years. They are all residents of East Baltimore neighborhoods with limited English proficiency. Their time in the U.S. ranged from 2 years to 15 years Facilitator: Adrianna Overdorff

IDENTIFIED HEALTH PRIORITIES: Substance Abuse (Mental Health)

IDENTIFIED SOCIAL/ENVIRONMENTAL PRIORITIES: Education (as it relates to Health Literacy) Immigration Safety and Violence Prevention

IDENTIFIED ACCESS ISSUE PRIORITIES: Cost Discrimination Language Barrier

SOCIAL/ENVIRONMENTAL PROBLEMS: • Fear of reporting crimes because of the threat of • Neighborhood Safety retaliation in the community • Violence and drugs in schools and in neighborhoods • “We can do more– we know where drugs are sold but because of fear, we don’t say anything. Next • “Children are the most affected. They like to be door to my sister’s house, there was a break-in and outside and it’s not good to have them shut in – it we saw who did it but we did not talk to the police. affects them just to see bad things happening around We stayed in the house and didn’t say anything.” them.”

• “Combat the drug situation here- the whole • Immigration concerns community is invaded by drugs, even the schools. • Fear of enrolling in assistance programs because Two years ago, my neighborhood didn’t have a drug identifying information could be shared with problem – today, in broad daylight, people use drugs. immigration authorities; fear of deportation There are families with children that are developing • “I worry that programs that help immigrants in this environment. This is something we must face are going to go away with the way the political for the health of our community. You can’t have a situation is.” community that’s healthy with all that.” • People worry about submitting these documents • “It is mental, as much as it is drug abuse, (for health care programs), believing they are alcoholism…here, on every corner there is a going to be somewhere vulnerable or accessible liquor store…they are like churches. This affects and immigration officers will come and take them the community as much physically as mentally.” away. These fears and rumors happen because one person says it to another and they tell someone else. We have to educate and inform people.”

130 Appendix

• Health education • Cost • • “We need to teach people about health. We need Prescribed medications are often unaffordable, to teach people that if they need a medication, they so people go without necessary treatment . need to buy it and take it and follow the treatment Receiving hospital bills keeps people from the doctor recommends. Many go to the doctor, but seeking care more than once . they don’t take their medications, so they are never • “Out of fear of getting high bills, we don’t going to get better.” seek medical attention.” • Poverty • “We go to appointments and then we receive a bill and we don’t go again because we see • “Fear of not having the right documents…people how much it costs. Cost is the first thing we rent little rooms and don’t have anyone to prove think about in this community.” they live there. You don’t want to ask your boss if they will write you a letter saying you work for • Lack of awareness them and sometimes you do, and they say no. All • The community is not aware of the resources these things build up and they are more afraid, and and programs available they don’t apply.” • “I come to the clinic a lot and every time I come • Difficulty with enrolling in programs I grab a handout or brochure and if I encounter • Documents required to apply for assistance a friend who tells me they aren’t going to the programs at Hopkins and elsewhere are difficult hospital even though they are sick, I tell them – to obtain . go to this clinic (EBMC), you will get good medical care.” • “The health of the community depends on having health insurance, or an alternative to • “The community needs more information about health insurance .” programs and services available. I learned about this clinic at church. But a lot of people, they don’t know about what’s out there for them.” REASONS PEOPLE DO NOT GET HEALTH CARE: • “A healthy community is one in which the work • Language barriers of health programs reaches the community, so that • Create access problems generally; specifically, one can go and be a part of them. Many times, we when it comes to scheduling appointments & don’t know where we can find help.” communicating with providers during visits • Racism and discrimination • “The first thing they ask you when you apply for • “We face discrimination in health care and it is assistance is, “Do you have your taxes, and do partly because we don’t have health insurance. you speak English?” No, I don’t have either. This We need access to affordable insurance.” means many people don’t get care.”

• “People think to themselves, I don’t speak IDEAS OR SUGGESTIONS: English, and no one wants to help me…they are those things that mean people don’t get the help • More communication about health programs they need.” is needed .

• “When you go to an appointment you are • Hospitals need to do more outreach and always afraid because you don’t speak English. communication about programs available, So, someone asks you a question and you say to through radio and television . yourself, “Oh no…what do I say? When they see that you are a Hispanic woman and they don’t look happy, well, then, you just don’t ever go back. That has happened to me.”

131 Community Health Needs Assessment APPENDIX B7 - FOCUS GROUP - CURRENTLY HOMELESS MEN AND WOMEN

Date/Time: 12/4/17, 5 p.m. Location/Host: Banner Neighborhoods Community Center Number of attendees: 5 (7 recruited, 2 decided not to participate) Attendee profile: 3 men and 2 women currently on the streets of East Baltimore. Facilitator recruited participants from local East Baltimore parks. Facilitators: Jonathan Sneddon, JH staff who are active in outreach to the homeless community and previously homeless.

IDENTIFIED HEALTH PRIORITIES: Drug/alcohol addiction Mental Health High Blood Pressure

IDENTIFIED SOCIAL/ENVIRONMENTAL PRIORITIES: Access to Insurance Housing Safety / Violence Transportation

IDENTIFIED ACCESS ISSUE PRIORITIES (identical for all three homeless focus groups regardless of status within the homeless population): Discrimination Lack of assistance with care navigation

HEALTH PROBLEMS: problems, that lead to addiction, which in turn • Drug/alcohol addiction leads to homelessness .

• One participant talked about being desperate and • High Blood Pressure smoking crack because he had no other way to cope with his environment . SOCIAL/ENVIRONMENTAL PROBLEMS:

• One woman said she was an active user and • Lack of job opportunities

decided to be homeless to escape the constant • It is important to mention that one participant criticism and attention of family and friends did not have an opinion on ANY needs other attempting to “help” her overcome her addiction than employment . His only concern related when she has no desire or motivation currently to his ability to work, get a job and provide to stop . a life for himself . • All the participants experience mental health • Lack of healthy food issues, addiction and violence/abuse . • Need for shelter/housing • A participant observed that for the homeless • Violence population the only true priority/top need was mental health treatment . It is mental health

132 Appendix

REASONS PEOPLE DO NOT GET HEALTH CARE: • Discrimination

• Access to compassionate sensitive caregivers who are trained to provide services to vulnerable populations is limited .

• Members of the homeless population are not comfortable visiting a healthcare facility other than in life threatening situations due to the poor treatment they receive (disrespected, marginalized, not seen on the same time schedule as others) . • Difficulty navigating the system

• Unable to successfully navigate care at clinics/ healthcare delivery facilities . Staff are not trained in serving diverse populations . • No insurance • Cost – too expensive • Lack of proper medical treatment • Transportation

IDEAS OR SUGGESTIONS: • Job training • Better access to information

133 Community Health Needs Assessment APPENDIX B8 - FOCUS GROUP - HOMELESS MEN IN TEMPORARY HOUSING AT THE HELPING UP MISSION (#1 OF 2)

Date/Time: 11/22/17, 3 p.m. Location/Host: Helping Up Mission Session #1 of 2 at the Helping Up Mission Number of attendees: 12 Attendee profile: Staff members (Program Directors) recruited participants from amongst the homeless populations using the Helping Up Mission facility. This first of two focus groups included men actively participating in the 12-month residential program at HUM (i.e. not active users). All had been at the Center for 1 to 5 months. Facilitators: Gary Byers, Helping Up Mission and Selwyn Ray, Director, Johns Hopkins Community Relations

IDENTIFIED HEALTH PRIORITIES: Drug/alcohol addiction Mental health

IDENTIFIED SOCIAL/ENVIRONMENTAL PRIORITIES: Education

IDENTIFIED ACCESS ISSUE PRIORITIES (identical for all three homeless focus groups regardless of status within the homeless population): Discrimination

Notes: The Helping Up Mission offers a 12-month transitional housing program for homeless men not actively using banned substances . The program is faith based and therefore the answers of the housing program participants prioritized the needs involving spirituality/ mental health, e .g . feeling hope and purpose where there is commonly despair and depression .

See comments combined for both focus groups following the summary of group 2 below .

134 Appendix APPENDIX B9 - FOCUS GROUP - HOMELESS MEN IN OVERNIGHT SHELTER SERVICES AT THE HELPING UP MISSION (#2 OF 2)

Date/Time: 11/29/17 3 p.m. Location/Host: Helping Up Mission Session #2 of 2 Number of attendees: 12 Attendee profile: Staff members (Program Directors) recruited participants from amongst the homeless populations using the Helping Up Mission facility. This second of two focus groups included men utilizing the overnight shelter services. Some still actively using drugs. Facilitators: Tom Bond, Helping Up Mission and Selwyn Ray, Director, Johns Hopkins Community Relations

IDENTIFIED HEALTH PRIORITIES: Mental Health

IDENTIFIED SOCIAL/ENVIRONMENTAL PRIORITIES: Education Jobs/Unemployment Youth Programs/Engagement

IDENTIFIED ACCESS ISSUE PRIORITIES: (identical for all three homeless focus groups regardless of status within the homeless population): Discrimination

HEALTH PROBLEMS: • Employment

• Mental health services must be easy access for all ages • Better jobs that have low unemployment rates . SOCIAL/ENVIRONMENTAL PROBLEMS: IDEAS OR SUGGESTIONS: • Education • Life support center - A centralized location • Both focus groups at the Helping UP Mission for programs for youth, social services help stressed that mental health and proper education etc ., everything needed to build a healthy are the root causes of the highest community community . This can be a space for teaching needs . Without proper education and mental children accountability and showing respect health services, it is impossible to maintain a to elders . job or a home . • Attractive welcome locations for mental • Education and spirituality to teach wisdom health treatment centers . to youth . • Job readiness programs . • Each one teaches one . • Information on how to sign up for screenings • Kids don’t want to go to school anymore . in the community . • Neighborhood Safety • Hospitals should work with churches and • Neighbors must hold everybody in the community organizations to enhance preventive community accountable . measures . • Invest in children not prisons – After school • Better patient-doctor relationship where programs in full affection/meals . doctors really care about the patient and know the patient .

135 Community Health Needs Assessment APPENDIX B10 - FOCUS GROUP - CANCER Date/Time: 11/10/2017, 9:30 a.m. Location/Host: Sinai Hospital Number of attendees: 3 Attendee profile: Attendees were recruited by LifeBridge Health and all were cancer patients seen at Northwest or Sinai. This group happened to be all men at various stages in their treatment process. Facilitators: Lane Levine & Yolanda Marzouk (Sinai Hospital) IDENTIFIED HEALTH PRIORITIES: Cancer Mental health/ isolation Smoking/tobacco use IDENTIFIED SOCIAL/ENVIRONMENTAL PRIORITIES: Access to doctors’ office Access to insurance Cost–too expensive IDENTIFIED ACCESS ISSUE PRIORITIES: Cost Poor patient-doctor relationship

HEALTH PROBLEMS: • “Side-effects and symptoms are ignored” so patients • Mental Health stated they will stop a medication without telling physicians since they felt like doctors didn’t listen . • Depression and isolation - “feel like I’m on my own” . • “Something that is missing is connections” • “Doctors look at charts and ignore patients .” • “Lack of community” • “Doctors don’t respect patients .” • Smoking/Tobacco use IDEAS OR SUGGESTIONS: • No follow-up from healthcare workers to “are you a smoker?” • Cancer Forums to raise awareness: Provide more • “Cigarettes are like a drug, just as addictive” awareness regarding the process of screenings . For example, explain what is entailed for a prostate SOCIAL/ENVIRONMENTAL PROBLEMS: screening since men don’t like going to doctors . • Food – more information on nutrition with regards • More information needed: Brochures and to what to eat and what to avoid . educational materials need to be distributed in churches, local YMCAs and senior centers . REASONS PEOPLE DO NOT GET HEALTH CARE: • Lower parking costs at Sinai . • Patients felt a lack of support from the system • The old want to interact with the young . • Insurance related issues • Field trips to help with isolation . • “Average person doesn’t know who to call to find out information on various health plans ”. • More peer-to-peer education: Patients would • Cost rather speak to those who have had similar experiences . More local support needed rather • “Cost of healthcare is too expensive, especially than being referred to a national foundation . those with pre-existing conditions .” • Donut hole is an issue for many seniors . • More support needed: create an internal Don’t have the funds to get out of the “hole” . mentorship program . • Poor patient-doctor relationship • Provide resources and guides for smoking cessation . • Patients stated they felt no continuum of care • Don’t want prompts when calling, we want with doctors to talk to a person . • “Doctors have a whole different language” . Patients • More suggestions for how to deal with symptoms . felt like it’s difficult for doctors to “bring it down to patients’ level” . 136 Appendix APPENDIX B11 - FOCUS GROUP - POPULATION HEALTH CLIENTS

Date/Time: 11/16/2017, 9 a.m. Location/Host: Sinai Hospital Number of attendees: 2 Attendee profile: Attendees are clients of community outreach programs in the department of Population Health at LifeBridge Health Facilitator: Yolanda Marzouk (Sinai Hospital)

IDENTIFIED HEALTH PRIORITIES: Drug/alcohol addiction Mental health Smoking/tobacco use

IDENTIFIED SOCIAL/ ENVIRONMENTAL PRIORITIES: Lack of job opportunities Neighborhood safety/violence Poverty IDENTIFIED ACCESS ISSUE PRIORITIES: Cost Wait is too long

HEALTH PROBLEMS: • Neighbors don’t do or say anything either • Drug/alcohol addiction because of fear of retaliation .

• “Liquor stores are too accessible, there need • “The drug dealers don’t even give respect to to be less liquor stores . Strict rules must be church members on Sundays .” enforced .” • Clean up the community so people feel safer • Young people ‘try to fit in” and they do drugs and can appreciate their community . and don’t seek help • Community does not want to be surrounded • This city has “a lot of peer pressure” by “drugs and alcohol” .

• Young people using suboxone to get high . • “People get murdered and no one cares”, Addicts sell strips for $8-$10 per strip . making you think that “killing is alright” and “people are killing for $2,000” . • “Traumatic home life leads to mental health issues” . • “Police harass people they shouldn’t and then leave the ones they should be policing alone” .

SOCIAL/ENVIRONMENTAL PROBLEMS: • “Police aren’t policing, they focus on small things and ignore the big” . • Neighborhood safety • “Depression and violence is big” . • Drug dealers “don’t reside there” . They just come there to sell drugs . Arrive at about 6 am • “Poor environment- it needs to improve” . and are there until 1 or 2 am . “some have wives “Lots of cleaning up to do” . and kids that come join them” . • Isolation

• “Can’t even get in to Corner Stores to make • Everyone needs to come together more . a purchase since dealers are selling drugs in the People feel isolated in the community . stores and store owners ignore them due to fear of retaliation ”.

137 Community Health Needs Assessment

• “Don’t make people feel segregated, people IDEAS OR SUGGESTIONS: need to be one unit” • More community engagement projects are needed . • “Communities need to come together more” Community needs to be “built back up” . • Exercise • Form organizations and designate advocates to start setting things in place and what they want to foresee • Participant “Involved with church but would in their community . like more wellness programs” . • More community programs like music in • “Would like to have a safe walking trail where community, reading book clubs, etc . everyone can get out and walk” . • “People don’t know that programs exist, there need • Education to be better ways to inform the community including • Law needs to be changed regarding school ads on billboards, TV’s, corner stores” . drop-out age, needs to change from 16 to 18 . • Programs need easier access, “shouldn’t have to • “More outreach” . enroll and wait to get accepted into drug programs, • Job Opportunities you should just be able to show up” .

• More technology classes .

• “People sell drugs because it’s hard to get jobs, it’s easier for females to get jobs” .

REASONS PEOPLE DO NOT GET HEALTH CARE: • Insurance is too expensive • Wait is too long to be seen

138 Appendix APPENDIX C1 - FOCUS GROUP - KEY COMMUNITY STAKEHOLDERS

Date/Time: 11/10/17, 1:30 p.m. and 11/15/17, 11 a.m. Location/Host: Mercy Medical Center and Forest Park Senior Center Number of attendees: 16 and 7 Attendee profile: Attendees were invited by members of the citywide CHNA Project Team and represented a variety of organizations throughout the city. They were chosen for their knowledge of specific communities, focus areas or disease states that were important for getting a full picture of community needs. See list of attendees at end of document. Facilitators: Lane Levine, Sinai Hospital, and Anne Williams, University of Maryland Medical System

IDENTIFIED HEALTH PRIORITIES: Drug/alcohol addiction Chronic disease Mental Health

IDENTIFIED SOCIAL/ ENVIRONMENTAL PRIORITIES: Housing Older adults* Safety, violence and trauma

IDENTIFIED ACCESS ISSUE PRIORITIES: Accessibility/availability of medical services and facilities in neighborhoods Caregiver needs Health literacy *The meetings attracted a high proportion of people in aging services fields – however, people not strictly in these fields also touched heavily on problems concerning older adults.

HEALTH PROBLEMS: • Mental health is an issue for all ages . It is often • Drug/alcohol addiction (top item) difficult for people to manage the symptoms of their illness and it becomes a barrier to living a • Drug addiction affects all ages and tends to healthy life . impact physical and mental health, leading to stroke, heart disease, cancer, and Alzheimer’s • Depression and anxiety are two major issues disease . and it was noted that the two mental illnesses can arise from being exposed to violence and • Lack of employment leads to substance abuse . being immobile . Outcomes include isolation • Mental Health (top item) and loneliness, which can lead to alcohol and drug addiction . • Mental health is often not talked about and is rarely ever seen as a health problem . • People are often unreceptive to references to mental health that include words they • Mental health issues are on the rise and there are not familiar with: “trauma is not the is a lack of adequate health care to address word they use” . the problem; more resources and providers are necessary .

139 Community Health Needs Assessment

• Chronic Diseases (top item) Community Building: • Conflict resolution training is critical . • Obesity: Stems from poor diet, sedentary lifestyle (often due to inability to exercise), and genetic • “Community members need to be empowered predispositions . to feel like they can work through issues instead of hurting or violating others to • Diabetes: There is a very high rate of diabetes in get what they want .” our communities . • Older adults • COPD: This is becoming increasingly prevalent in older adults • Abuse of older adults is increasing .

• Heart disease, high blood pressure, and cancer are • Housing is a major problem that older the leading causes of death for adults . adults face . Not only is cost a problem, but infrastructure that ensures safety is • Pregnancy complications a problem too (i .e . lack of sturdy railings) . • Infant mortality is a huge issue as is preterm birth . • There is not enough access to resources • Women with high blood pressure or drug/alcohol in general for older adults . addiction are more likely to have a preterm baby . • Isolation, their inability to manage daily living, • Tobacco use and basic gaps (such as lack of hearing aids to • Alzheimer’s and Dementia use phones to get help) are also major issues . • ADHD/Autism • Housing • Lack of oral hygiene Homelessness and children • Hearing impairment • Lack of a consistent source of food and switching schools leads to poor education outcomes . • HIV/Aids • Mental health deteriorates because living with • Asthma many different people is not conducive to learning - “don’t have own space, can’t get homework done, can’t sleep because there are SOCIAL/ENVIRONMENTAL PROBLEMS: 6 people in their room” . • Safety, violence and trauma Accessibility and affordability Effects on youth: • There is a need for more affordable and • Violence is a leading cause of death for disability-friendly housing . Baltimore kids . • “Home based setting vs institutional housing for • Children encounter violence before they even people with developmental disabilities leads to encounter school . improved outcomes” . • Teen violence is on the rise . Quality Issues • There are many abused and neglected children . • Lead paint poisoning is a major problem . • Violence has a lifelong effect on outcomes . • Safe infrastructure is lacking . Effects on the community: • Rat and roach infestation hinder health . • Even if housing is available and accessible, • 1/3 of house are vacant or boarded up – attracting violence can prevent people from moving rodents and illegal activities . into the community . • Mold • Healthy food initiatives in conjunction with • Law enforcement corner stores are jeopardized if safety to and • Police need to address drug dealer problem . from the stores is an issue . • Over policing is meant to reduce violence, but it does the exact opposite, it creates a strong divide (police vs . community) .

140 Appendix

• “Police used to live in communities they REASONS PEOPLE DO NOT GET HEALTH CARE: served and knew people there . Now they are • Medical care accessibility assigned to a block where they know no one” . • “Just having a health presence in the community • Green space reduces crime rate” .

• Green space is necessary for health, both mental • There needs to be not just access, but quality and physical . However, illicit and dangerous access . activities take place in these green spaces at night . • Transportation • Parental guidance • Getting to locations for care is difficult, especially • Lack of crisis intervention resources . for older adults . • Employment • Physicians

• Frequent lack of opportunities and • Availability of physicians in the community is an benefits (days off for medical care and issue . lack of, or ever-changing health insurance) . • There are also language and communication • A sense of autonomy and self-determination barriers: “We’re all speaking the same language, provided by stable employment is critical to health . but things are not being explained in a way that’s • Many must work multiple jobs to just afford understandable” . the necessities . • Continuity of care is usually an issue because • Education there isn’t a doctor or health system nearby . In addition, there is a lack of care management . • There is a lack of services and resources: “are they Information is dispersed, but follow ups are rare . getting an appropriate education?” . • There is a need for a smoother transition • There is also a lack of leadership in Baltimore City between pediatric and adult services . Schools . • Health literacy • Schools are underfunded: “the community cannot be supported by the schools we have” . • “Health insurance literacy – people do not understand how to navigate their insurance, • Food how to use it to address their needs” • Food deserts and lack of healthy food affect the • Unfamiliar terminology prohibits understanding health of the community . health care . • Institutionalized racism • Pharmacy deserts and unaffordable prescriptions • Redlining make it difficult to remain healthy . • Lack of ability to accumulate wealth and have • Caregiver resources sustained environments . • Dental Care and Vision • Inequities we see are a direct result of racism • Although important, dental care and vision in the U .S . are rarely a priority . • We can address the symptoms but need to address the underlying causes .

141 Community Health Needs Assessment

ATTENDEES:

11/10/17 Name Title Organization Email Phone Quality and Systems American Heart Association, Amanda Davani Improvement Director Mid-Atlantic Affiliate [email protected] 443-824-4379 Promise Heights, U Maryland [email protected]. Bronwyn Mayden Executive Director SSW edu 410-706-2077 Elizabeth “Ibby” Tan- Director of Interprofes- Community Public Health Nursing, ner, PhD, RN, FAAN sional Education Hopkins [email protected] 410-614-5303 Director, SAFE: Stop Jacke Schroeder Abuse of Elders CHANA [email protected] 410-234-0030 Director, Community Karen Nettler Connections Jewish Community Services [email protected] 410-843-7409 Kathryn Lothschuetz U Maryland Department of Part- Montgomery, PhD, Associate Professor and nerships, Professional Education, kmontgomery@umaryland. 410-706-8198 RN, NEA-BC Chair & Practice edu Director of Communica- American Heart Association, Kerri Johnston tions Mid-Atlantic Affiliate [email protected] Senior Director, Commu- American Heart Association, Kimberly Mays nity Impact Mid-Atlantic Affiliate [email protected] 410-246-6718 lesliem@disabilityrightsmd. 410-727-6352 Leslie Margolis Managing Attorney Disability Rights MD org x2505 Marina Nellius, Community Social LGSW, MSW Worker MedStar Total Elder Care [email protected] 443-444-6100 Manager, Program De- Mira Appleby velopment Sinai VSP [email protected] 443-955-7526 Comprehensive Housing Assis- Mitchell Posner Executive Director tance, Inc. [email protected] Executive Director, LGBT Nate Sweeney Health Resource Center Chase Brexton Health Care [email protected] U Maryland Geriatrics and Geron- Reba Cornman Director tology Education and Research [email protected] 410-706-4327 Program Vice President, American Heart Association, Rhonda Chatmon Multi-Cultural Markets Mid-Atlantic Affiliate [email protected]

Wendy Lane U of Maryland [email protected]

11/15/17 MedStar Center for Successful Adrienne Kilby Geriatric Social Worker Aging [email protected] 443-444-4720 Deputy Commissioner, Heang Tan Division on Aging and Baltimore City Health Department [email protected] CARE Services Senior Director, American Heart Association, Kimberly Mays Community Impact Mid-Atlantic Affiliate [email protected] 410-246-6718

VP of Development and Liz Kaylor Community Relations Baltimore Medical System, Inc. [email protected] 443-703-3452

MedStar Center for Successful Margi Lenz Geriatric Social Worker Aging [email protected] 443-444-4720

VP of Policy Green and Healthy Homes Michael McKnight and Innovation Initiative [email protected] 410-534-6447

Director, Community American Diabetes Association, 410-265-0075 Tracy Newsome Health Strategies Maryland Area [email protected] x4679

142 Appendix APPENDIX C2a - SINAI/LEVINDALE COMMUNITY STAKEHOLDER INTERVIEWS

STAKEHOLDER MEETING: of the available jobs are outside the community TONY BRIDGES, PARK HEIGHTS RENAISSANCE in other counties (Carroll and Anne Arundel), DATE/TIME: 01/09/2018 requiring applicants to have transportation, FACILITATOR: LANE LEVINE (SINAI HOSPITAL) which is often a barrier to accepting these jobs .

HEALTH PROBLEMS: REASONS PEOPLE DO NOT GET HEALTH CARE: • Drug/alcohol abuse – There are many liquor stores • Lack of knowledge – Because many people do in Park Heights, providing easy access to alcohol . not understand the complicated health care system, In addition, drug abuse is becoming more common they often don’t seek medical care until their among younger populations . condition has escalated to an acute issue . • Mental health – Support is needed for children • No insurance – People expressed a lack of dealing with abuse and family issues . Schools do knowledge and understanding about the insurance not have these resources . The adult population options that are available to them . has these same issues and limited resources available to them . IDEAS OR SUGGESTIONS: • High blood pressure – Many people have issues with • Employment centers should include mentoring high blood pressure and experience barriers staying on services, life coaching, and career pathways their medication, particularly seniors . education . Additionally, services and resources should be provided to those in their probationary SOCIAL/ENVIRONMENTAL PROBLEMS: employment period to ensure success for them . • Access to healthy food options – Residents must go • Other services that would be helpful include outside of the Park Heights community to find healthy childcare and transportation . food choices . Park Heights Renaissance continues to partner with Park Heights Community Health Alliance (PHCHA) to address this problem . STAKEHOLDER MEETING: • Public safety – There was concern around high MALKIA PIPKIN, COMMUNITY SCHOOL COORDINATOR, murder rates in the community . Participants also PARK HEIGHTS RENAISSANCE, INC. noted that blight and public safety issues are DATE/TIME: 01/11/2018, 9:35 a.m. connected . There was agreement that it is not a FACILITATOR: YOLANDA MARZOUK (SINAI HOSPITAL) safe community, but that a high police presence, while helping with the crime issue, is a painful, visible reminder of the crime problem . HEALTH PROBLEMS: • Job opportunities – Job opportunities require • Drug/alcohol addiction workforce training and access to transportation . • Mental health There are not enough real job opportunities in the • Overweight/obesity community, other than Sinai Hospital . (Pimlico Race Course used to employee more residents) . While there are some workforce training centers in the SOCIAL/ENVIRONMENTAL PROBLEMS: neighborhood, not everyone is able to take • Availability/Access to doctor’s office advantage of these resources; and those that do find that completing a training course does not • Access to healthy foods necessarily guarantee employment . Also, many • Cost-too expensive/can’t pay

143 Community Health Needs Assessment

• School dropout/poor schools IDEAS OR SUGGESTIONS: • Transportation • “Racism is the most constant issue that should be addressed . It impacts all residents of Park Heights . Frankly, the categories listed don’t begin to address REASONS PEOPLE DO NOT GET HEALTH CARE: any solutions . It just continues the downstream • Lack of knowledge – “people are too practice of responding to the problems . We need to embarrassed to ask” be proactive to solve social determinate issues…we must think upstream to get to the core problems” . IDEAS OR SUGGESTIONS: • “Poverty is caused by a system of racism . Economic opportunities, combined with • More in-person workshops are needed-- educational and workforce development, is information is better absorbed and pamphlets needed to improve the health of the community .” are often just thrown in the trash . • The community needs access to education • More in person educational workshops on at all levels to improve and stabilize long-term food and nutrition are needed . economic development . • More healthy food options are needed . • “People need job opportunities” The community needs more grocery stores that carry fresh produce and meats, especially • Restructured economic opportunities that expand in lower Park Heights . home ownership are needed . It was suggested that the hospital could purchase a block of blighted homes and then refurbish them to improve the community . • Community members who work at the hospital STAKEHOLDER MEETING: should be more aware of the many programs WILLIE FLOWERS, EXECUTIVE DIRECTOR, available to them (e .g . tuition reimbursement, PARK HEIGHTS COMMUNITY HEALTH ALLIANCE Live Where You Work program, and classes and DATE/TIME: 12/14/2017, 1:30 p.m. training) . LOCATION/HOST: PARK HEIGHTS COMMUNITY HEALTH ALLIANCE • Provide children in the community with an FACILITATOR: YOLANDA MARZOUK (SINAI HOSPITAL) education in technology fields—the areas with future job growth potential . Donated, refurbished laptops could support this concept . HEALTH PROBLEMS: • Empower families • Drug/alcohol addiction • Provide meditation and other mindfulness • Heart Disease modalities . • Mental health

SOCIAL/ENVIRONMENTAL PROBLEMS: • Racism

REASONS PEOPLE DO NOT GET HEALTH CARE: • Cost –too expensive • No insurance • Wait is too long

144 Appendix APPENDIX C2b - NORTHWEST COMMUNITY STAKEHOLDER INTERVIEWS

STAKEHOLDER INTERVIEW: applying for emergency funds, finding temporary BALTIMORE COUNTY PUBLIC HEALTH OFFICIALS shelters, enabling rapid rehousing, and applying for DATE/TIME: 02/02/2018 energy assistance and eviction FACILITATOR: LANE LEVINE (SINAI HOSPITAL) prevention funds . • Transportation – The biggest transportation HEALTH PROBLEMS: challenge in Baltimore County is the lack of • Overweight/obesity – County health officials transportation between the east and west sides acknowledge the high obesity rates and have been of the county . The limited transportation options working towards increasing physical activity are very time-consuming . opportunities for families . The county is also • Poverty – The county has large Medicaid addressing primary prevention through implementation populations in certain areas . Although the of a Diabetes Prevention Program for at-risk individuals . Affordable Care Act provided many people with The program emphasizes lifestyle changes including insurance, there are still a large number of working losing weight . class individuals who are uninsured due to the cost of • Behavioral health–Many behavioral health disorders self-insurance or the cost of the many high deductible are not treated adequately, including opioid addiction . plans offered through low wage jobs . The County • Infant deaths/low birth weight babies – While there received some funding from Kaiser Permanante are many initiatives around SIDS and safe sleep, there to help enroll individuals in insurance plans and is still a high incidence of low birth weight babies they also have some emergency funds available and infant mortality in the county . The county has for the uninsured . identified a disparity issue and has maps showing clusters of occurrences on both the east and west REASONS PEOPLE DO NOT GET HEALTH CARE: sides of the county . The west side zip codes with • There are only two Federally Qualified Health greatest infant deaths and low birth weight babies Centers (FQHCs) in Baltimore County . are 21136, 21117, and 21144—the areas right around Northwest Hospital . However, since • Transportation can be a barrier . Northwest is not a birthing hospital, LifeBridge • There may be language barriers for some Health has been working with the Health populations, particularly Spanish, Russian, and Department to discuss ways to address this issue . Burmese populations . Some ideas include working with other LifeBridge • The cost of health care can be prohibitive Health birthing hospitals, more formalized (e .g . copays, no insurance, limited sliding scale relationships with Healthy Families America primary care providers) . programs in the city and the county, and expanded breastfeeding support programs . IDEAS OR SUGGESTIONS: SOCIAL/ENVIRONMENTAL PROBLEMS: • The Baltimore County Health Department • Affordable housing – The county works with and Northwest Hospital should partner on more the Office of Planning, Project HOME Adult Foster regional projects addressing the opioid epidemic, Care, county homeless shelters, and Health and perhaps working on advocacy issues with the Human Services to assess and assist unaccompanied Maryland Hospital Association, including improved youth living and older adults without stable housing behavioral health/detox services and registries . by providing integrated case management to assist in

145 Community Health Needs Assessment

• Baltimore County Health Department nurses STAKEHOLDER INTERVIEW: have assisted LifeBridge Health in hypertension KELLY CARTER, EXECUTIVE DIRECTOR, LIBERTY ROAD prevention activities by providing short-term case BUSINESS ASSOCIATION DATE/TIME: 01/18/2018, 11 a.m. management for clients in the Changing Hearts FACILITATOR: LANE LEVINE (SINAI HOSPITAL) Program . • LifeBridge Health has been an active member of the Baltimore County Local Health Improvement HEALTH PROBLEMS: Coalition and has been contributing to the county • Obesity – The obesity problem is evident in the health department strategic plan . The county sees community this as a very successful model and would like this • Mental health –There are a number of young participation to continue and expand—perhaps to people who are mentally unstable and disruptive shared CHNA efforts and integrated programs who congregate in public places . In addition, there addressing homelessness and chronic disease . are elderly folks who walk along the road and sit at • There is a preponderance of group homes/assisted bus stops having conversations with themselves . living facilities in the Northwest Hospital service area • Heart disease – Hypertension is a key concern needing additional supportive services from public for everyone, especially seniors, who recognize the health and from health care providers . healthy living leads to a healthy heart and life . • The county will be implementing a Diabetes • Cancer – The interviewee recounted that she Prevention Program and intends to become certified . has personally witnessed the effects of cancer in Some shared activities around an education campaign her family—her uncle, her grandfather, and her for prediabetes could be a natural starting point father all died of cancer within the last two years . for a partnership . Northwest Hospital has already She feels that she is constantly hearing of someone committed to partner with the health department being diagnosed with cancer . to administer the DPP as part of this CHNA Implementation Strategy . SOCIAL/ENVIRONMENTAL PROBLEMS: • Healthy foods – Due to the preponderance of fast food restaurants and convenience stores along the Liberty Road corridor, coupled with the lack of quality grocery stores, healthy food is not readily available in the community . Transportation is required to access quality grocery stores, as they are located outside the neighborhood . The community continues to work with elected officials to have a local food chain locate in the community . The Farmer’s Market does provide healthy fruits and vegetables and accepts vouchers, but is not a solution off-season, or off-hours . • Transportation – The county councilman and the MTA have worked together and have recently improved local transportation routes . These improvements have made grocery store access better, but not easy . • Domestic violence – “There is an alarming number of individuals that come to Northwest Hospital as a result of domestic violence .”

146 Appendix

REASONS PEOPLE DO NOT GET HEALTH CARE: STAKEHOLDER INTERVIEW: VIVIAN PAYSOUR, PRESIDENT, OAKWOOD VILLAGE • Too expensive/No insurance – Much of the COMMUNITY ASSOCIATION community finds it cheaper to pay out of pocket DATE/TIME: 01/11/2018, 10 a.m. than to acquire health insurance due to the many FACILITATOR: LANE LEVINE (SINAI HOSPITAL) working class individuals who face high deductibles in the insurance plans available to them . There is, however, excellent information about health HEALTH PROBLEMS: care screenings and other offerings available • Heart Disease – Many people have heart at Northwest Hospital . problems; some have died from heart attacks • No doctors nearby – There are not many or strokes . physician practices in the community . • Obesity - Many neighbors are obese, which leads to further inactivity and lung/heart/blood IDEAS OR SUGGESTIONS: pressure problems . • Continue to advertise and provide free • Cancer – The interviewee is aware of several screenings – “the more we know, the better people who have died from cancer recently, we are” . including one board member . • There can never be too much community outreach work . SOCIAL/ENVIRONMENTAL PROBLEMS: • Neighborhood safety – The neighborhood works hard to keep violence and crime out, by actively and anonymously reporting suspicious activity . The neighborhood has a good relationship with the police and Citizens on Patrol . The biggest safety concerns are drug-related activities and crimes that come along with addiction . • Places to exercise – The neighborhood would like to see more fitness classes for community members .

REASONS PEOPLE DO NOT GET HEALTH CARE: • Cost – Although many community members are on Medicare, there are some people who find carrying insurance to be too expensive .

IDEAS OR SUGGESTIONS: • Yoga classes at nearby LifeBridge Health facilities • Other exercise classes • Nutrition classes • Better lighting in front of the neighborhood to deter crime

147 Community Health Needs Assessment

STAKEHOLDER INTERVIEW: AARON PLYMOUTH, PRESIDENT, STEVENSWOOD IMPROVEMENT ASSOCIATION DATE/TIME: 01/23/18, 12:30 p.m. FACILITATOR: LANE LEVINE (SINAI HOSPITAL)

HEALTH PROBLEMS: • Diabetes – 95% of residents are African American, with a high diabetes rate . • High Blood Pressure • Stroke • Overweight/obese

SOCIAL/ENVIRONMENTAL PROBLEMS: • Neighborhood safety – Neighbors help each other in this community . The neighborhood has Citizens on Patrol and there is minimum theft . They also have an Operation Clean Sweep, which enforces codes, organizes community cleanups, food and clothing drives, and street sweeping services . This community has access to transportation and places to exercise .

IDEAS OR SUGGESTIONS: • More health education about diabetes . • More men’s health topics at health fairs, such as prostate cancer . • Increase awareness of holistic health . • Host health related panels/seminars and healthy cooking demos .

148 Appendix APPENDIX D1 - SINAI PUBLIC HEALTH DATA SUMMARY

QUANTITATIVE PROFILE SUMMARY SEE APPENDIX FOR COMMUNITY STATISTICAL AREAS (CSAS) INCLUDED IN PROFILE - DECEMBER 8, 2017

Demographics 1 Regarding the built environment, the vacant building Baltimore City, Maryland, has a population of 622,454 density is 562 per 10,000 housing units in Baltimore City and the geographic area of the CSAs included in this vs . 462 vacant buildings per 10,000 housing units in profile (referred to hereafter as the “CHNA area”) has the CHNA area . There are about 4 liquor stores per a total population of 85,377 (14% of Baltimore City’s 10,000 residents of Baltimore City and about 2 liquor population) . In 2040, Baltimore City’s population is stores per 10,000 residents of the CHNA area . Food access projected to be 693,029 (11 .6% change from 2010 is a major challenge in Baltimore City with nearly 13% decennial census) while the CHNA area’s population is of land classified as a food desert . The food desert expected to be 85,767 (6 .0% change from 2010 decennial estimate for the CHNA area is 12% . Exposure to violence census) (Baltimore City Health Department (BCHD) is another concern; the homicide rate (which is based on the analysis of data provided by the Baltimore City geographic location of the homicide incident rather than Department of Planning) . 55 percent of the CHNA area the victim address) is 4 per 10,000 residents in Baltimore is female sex and 71% of the area is African American City and 4 per 10,000 residents in the CHNA area . race, compared to 53% and 63% for Baltimore City, 1 respectively . Twenty-one percent of Baltimore City’s Health Outcomes population is aged less than 18 years and 12% is aged Life Expectancy 65+ years compared to 23% and 17% in the CHNA The overall life expectancy at birth in Baltimore City area, respectively . is 73 .6 years compared to 75 .6 years in the CHNA area . Life expectancy is highly impacted by deaths among 1 Social Determinants of Health young people, which are often due to intentional and The social determinants of health include a wide variety unintentional injuries . of exposures that impact health across all ages, from the individual to the population level . They include factors Mortality (Death) such as employment, income, education, the built The all-cause age-adjusted mortality rate in Baltimore City environment, access to healthy foods, exposure to is 100 per 10,000 residents vs . 87 per 10,000 residents in violence, and stress . the CHNA area . The top causes of death in Baltimore City Like most places, employment and income are key are cardiovascular disease, cancer, stroke, and drug- and/ social determinants of health in Baltimore . The or alcohol-related . In the CHNA area, the top causes unemployment rate is 13% and the family poverty are cardiovascular disease, cancer, stroke, and homicide . rate (families with children under 18 years) is 29% Among cancer deaths, lung cancer is the most common in Baltimore City compared to 15% and 27% in the in Baltimore City, and lung cancer is the most common CHNA area, respectively . In terms of education 2, in the CHNA area . more than 77% of kindergarteners are “fully ready” to learn in Baltimore City, and this ranges from Morbidity (Disease) 59-100% among the CSAs included in the CHNA Other health outcomes of interest include maternal and area . About 55% of 3rd and 8th graders are at child health and sexually transmitted infections . The infant “proficient or advanced” reading levels in Baltimore mortality rate in Baltimore is 10 per 1,000 live births, and City . Among the CSAs of interest in the CHNA area, it is 10 per 1,000 live births in the CHNA area . Among this ranges from 50-97% for 3rd graders and 54-85% children aged 0-6 years who were tested for elevated blood for 8th graders . lead levels, 1% tested positive in Baltimore City

149 Community Health Needs Assessment vs . 1% in the CHNA area . The teen birth rate among for elementary school students, 4-18% for middle school females in Baltimore City is 42 per 1,000 females aged students, and 10-46% for high school students . 15-19 years . This value in the CHNA area is 38 per 1,000 In terms of adult educational attainment, 47% of adults females aged 15-19 years . In Baltimore City, the incidence have a high school degree or less and 29% have a bachelor’s rate of gonorrhea is 56 per 10,000 residents vs . 46 per degree or more in Baltimore City . This is compared to 10,000 residents in the CHNA area (BCHD analysis of 50% and 25%, respectively, in the CHNA area . 2016 gonorrhea cases reported to BCHD) . The vacant lot density is 647 per 10,000 housing units Additional Metrics1 in Baltimore City vs . 536 per 10,000 housing units in the CHNA area . Demographics Regarding tobacco outlets, in Baltimore City, there are In Baltimore City, 65% of children live in single-parent 21 tobacco stores per 10,000 residents . In the CHNA households compared to 55% in the CHNA area . area, there are 14 tobacco stores per 10,000 residents . In terms of language, 3% of Baltimore City residents Access to food is an important social determinant of report themselves as speaking English less than health . In Baltimore City, there are 11 carry-out restaurants “very well” vs . 3% in the CHNA area . per 10,000 residents and about 3 fast food restaurants per 10,000 residents . This is compared to 9 and 1 per Social Determinants of Health 10,000 residents in the CHNA area, respectively . In terms The Hardship Index is a combined measure of six of corner stores, there are 14 corner stores per 10,000 socioeconomic indicators: crowded housing, poverty, residents in Baltimore City and 10 corner stores per unemployment, education (less than high school diploma), 10,000 residents in the CHNA area . per capita income, and dependency (persons aged In terms of exposure to violence based on the non-fatal less than 18 years and 65+ years) . In Baltimore City, shootings rate, the overall rate for Baltimore City is the Hardship Index is 51 . The Hardship Index for the 7 non-fatal shootings per 10,000 residents (based on the CSAs in the CHNA area ranged from 23-73 3 . injury location and not the victim residence) . The same Thirty-three percent of land in Baltimore City is covered rate for the CHNA area is 6 per 10,000 residents . by green space (tree canopy, vegetation, and parkland) In terms of exposure to violence, in Baltimore City, the vs . 46% of land in the CHNA area . rate of homicide among youth (aged less than 25 years) Twenty-three percent of land in Baltimore City is zoned is 31 homicide deaths per 100,000 youth compared to as industrial vs . 6% of land in the CHNA area . 32 homicide deaths per 100,000 youth in the CHNA The overall rate of citizen-generated rat service requests area . These data are based on the residence location to 311 in Baltimore City was 409 per 10,000 households of the victim . vs . 233 per 10,000 households in the CHNA area . This measure may not accurately reflect the true burden of rat Health Outcomes problems because it is affected by citizen engagement with The rate of reported foodborne illness in Baltimore government (311 is a government service) and it does City is about 5 per 10,000 residents per year (based not reflect private pest services . on residence location of patient) . The same rate in the Exposure to lead paint can cause lead poisoning among CHNA area is 6 per 10,000 residents per year . children . In Baltimore City, there are 10 lead paint In Baltimore City, the rate of hepatitis C infection is violations per 10,000 households per year, while in the 35 per 10,000 per year (based on residence location CHNA area there are 8 lead paint violations per 10,000 of patient) compared to 33 per 10,000 per year in the households per year . CHNA area . Regarding chronic absenteeism 2, the percent of school The age-adjusted mortality rate due to fall injury is children who missed 20 days or more in Baltimore City 1 per 10,000 in Baltimore City vs . 1 per 10,000 in is 15% for elementary school students, 15% for middle the CHNA area . school students, and 39% for high school students . In the Crude mortality rates represent the public health burden CSAs making up the CHNA area, this ranged from 1-23% of death in the population . In Baltimore City, the greatest

150 Appendix mortality rate (1,316 per 10,000) is among ages 85+ years Notes and the lowest mortality rate (2 .2 per 10,000) is among 1 All data are calculated from the Baltimore City Health ages 1-14 years . In the CHNA area, the greatest Department’s 2017 Neighborhood Health Profiles (NHPs) mortality rate is 1216 per 10,000 among ages 85+ years unless otherwise noted . Please see the 2017 NHPs for a list and the lowest mortality rate is 2 per 10,000 among of data sources, including year(s), and methodology . ages 1-14 years . https://goo .gl/GCEYKF Measures of maternal health are important to 2 Due to its agreement with the Baltimore City Public understanding the public’s health . Schools, the Baltimore Neighborhood Indicators Alliance The birth rate in Baltimore City is 14 live births was unable to calculate education metrics for CHNA areas . per 1,000 residents while the same rate in the CHNA BCHD does not have access to these education data . area is 13 live births per 1,000 residents . 3 The Hardship Index is a measure of comparison, weighing Fifty-five percent of pregnant women receive prenatal relative hardship of one CSA against another or against the care in the first trimester in Baltimore City vs . 55% City as a whole . The calculation methodology reflects this in the CHNA area . relativity by standardizing six socioeconomic components Nearly 11% of women report smoking while pregnant of Baltimore’s 55 CSAs to a scale of 1 to 100, then in Baltimore City compared to 8% in the CHNA area . averaging the component scores to provide a final index score . Aggregating CSAs into a single CHNA area and Regarding pre-term births (less than 37 weeks gestation), calculating a score using that discrete area can impact 12% of all live births are pre-term in Baltimore City the scores of the remaining individual CSAs, thus changing compared to 11% in the CHNA area . the apparent relative hardship of the CHNA area . Almost 12% of births are classified as low birth weight Therefore, a range of scores within a CHNA area is (less than 5 lbs 8 oz) in Baltimore City vs . 10% in the provided . In this way, we hope to show the range of CHNA area . socioeconomic conditions within the CHNA area . In Baltimore City, about 31% of mothers had a body mass index (BMI) of 30 or greater at her child’s birth . Appendix In the CHNA area, this was 30% . The following CSAs were selected by Sinai Hospital to be included in this CHNA quantitative profile: Cross-Country/Cheswolde, Dorchester/Ashburton, Glen-Falstaff, Howard Park/West Arlington, Mt . Washington/Coldspring, Pimlico/Arlington/Hilltop, Southern Park Heights .

151 Community Health Needs Assessment APPENDIX D2 - CHNA SINAI MORTALITY MAP

152 Appendix APPENDIX D3 - CHNA SINAI DRUG ALCOHOL MORTALITY MAP

153153 Community Health Needs Assessment Appendix APPENDIX D4 - CHNA SINAI FAMILY POVERTY MAP

154 Appendix APPENDIX D5 - CHNA SINAI LIFE EXPECTANCY MAP

155 Community Health Needs Assessment Appendix APPENDIX E1 - KUJICHAGULIA CENTER PROGRESS REPORT SINAI PROGRAM

Progress Report from 2015 CHNA Implementation Strategy – Kujichagulia Center

Youth/Street Violence was identified as a top priority concern of the Park Heights community during the 2012 and 2015 Community Health Needs Assessments. As a result of the identified need, services to prevent Identified Need violent retaliation and reduce street violence were developed. This includes expanding the Middle School Mentoring Program and enhancing the Workforce Readiness/Life skills program and the Sinai Violence Intervention Program within the Kujichaguila Center.

Name of hospital initiative Kujichagulia Center, M. Peter Moser Community Initiatives During FY17, 218 male youth, between 18 and 25 years of age, were admitted to Sinai Hospital for Total number of people violence-related injuries. Upon recognizing the need to broaden services, the program has expanded within the target population to serve men older than 25 years as well as include women, thus an additional 1,147 patients were within the potential clientele population. Total number of people reached by the initiative 138 participants were engaged across all programs under the Kujichagulia Center during FY17

1) Prevent violent retaliation and reduce street violence by creating a venue to escape the cycle of violence. This includes: • Provide service coordination, advocacy, education and support • Address trauma through ongoing social work support Primary Objective of the Initiative 2) Provide services for male opportunity youth residing in 21215 to secure a viable future. This includes: • Internship and job placement services • Providing on-going wraparound social services 3) Mentoring middle school students from Grade 5 – Grade 8 in Park Heights community regarding bullying and violence in the African American/Black community.

Single or Multi-Year Plan Multi-year plan started in 2013 • Sinai Vocational Services, Sinai Emergency Medicine Department, Trauma Unit, and Palliative Medicine • Park Heights Renaissance--Tony Bridges, Director, Human Services and Operations • Baltimore City Health Department – Safe Streets—Rashard Singletary, Director Safe Streets Park Heights Key Collaborators in Delivery • South Baltimore Learning Center—Natashia Heggins, Program Manager • University of Maryland School of Social Work--Tanya Sharpe & Jodi Frey, Professors • HomeFree USA—Milan Griffin, Vice President, Marketing & Outreach • NPower—Marquise O’Neal, Program Coordinator

SVIP Program: • Among 33 clients enrolled since program inception (27 new clients enrolled beginning January 2017), there has been a 75% reduction in Inpatient admissions within 30 days of the intervention Workforce Readiness/Lifeskills program: • 27 active and 7 new clients participated Impact of Hospital • 70% (5 of the 7 new clients) completed Workforce Readiness and Life skills training Initiative • 80% (4 of the 5 clients with completed training) completed internships • 88% (30 of the 34 active clients) received assistance with job placement and 53% (16 of the 30 clients) are currently employed Middle School Mentoring Program • 96 students engaged in the “Dare To Be King” curriculum over 29 weeks during FY17 • 88% was the average attendance rate

The program outcomes are based on the reduction in violent retaliation, increase in workforce readiness Evaluation of outcome and life skills training, and improved engagement in positive male development. Future short and mid-term targets will be set during FY 18. Upon recognition of the need to provide services to more victims of street violence in the community, the Continuation of Initiative program has been expanded to serve both men and women of all age groups. 156 Appendix APPENDIX E2 - COMMUNITY HEALTH EDUCATION PROGRESS REPORT SINAI-LEVINDALE-NORTHWEST PROGRAM

Progress Report from 2015 CHNA Implementation Strategy - Community Health Education Health education was identified as a top priority need during the 2012 Community Health Needs Assessment (CHNA). Based on responses to the question “What health screenings or education services are needed in your community” during the 2015 CHNA, the top five responses were Blood Pressure, HIV/Sexually Transmitted Diseases, Diabetes, Mental Health and Heart Disease. In addition, Identified Need diabetes and hypertension are two leading indicators of heart disease, a top cause of death in Baltimore City, Baltimore County, and across Maryland. This initiative provides a forum for the community to understand how to manage chronic conditions and overcome barriers to self-care.

Name of hospital initiative Community Health Education, Office of Community Health Improvement (OCHI)

Total number of people 153,424 patients over 18 years, utilizing LifeBridge Health facilities qualified for comprehensive within the target adult wellness. population Source: Cerner HealtheIntent, Comp Wellness Registry, LifeBridge Health facilities

Total number of people reached by the 3,804 individuals were educated through multiple forums and health fairs across Sinai, Northwest, and initiative Levindale service areas during FY17

The initiative is focused on improving health literacy. Primary goals include: Primary Objective • Provide health education offerings to the community of the Initiative • Provide tools for dealing with hypertension and other components of metabolic syndrome • Provide community-based offerings focused on health-related services and information

Single or Multi-Year Plan Multi-year initiative started prior to 2013

• American Heart Association, Kimberly Mays, Senior Director – Community and Multicultural Health • BCHD Cardiovascular Disparities Task Force, Emilie Gildie, Director of Tobacco Use and Cardiovascular Disease Prevention • Baltimore City Dept of Aging, Reverend J. Worthy, Director of Forest Park Senior Center Key Collaborators • American Stroke Association, Faye Elliott, RN (Stroke Ambassador) in Delivery • Sandra and Malcolm Berman Brain and Spine Institute Stroke Programs at LBH, Lorraine Newborn-Palmer, RN Program Coordinator • Shop Rite Howard Park, Josh Thompson, Manager and Susan Tran, Pharmacist • Park Heights Community Health Alliance, Willie Flowers, Executive Director • Various community churches and local businesses

Process metrics to support the program include: Impact of Hospital • Attended 342 community-based forums by Community Health Education Staff Initiative • Provided 651 hours of community health fairs and risk assessments • Completed 25 community blood pressure screenings

Outcomes are based on the participants’ understanding of how to manage health and the ability to exhibit Evaluation of outcome an improved change in lifestyle. Future short term and mid-term targets will be set during FY18.

The initiative will continue to be funded by the hospital with a goal to provide program services to more Continuation of individuals in the community. The program has identified methods to improve data collection and reporting Initiative as well as use data analytics for program development and capacity building. In addition, OCHI staff also plan to increase the educational offerings as part of efforts to prevent chronic disease and provide tools for dealing with hypertension and other components of metabolic syndrome.

157 Community Health Needs Assessment Appendix APPENDIX E3 - CHANGING HEARTS PROGRAM PROGRESS REPORT SINAI-LEVINDALE-NORTHWEST PROGRAM

Progress Report from 2017 CHNA Implementation Strategy – Changing Hearts Program According to the Baltimore City Health Department, Heart Disease is the No. 1 cause of death in Baltimore City with a 20 year life expectancy gap between high and low income neighborhoods. Similar statistics were reported by the Baltimore County Health Department as well. Heart Disease was identified as a top priority concern of the community during the 2012 and 2015 Community Health Needs Assessments and the Office of Community Health Identified Need Improvement (OCHI) developed the Changing Hearts Program in response to the identified need. The program is focused on improving the cardiovascular health of pre-hypertensive individuals in the community. The collaborative nurse and community health worker model enables program participants to identify wellness strategies related not only to their clinical status, but also psychosocial needs. Participants receive focused attention to reduce risk factors that are important components of a cardiovascular health improvement plan. Name of hospital initiative Changing Hearts Program, Office of Community Health Improvement

Total number of 4,800 patients were identified as pre-hypertensive based on primary blood pressure screenings recorded across people within the LifeBridge Health facilities during the fiscal year target population *Source: Cerner HealtheIntent, Comp Wellness Registry, BP Re-Screen, LifeBridge Health facilities

Total number of people reached 101 participants were enrolled in the program across Sinai, Northwest, and Levindale service areas during FY17 by the initiative

The program is focused on improving cardiac health among pre-hypertensive patients. Staff provide Heart Risk Assessments in the community to identify pre-hypertensive patients (assessment includes cholesterol, glucose, blood Primary Objective pressure and body composition analysis). Based on the assessment, health education counseling is provided by a of the Initiative registered nurse. Patients receive ongoing support from staff to facilitate lifestyle changes. This includes follow-up calls and/or home visits by a community health worker with a focus on individualized care plans developed with patients, lifestyle classes to maintain long term change, and educational material and resources to improve health. Single or Multi- Year Plan Multi-year initiative started in 2013 • American Heart Association, Kimberly Mays, Senior Director – Community and Multicultural Health • BCHD Cardiovascular Disparities Task Force, Emilie Glide, Director of Tobacco Use and Cardiovascular Disease Prevention • Baltimore City Dept of Aging, Reverend J. Worthy, Director of Forest Park Senior Center Key Collaborators • American Stroke Association, Faye Elliott, RN (Stroke Ambassador) in Delivery • Sandra and Malcolm Berman Brain and Spine Institute Stroke Programs at LBH, Lorraine Newborn-Palmer, RN Program Coordinator • Shop Rite Howard Park, Josh Thompson, Manager and Susan Tran, Pharmacist • Park Heights Community Health Alliance, Willie Flowers, Executive Director • Various community churches and local businesses Cumulative changes in maintaining and improving behavioral and biometric outcomes for 76 patients are below:

METRIC % MAINTAINED AND IMPROVED METRIC % MAINTAINED AND IMPROVED Blood pressure 85% Quality of life 69% Impact of Hospital Blood sugar 60% Smoking cessation 96% Initiative BMI 89% Physical Activity 68% HDL 66% Healthy Eating 75% LDL 63%

Evaluation of Changing Hearts has been able to pilot successfully with a subgroup of participants in need. Future short-term and outcome mid-term targets will be set during FY18.

The initiative will continue to be funded by the hospital with a goal to provide program services to more individuals Continuation of Initiative in the community. The program has identified methods to improve data collection and reporting, as well as use data analytics for program development and capacity building.

158 Appendix APPENDIX E4 - SAFE PROGRAM PROGRESS REPORT LEVINDALE PROGRAM

Progress Report from 2015 CHNA Implementation Strategy – SAFE Program

The Maryland Department of Health and Mental Hygiene, Office of Health Care Quality, receive allegations of abuse and neglect regarding residents/patients in all licensed and/or federally certified facilities. During calendar year 2015, approximately 1,138 reports of alleged vulnerable adult abuse and neglect were Identified Need reported. According to the Maryland Department of Aging, only 1 in 14 cases of elderly and vulnerable adult abuse are reported, drastically emphasizing the magnitude of the issue plaguing the elderly community. Source: Maryland Department of Aging, 2015. Factsheet: Elder/Vulnerable Adult Abuse Prevention Public Awareness Info Sheet

Name of hospital Stop Abuse of Elders (SAFE) program, Levindale Hebrew Geriatric and Specialty Hospital - Social Work initiative Department

The 2016 Vital Statistics published by the Maryland Department of Health and Mental Hygiene estimates Total number 220,000 individuals 65 years of age or older live within Baltimore City and Baltimore County. The majority of of people within the these individuals reside in Baltimore County, however the SAFE project at Levindale is one of a handful of target population facilities around the state providing this type of support. Source: Maryland Department Health and Mental Hygiene, 2016. Vital Stats.

Total number of people During FY17, no new clients required support, however 1 active client received continued support. During reached by the initiative the beginning of FY18, 2 new clients received services. All 3 clients now reside within the Levindale nursing home facility for continued support.

The SAFE (Stop Abuse of Elders) program reflects the collaboration of three ASSOCIATED organizations - Levindale Hebrew Geriatric and Specialty Hospital, Jewish Community Services (JCS) and CHANA - to establish an inter-agency response to elder abuse in the community by creating a SAFE Program for the treatment and prevention of elder abuse. This collaboration assures the community of an effective and coordinated response for victims, perpetrators, and their families and provides prevention education for the entire community. Primary Objective of the Initiative This comprehensive approach includes: • crisis intervention • shelter • psychotherapy • advocacy • service coordination • community education

Single or Multi-Year Plan Multi-year initiative began in 2013

• CHANA • Jewish Community Services Key Collaborators • Maryland Department of Aging in Delivery • The Women’s Law Center of Maryland, Inc, Lifson Law, and 2 representatives from Harford and Montgomery County SAFE programs in conjunction with Levindale representatives lobbied for improved support of patients

The SAFE program has served 5 clients since program inception. The greater impact of the program has been viewed on a statewide level, resulting in legislative action under the Maryland Health Care Decisions Impact of Hospital Act of 2017. These unique cases shed light on inconsistencies in legal definitions and intentions of support Initiative allowed by surrogate decision makers. Key collaborators shared specific examples of overarching ethical implications related to protective orders designed to aid victims with limited decision-making capacity that were undermined by current surrogate decision maker guidelines. This has been amended in favor of the patient, further supporting the mission of SAFE programs.

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