Sharp Grossmont Hospital 2016 CHNA

Sharp Grossmont Hospital Community Health Needs Assessment Fiscal Year 2016

~ Committed to Improving the Health and Well-being of the Community ~

Sharp Grossmont Hospital Community Health Needs Assessment Fiscal Year 2016

Table of Contents

Preface ...... i Section 1: Overview ...... 1 Section 2: Executive Summary ...... 3 Section 3: Methodology ...... 13 Section 4: Community Defined ...... 38 Section 5: Findings...... 44 Section 6: Description of Identified Community Health Needs and Social Determinants of Health . 90 Section 7: Conclusion/Community Assets ...... 117

List of Appendices

Appendix A: SGH Programs and Services ...... 133 Appendix B: An Overview of Sharp HealthCare ...... 135 Appendix C: Description of Partnering Organizations – HASD&IC and IPH...... 146 Appendix D: Vulnerable Populations Report ...... 148 Appendix E: Description of Community Needs Index (CNI) ...... 171 Appendix F: CNI Map of San Diego County ...... 172 Appendix G: Health Access and Navigation Survey…………………………………………………….173 Appendix H: Key Informant Interview Questions ...... 180 Appendix I: Case Manager/Health Navigator Discussion Tool ...... 182 Appendix J: Map of Community and Region Boundaries in San Diego County ...... 184 Appendix K: SGH Behavioral Health Hospital Data ...... 185 Appendix L: SGH Cardiovascular Health Hospital Data ...... 189 Appendix M: SGH Diabetes Hospital Data ...... 193 Appendix N: SGH Obesity Hospital Data ...... 199 Appendix O: SGH Senior Health Hospital Data...... 202 Appendix P: SGH Oncology Health Hospital Data ...... 210 Appendix Q: HASD&IC Health Access and Navigation Survey Demographics ...... 214 Appendix R: SGH Health Access and Navigation Survey Demographics ...... 216 Appendix S: 2-1-1 San Diego Directory of Services ...... 219 Appendix T: Health Need Profiles ...... 226 Appendix U: Map of Sharp HealthCare Locations ...... 235 Appendix V: List of Sharp HealthCare Involvement in Community Organizations ...... 236 Appendix W: SGH FY 2017 – FY 2020 Implementation Plan ...... 242 Appendix X: Glossary of Abbreviations ...... 244

Preface

Sharp Grossmont Hospital (SGH) prepared this Community Health Needs Assessment (CHNA) for Fiscal Year 2016 (FY 2016) in accordance with the requirements of Section 501(r)(3) within Section 9007 of the Patient Protection and Affordable Care Act (Affordable Care Act) and Internal Revenue Service (IRS) Form 990, Schedule H for not-for-profit hospitals.1

Under the Affordable Care Act enacted in March, 2010, IRS Code Section 501(r)(3) requires not-for-profit hospitals to conduct a triennial assessment of prioritized health needs for the communities served by its hospital facilities, and to adopt an implementation plan to address health needs identified as a result of the CHNA.

The Sharp Grossmont Hospital 2016 Community Health Needs Assessment (SGH 2016 CHNA) and Implementation Plan received approval from the Sharp Grossmont Hospital Board of Directors on September 20, 2016.

Daniel L. Gross Executive Vice President, Hospital Operations Sharp HealthCare

1 See Section 9007(a) of the Patient Protection and Affordable Care Act (“Affordable Care Act”), Pub. L. No. 111-148, 124 Stat.119, enacted March 23, 2010. Notice 2011-52.

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Acknowledgements

SGH’s 2016 CHNA process included the time, effort, insight and contributions of many members of the San Diego community. For both SGH’s 2016 CHNA and the Hospital Association of San Diego and Imperial Counties (HASD&IC) 2016 CHNA process, this included not only HASD&IC, the Institute for Public Health (IPH) at San Diego State University (SDSU), and other representatives from not-for-profit hospitals in San Diego County (SDC), but also hundreds of community members including physicians, health care practitioners and professionals, community health leaders, public health officials, academics, and other concerned residents who are dedicated to the care of vulnerable members of our community. We would like to express our profound appreciation for the contributions made by all who participated in this CHNA.

In particular, we are grateful to those patients and community residents who shared their personal insight regarding health care access and navigation in SDC. These members of the community volunteered their time and effort to contribute to this CHNA in order to improve the care, health and well-being for themselves, their families, and the communities in which they live. For this commitment and caring, we extend our deepest thanks.

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Background: Sharp HealthCare CHNA History

For the past 20 years, Sharp HealthCare (Sharp) has been actively involved in a triennial CHNA process, in accordance with the requirements of Senate Bill 697, community benefit legislation that requires not-for-profit hospitals in California to file an annual report with the Office of Statewide Health Planning and Development (OSHPD) on activities undertaken to address high-priority community needs within their mission and financial capacity, as well as the financial value of those community benefit programs and services. In FY 2015, Sharp provided more than $289 million in community benefit programs and services. To view the most recent Sharp HealthCare Community Benefit Plan and Report, please visit: http://www.sharp.com/about/community/community-benefits-health-needs.cfm.

Since 1995, Sharp has participated in a countywide collaborative that includes a broad range of hospitals, health care organizations, and community agencies to conduct a triennial CHNA. Findings from the CHNA, program and services expertise of each Sharp hospital, and knowledge of the populations and communities served by those hospitals provide a foundation for community benefit planning and program implementation.

In 2013, Sharp participated in a collaborative, countywide CHNA effort under the auspices of HASD&IC and in contract with the IPH. This collaborative effort provided a strong base for Sharp’s individual hospital CHNAs and significantly informed both the process and findings for each of the CHNAs completed by Sharp’s hospitals.

2013 CHNA: Progress Update

Upon completion of the 2013 CHNA, Sharp participated in a collaborative “Phase 2” effort also led by HASD&IC and in contract with the IPH. Phase 2 of the 2013 CHNA process was conducted from September to December 2014 and included community dialogues with San Diego residents from high need communities, as well as a community health leader/expert online survey. Goals of the Phase 2 process included:

 Collect feedback on the 2013 CHNA process from community stakeholders  Collect input on hospital programs provided to address the identified community health needs from the 2013 CHNA (e.g., implementation plans)

Findings from the 2013 CHNA Phase 2 provided critical guidance for the 2016 CHNA process, which will be detailed in the following pages, as well as valuable insight for the programs that Sharp provides to address identified community health needs. Please see Figure 8 for a summary of findings from the collaborative 2013 CHNA Phase 2 effort.

Further, since the completion of the 2013 CHNA, Sharp hospitals, including SGH, developed implementation plans that detail various programs, services and

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collaborations designed to address the needs identified in the 2013 CHNA. Implementation plans are revised annually with program updates and are available to the public on Sharp.com at: http://www.sharp.com/about/community/health-needs- assessments.cfm. Notable program/resource developments for SGH since the completion of the 2013 CHNA include:

Access to Care:  Creation of a new “Public Resource Specialist” position in Sharp Patient Financial Services  The Care Transitions Intervention (CTI) program for vulnerable populations; includes new partnerships with Feeding America San Diego and 2-1-1 San Diego to more proactively address food insecurity, housing, and other social determinants of health issues for high-risk community members

Diabetes:  Increased focus on community clinic collaboration, including: o Partnership with Family Health Centers of San Diego on their Diabetes Management Care Coordination Program o Support to La Maestra Community Health Centers for gestational diabetes patients  Targeted community education for vulnerable populations, including: o Partnership with Feeding America San Diego on their Diabetes Wellness Project

Senior Health:  Continued growth of partnerships with community organizations serving vulnerable seniors, including Meals on Wheels San Diego County, San Diego Food Bank, Salvation Army, etc.  Provision of a telephone reassurance call program for homebound seniors and the disabled in SDC’s east region  Extensive community education and caregiver support for advanced illness management

For complete details on the progress of programs developed by SGH in response to CHNA findings, please refer to the SGH FY 2017 – FY 2020 Implementation Plan included in Appendix W as well as online at: http://www.sharp.com/about/community/health-needs-assessments.cfm.

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2016 CHNA: Collaborative Overview

The 2016 CHNA responds to IRS regulatory requirements that private not-for-profit (tax- exempt) hospitals conduct a health needs assessment in the community once every three years. Although only not-for-profit 501(c)(3) hospitals and health systems are subject to state and IRS regulatory requirements, the 2016 CHNA collaborative process also includes hospitals and health systems who are not subject to any CHNA requirements, but are deeply engaged in the communities they serve and committed to the goals of a collaborative CHNA.

For the 2016 CHNA, the HASD&IC Board of Directors convened a CHNA Committee to plan and implement the collaborative CHNA process. The CHNA Committee comprises representatives from all seven participating hospitals and health care systems:

 Kaiser Foundation Hospital – San Diego  Palomar Health  Rady Children's Hospital – San Diego  Scripps Health (Chair)  Sharp HealthCare (Vice Chair)  Tri-City Medical Center  University of California (UC) San Diego Health

In May 2015, HASD&IC contracted with the IPH at SDSU to provide assistance with the collaborative health needs assessment that was officially called the Hospital Association of San Diego and Imperial Counties 2016 Community Health Needs Assessment (HASD&IC 2016 CHNA). The objective of the collaborative HASD&IC 2016 CHNA is to identify and prioritize the most critical health-related needs in SDC based on feedback from community residents in high need neighborhoods and quantitative data analysis.

The results of the collaborative HASD&IC 2016 CHNA process significantly informed this CHNA for SGH, and was further supported by additional data analysis and community outreach specific to the community served by SGH. The results of this CHNA will be used to help guide current and future community benefit programs and services, especially for high need community members. The pages that follow detail the methodology and results of SGH’s 2016 CHNA. In addition, SGH will submit an implementation plan to address the needs identified through the 2016 CHNA process.

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Section

1 Overview

SGH is located at 5555 Grossmont Center Drive in La Mesa, ZIP code 91942.

History

When Grossmont Hospital opened its doors in 1955 on a hilltop in La Mesa, the 100- bed hospital provided care to a population of 70,000 in East SDC. Throughout the decades, the publicly-owned hospital has expanded its facilities and services to meet the growing health care needs of the community it serves, which has now topped nearly 700,000.

In 1989, the first women’s health center of its kind in SDC opened on the medical campus with 48 private rooms equipped with the comforts of home. In 1991, Grossmont Hospital affiliated with Sharp HealthCare, becoming Sharp Grossmont Hospital. In 1993, the region’s first comprehensive, free-standing cancer center made its debut and became known as the David and Donna Long Center for Cancer Treatment. In 2004, SGH dedicated phase one of the state-of-the-art Emergency and Critical Care Center, housing a 43-bed emergency department (ED) and a 24-bed intensive care unit (ICU). The center was completed and expanded in 2009 with 90 intensive care and med/surge beds.

Today, SGH is a 536-bed medical center and the largest and most preferred hospital in East County – recognized for its excellence in cardiac care, oncology services, orthopedics, women’s and infant’s services, as well as other programs. The hospital’s Emergency and Critical Care Center is one of San Diego’s busiest – treating more than 100,000 patients each year. SGH is nationally recognized as a Magnet hospital for its excellence in nursing practices and quality patient care, while only three other hospitals in SDC have received this recognition, including Sharp Memorial Hospital (SMH).

As part of its mission to transform patient care in East SDC, SGH recently broke ground on a new Heart and Vascular Center. Constructed in phases between August 2013 and 2015, the 71,000 square-foot facility will expand the hospital’s surgical capabilities with new cardiac catheterization labs and multipurpose procedural rooms and will provide services ranging from general cardiology and treatment of heart and vascular conditions to advanced surgical and interventional procedures.

The more than $60 million construction cost for the center is being financed by taxpayer dollars. East County voters passed a $247-million bond measure called Proposition G in 2006. Prop. G has already funded several infrastructure construction improvements at the hospital. The bond-financed construction began in 2007, and is scheduled to continue over the next several years.

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For a complete listing of the programs and services provided at SGH, please refer to Appendix A.

SGH is part of Sharp HealthCare – an integrated, regional health care delivery system based in San Diego, Calif. The Sharp system includes four acute care hospitals; three specialty hospitals; two affiliated medical groups; 22 medical clinics; five urgent care centers; three skilled nursing facilities; two inpatient rehabilitation centers; home health, hospice, and home infusion programs; numerous outpatient facilities and programs; and a variety of other community health education programs and related services. Sharp offers a full continuum of care, including emergency care, home care, hospice care, inpatient care, long-term care, mental health care, outpatient care, primary and specialty care, rehabilitation and urgent care. Sharp also has a Knox-Keene-licensed care service plan, Sharp Health Plan (SHP).

Sharp serves a population of approximately 3.2 million in SDC and as of June 2016, is licensed to operate 2,069 beds. Sharp’s mission is to improve the health of those it serves with a commitment to excellence in all that it does. Sharp’s goal is to offer quality care and services that set community standards, exceed patient expectations and are provided in a caring, convenient, cost-effective and accessible manner. More than 18,000 employees, affiliated physicians, and volunteers are dedicated to providing the extraordinary level of care that is called The Sharp Experience.

Please refer to Appendix B for a detailed overview of the Sharp HealthCare system.

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Section

2 Executive Summary

Overview and Background

Sharp has been a long-time partner in the process of identifying and responding to the health needs of the San Diego community. This partnership includes a broad range of hospitals, health care organizations, and community agencies that have worked together to conduct triennial CHNAs over the past 16 years. Previous collaborations among not-for-profit hospitals and other community partners have resulted in numerous well-regarded CHNA reports. Sharp hospitals, including SGH, base their community benefit and community health programs on both the findings of these needs assessments and the combination of expertise in programs and services offered and the knowledge of the populations and communities served by each Sharp hospital.

For the 2016 CHNA process, seven hospitals and health care systems – including Sharp HealthCare – came together under the auspices of the HASD&IC and the IPH to conduct a CHNA that identifies and prioritizes the most critical health-related needs of SDC residents, resulting in the collaborative, HASD&IC 2016 CHNA.

A longitudinal review of CHNAs conducted over the past 15 years reveals the overarching health needs in SDC have remained relatively stable over time. Based on 2013 CHNA findings and the consistency of these findings over time, it is likely that going forward, cardiovascular disease, Type 2 diabetes, behavioral health and obesity will continue to be top community health concerns in our region, particularly in high need communities.

Sharp based its individual hospital CHNAs on the collaborative 2016 model. Through further outreach and analyses, Sharp identified additional health needs for certain hospitals to address, including: cancer, high-risk pregnancy, and senior health.

CHNA Objectives

Given the same understanding, Sharp’s 2016 CHNA process more closely examined the priority health needs identified in the 2013 CHNAs for its individual hospitals. For SGH, these priority health needs included: behavioral health, cardiovascular disease,

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diabetes (type 2), obesity and senior health. In addition, in recognition of the significance of various forms of cancer prioritized in the 2013 CHNA process (see Figure 7), as well as discussion with Sharp team members and the priorities they observe in their patient population, SGH also identified cancer as a priority health need to further analyze in its 2016 CHNA process.

The overall purpose of collecting primary data was to gather information about the health needs and social determinants of SDC residents, including specifically Sharp patients.

Specific objectives of the 2016 CHNA process included:

 Gather in-depth feedback to aid in the understanding of the most significant health needs impacting community members in SDC.  Connect the identified health needs with associated social determinants of health to further understand the challenges that community members – particularly those in communities of high need – face in their attempts to access health care and maintain health and well-being.  Identify currently available community resources that support identified health conditions and health challenges.  Provide a foundation of information to begin discussions of opportunities for programs, services and collaborations that could further address the identified health needs and challenges for the community.

Study Area Defined

For the purposes of the collaborative HASD&IC 2016 CHNA, the service area is defined as SDC overall, due to a broad representation of hospitals in the area. Over three million people live in SDC, a socially and ethnically diverse area composed of six regions defined by the County of San Diego Health and Human Services Agency (HHSA): central, east, north central, north coastal, north inland and south. Select key demographic information is summarized in Figure 1. Additional information on socioeconomic factors, access to care, health behaviors, and the physical environment can be found in the full HASD&IC 2016 CHNA report at: http://hasdic.org.

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Figure 1: Selected Community Health Statistics

A greater proportion of Nearly 15% of San Diegans Latinos, African Americans, live in households with Native Americans, and Approximately 1 in 7 San income below 100% of the individuals of other race live Diegans are food insecure Federal Poverty Level* in poverty compared to the overall San Diego population

Approximately 16% of San Almost 15% of San Diegans Approximately 46% of Diegans aged 5 and older aged 25 and older have no households in San Diego have limited English high school diploma or have housing costs that proficiency and 8.5% are equivalency exceed 30% of their income linguistically isolated

*Federal Poverty Level (FPL) is a measure of income issued every year by the Department of Health and Human Services. In 2016, the FPL for a family of four was $24,300.

The community served by SGH includes the entire east region of SDC, including the sub-regional areas of Jamul, Spring Valley, Lemon Grove, La Mesa, El Cajon, Santee, Lakeside, Harbison Canyon, Crest, Alpine, Laguna-Pine Valley and Mountain Empire. Approximately five percent of the population lives in remote or rural areas of this region. Table 1 below presents the ZIP codes where the majority of SGH patients reside.

Table 1: Primary Communities Served by SGH

ZIP Code Community 91941 La Mesa 91942 La Mesa 91945 Lemon Grove 91977 Spring Valley 92019 El Cajon 92020 El Cajon 92021 El Cajon 92040 Lakeside 92071 Santee Source: Sharp HealthCare Inpatient Data, FY 2015.

Recognizing that health needs differ across the region and that socioeconomic factors impact health outcomes, both HASD&IC’s and SGH’s 2016 CHNA processes utilized the Dignity Health Community Need Index (CNI) to identify communities with the highest level of health disparities and needs. Table 2 presents communities (by ZIP code) served by SGH that have especially high need based on their CNI score (score > 4).

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Table 2: High Need Primary Communities Served by SGH, CNI Score > 4.0

ZIP Code Community 91905 Boulevard 92020,92021 El Cajon 91934 Jacumba 91945 Lemon Grove 91963 Potrero 91977 Spring Valley 91980 Tecate Source: Dignity Health Community Need Index. 2013.

Data Collection and Analysis

The HASD&IC 2016 CHNA process and findings significantly informed the SGH 2016 CHNA process and as such are described as applicable throughout this report. For complete details on the HASD&IC 2016 CHNA process, please visit the HASD&IC website at: www.hasdic.org or contact Lindsey Wade at [email protected].

For the collaborative HASD&IC 2016 CHNA process, the IPH employed a rigorous methodology using both community input and quantitative analysis to provide a deeper understanding of barriers to health improvement in SDC. Figure 2 provides an overview of the process used to identify and prioritize the health needs for the HASD&IC 2016 CHNA. For the purposes of the CHNA, a “health need” is defined as a health outcome and/or the related conditions that contribute to a defined health outcome.

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Figure 2: HASD&IC 2016 CHNA Process Map

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The 2016 CHNA process began with a comprehensive scan of recent community health statistics in order to validate the regional significance of the top four health needs identified in the 2013 CHNA. Quantitative data for both the HASD&IC 2016 CHNA and SGH 2016 CHNA included 2013 OSHPD demographic data for hospital inpatient, ED and ambulatory care encounters to understand the hospital patient population. Clinic data was also gathered from OSHPD’s website and incorporated in order to provide a more holistic view of health care utilization in SDC. The variables analyzed are included in Table 3 below and were analyzed at the ZIP code level wherever possible.

Table 3: Variables Analyzed in the HASD&IC and SGH 2016 CHNAs

Secondary Data Variables Hospital Utilization: Inpatient discharges, ED and ambulatory care encounters Community Clinic Visits Demographic Data (socio-economic indicators) Mortality and Morbidity Data Regional Program Data (childhood obesity trends and community resource referral patterns) Social Determinants of Health and Health Behaviors (education, income, insurance, physical environment, physical activity, diet and substance abuse)

Based on the results of the community health statistics scan and feedback from community partners received during the 2016 CHNA planning process, a number of community engagement activities were conducted across SDC, as well as specific to SGH, in order to provide a more comprehensive understanding of the identified health needs, including their associated social determinants of health and potential system and policy changes that may positively impact them. In addition, a detailed analysis of how the top health needs impact the health of San Diego residents was conducted. Figure 3 below outlines the number and type of community engagement activities conducted as part of the collaborative HASD&IC 2016 CHNA.

Figure 3: HASD&IC 2016 CHNA Community Engagement Activities

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For the SGH 2016 CHNA, Sharp contracted with IPH to collect additional community input through three primary methods: facilitated case manager discussions, key informant interviews, and the Health Access and Navigation Survey (noted as “Roadmap Survey” in Figure 4 below) with patients and community members. This input focused on behavioral health, cardiovascular health, cancer, diabetes, senior health and the needs of highly vulnerable patient populations. Figure 4 below outlines the engagement activities specific to SGH’s 2016 CHNA. Nearly 40 Sharp providers and more than 100 patients/community members were reached through these efforts.

Figure 4: SGH 2016 CHNA Community Engagement Activities

Findings

The collaborative, HASD&IC 2016 CHNA prioritized the top health needs for SDC overall through application of the following five criteria:

1. Magnitude or Prevalence 2. Severity 3. Health Disparities 4. Trends 5. Community Concern

Using these criteria, a summary matrix translating the 2016 CHNA findings was created for review by the CHNA Committee.

As a result of this review, the CHNA Committee identified behavioral health as the number one health need in SDC. In addition, cardiovascular disease, Type 2 diabetes, and obesity were identified as having equal importance due to their interrelatedness. Health needs were further broken down into priority areas due to the overwhelming agreement among all data sources and in recognition of the complexities within each health need. Figure 5 illustrates the prioritization of the top health needs for SDC.

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Figure 5: HASD&IC 2016 CHNA Top Health Needs

Further, the IPH conducted a content analysis of the input collected by the community engagement activities of the HASD&IC 2016 CHNA process, and found that social determinants of health were a key theme in all of the community engagement activities. Ten social determinants were consistently referenced across the different community engagement activities. The importance of these social determinants was also confirmed by quantitative data. Hospital programs and community collaborations have the potential to impact these social determinants, which Figure 6 outlines in order of priority.

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Figure 6: Social Determinants of Health, HASD&IC 2016 CHNA

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Conclusion / Next Steps

SGH is committed to the health and well-being of its community, and the findings of SGH’s 2016 CHNA will help to inform the activities and services provided by SGH to improve the health of its community members. These programs are detailed in SGH’s FY 2017 – FY 2020 Implementation Plan, which will be made available online to the community at: http://www.sharp.com/about/community/health-needs-assessments.cfm.

The 2016 CHNA process generated a list of currently existing resources in SDC that address the health needs identified through the CHNA process. While not an exhaustive list of San Diego’s available resources, this information serves as a resource for SGH to help continue, refine and create programs that meet the needs of its community.

In addition, Phase 2 of the CHNA will focus on the development of a multi-hospital and health system collaborative effort to address priority health needs, including a policy agenda to focus and strengthen the role of hospitals as advocates for community health.

The health needs and social determinants of health identified in this CHNA will not be resolved with a “quick fix.” Rather, these resolutions require time, persistence, collaboration and innovation. It is a journey that SGH and the entire Sharp system are committed to, and Sharp remains steadfastly dedicated to the care and improvement of health and well-being for all San Diegans.

The complete SGH 2016 CHNA is available online at: http://www.sharp.com/about/community/health-needs-assessments.cfm or by contacting Sharp HealthCare Community Benefit at: [email protected].

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Section 3 Methodology

SGH’s 2016 CHNA draws from and is based on the process and findings of the collaborative, HASD&IC 2016 CHNA. Sharp actively participated in and collaborated on the HASD&IC 2016 CHNA process, which began in May 2015 and concluded in June 2016.

Based on the findings of the 2013 CHNA and recommendations from the community, the HASD&IC 2016 CHNA process was designed to provide a deeper understanding of barriers to health improvement in SDC and to inform and guide local hospitals in the development of their programs and strategies that address community health needs. The process included an analysis of health outcomes, as well as associated social determinants of health that create health inequities, understanding that the burden of illness, premature death, and disability disproportionally affects racial and minority population groups and other underserved populations. Understanding regional and population-specific differences is an important step to understanding and strategizing ways to effectively impact the health of our community.

The goal of the HASD&IC 2016 CHNA was to more deeply analyze the top four identified community health needs (behavioral health, cardiovascular disease, Type 2 diabetes and obesity) from the 2013 CHNA process. The effort also responds to IRS regulatory requirements that tax-exempt hospitals conduct a health needs assessment in the community once every three years. Complete details of the methodology and findings of the HASD&IC 2016 CHNA are available at: http://www.hasdic.org.

SGH conducted additional analyses of hospital discharge data and patient and community member input to identify and address the specific needs of the communities it serves. As such, this section details the collaborative HASD&IC 2016 CHNA process, followed by a description of the additional methods and analyses employed by Sharp.

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HASD&IC 2016 CHNA Committee

For the HASD&IC 2016 CHNA, the HASD&IC Board of Directors convened a CHNA Committee to plan and implement the collaborative CHNA process. The CHNA Committee comprises representatives from seven local participating hospitals and health care systems. Members of the 2016 CHNA Committee are listed below.

Jillian Barber Sharp HealthCare

Anette Blatt Scripps Health

Aaron Byzak UC San Diego Health

Elly Garner Palomar Health

Jamie Johnson Tri-City Medical Center

Lisa Lomas Rady Children’s Hospital – San Diego

Tana Lorah Kaiser Foundation Hospital – San Diego

Shreya Sasaki Kaiser Foundation Hospital – San Diego

In May 2015, HASD&IC contracted with the IPH at SDSU to provide assistance with the collaborative health needs assessment for SDC (HASD&IC 2016 CHNA). The objective of the HASD&IC 2016 CHNA is to identify and prioritize the most critical health-related needs in SDC based on feedback from community residents in high need neighborhoods and quantitative data analysis. Please see below for the list of individuals from HASD&IC and IPH that led the HASD&IC 2016 CHNA process. Please see Appendix C for detailed descriptions of HASD&IC and IPH 2016 CHNA members.

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Hospital Association of San Diego & Imperial Counties Dimitrios Alexiou President and Chief Executive Officer

Lindsey Wade Vice President, Public Policy

Institute for Public Health, San Diego State University Tanya Penn Epidemiologist

Nicole Delange Research Assistant

Amy Pan Senior Research Scientist

The HASD&IC 2016 CHNA involved a mixed methods approach using the most current quantitative data available and more extensive qualitative outreach. Throughout the process, the IPH met bi-weekly with the HASD&IC CHNA Committee to analyze, refine, and interpret results as they were being collected.

SGH 2016 CHNA Planning Team

Team members from SGH and Sharp HealthCare either provided insight to or participation in the 2016 CHNA process for SGH. In addition, Sharp contracted with the IPH in the development and implementation of the SGH 2016 CHNA community engagement activities. Members of the SGH 2016 Planning Team are listed below.

Sharp HealthCare Jillian Barber Program Manager, Community Benefits and Health Improvement Sharp HealthCare

Elizabeth Rains Planning Analyst Sharp HealthCare

Scott Evans Chief Executive Officer Sharp Grossmont Hospital

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Tony D’Amico Chief Operating Officer Sharp Grossmont Hospital

Jason Broad Vice President, Performance Excellence Sharp Grossmont Hospital

Beth Morgante Vice President, Major Gifts Sharp HealthCare

Sandy Pugliese Manager, Community Relations Sharp Grossmont Hospital

Institute for Public Health, San Diego State University Tanya Penn Epidemiologist

Nicole Delange Research Assistant

Amy Pan Senior Research Scientist

Additional support for the development of the SGH 2016 CHNA was provided by:

Kristine White Planning Research and Community Benefits Specialist Sharp HealthCare

Diana Romaya Planning Research and Administrative Analyst Sharp HealthCare

Valerie Provenza Planning Research and Administrative Analyst Sharp HealthCare

Additionally, early in the SGH 2016 CHNA process, insight from the Grossmont Healthcare District was sought regarding suggestions for community organizations (e.g., community clinics) to engage in the 2016 CHNA process. This insight was highly valued and incorporated as relevant into the methods of SGH’s 2016 CHNA.

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HASD&IC 2016 CHNA: Data Collection Framework and Rationale

The CHNA Committee designed the 2016 CHNA process based on the findings and feedback from the HASD&IC 2013 CHNA. The aim of the HASD&IC 2016 CHNA methodology was to provide a more complete understanding of the top four identified health needs and associated social determinants of health in the San Diego community. The methodology that was used in 2013 to identify the top four health needs is described in Figure 7 below.

Figure 7: HASD&IC 2013 CHNA Methodology

When the results of all of the data and information gathered in 2013 were combined, four conditions emerged clearly as the top community health needs in SDC (in alphabetical order): 1. Behavioral/Mental Health 2. Cardiovascular Disease 3. Type 2 Diabetes 4. Obesity

The CHNA Committee completed a collaborative follow-up process (Phase 2) to ensure the 2013 CHNA findings accurately reflected the health needs of the community. Phase 2 collected community feedback on both the process and findings of the 2013 CHNA, as well as recommendations for the 2016 CHNA process. Figure 8 displays a summary of the overall findings from Phase 2 of the 2013 CHNA. For a complete description of the HASD&IC 2013 CHNA process and findings, see the full report available at: http://www.hasdic.org/chna.htm.

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Figure 8: HASD&IC 2013 CHNA Phase 2 Overall Findings & Recommendations

Common set of barriers make 78% of respondents agreed the 87% of respondents agreed the hospital programs inaccessible methodology for the next CHNA 2013 CHNA identified the top for residents in high need should include a deeper dive health needs of SDC Residents communities into the top 4 health needs

Based on the findings and feedback from the two phases of the 2013 CHNA, the goal of the HASD&IC 2016 CHNA methodology was to do a deeper analysis of the top four identified community health needs for SDC: behavioral health, cardiovascular disease, Type 2 diabetes and obesity.

Prior to the beginning of this focused analysis, the CHNA Committee completed a scan of recent community health statistics which validated the regional significance of the top four health needs identified in the 2013 CHNA. In addition, the CHNA Committee met with community partners who participated in the 2013 CHNA process to discuss how best to move forward with a deeper analysis and identify how to engage the community.

Based on the results of the scan and input received from the community during the 2016 planning process, a number of community engagement activities were conducted to further understand the identified health needs, including their associated social determinants of health as well as potential system and policy changes to impact them. In addition, a detailed analysis of how the top four needs impact the health of San Diego residents was conducted.

Figure 9 provides an overview of the community engagement activities and the quantitative data that were used to identify and prioritize the health needs for the 2016 CHNA. For the purposes of the CHNA, a “health need” is defined as a health outcome and/or the related conditions that contribute to a defined health outcome.

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Figure 9: HASD&IC 2016 CHNA Process Map

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Guided by the same rationale, the SGH 2016 CHNA process continued its focus on the needs identified in the 2013 CHNA (behavioral health, cardiovascular disease, Type 2 diabetes, obesity and senior health). In addition, in recognition of the significance of various forms of cancer prioritized in the 2013 CHNA process (see Figure 7 above), as well as discussion with Sharp team members and the priorities they observe in their patient population, SGH also identified cancer as a priority health need to address in its community.

Quantitative Data Collection and Analysis: HASD&IC 2016 CHNA

The purpose of gathering quantitative data was to:  Gain a baseline understanding of SDC and the health of its residents.  Describe the community served through existing demographic and health related data sources.  Provide a scan of current community health statistics to ensure the regional significance and influence of the top four health needs identified in the 2013 CHNA on health status.  Gain a better understanding of how the top identified health needs impact San Diego health systems and hospitals through a detailed analysis of hospital discharge data.

The CHNA Committee used the Kaiser Permanente (KP) CHNA Data Platform2 to review over 150 indicators from publically available data sources. Data on gender and race/ethnicity breakdowns were analyzed when available. In addition to the KP CHNA Data Platform, supplemental demographic and health data were summarized. For details on specific sources and dates of the data used, please refer to: http://hasdic.org.

For the 2016 CHNA process, consideration was given to newly available data as well as to the 2013 CHNA findings and recommendations. Current SDC data was assessed through a scan of recent community health statistics including an analysis of ED and hospitalization discharge data, indicators in KP’s Community Benefit Tool3 and an analysis of additional quantitative data.

2 The KP Data Platform is a web-based resource designed to support community health needs assessments and community collaboration. This platform includes a focused set of community health indicators that allow users to understand what is driving health outcomes in particular neighborhoods. The platform provides the capacity to view, map and analyze these indicators as well as access additional public data and assess community assets available to meet the needs identified. 3Kaiser Permanente Community Benefit Data Analysis Tool organizes the Kaiser Permanente common indicators against 14 common health needs, using a combination of morbidity/mortality and health driver indicators. The common health needs are Access to Care, Asthma, Cancers, Climate and Health, CVD/Stroke, Economic Security, HIV/AIDS/STDs, Maternal and Infant Health, Mental Health, Obesity/HEAL/ Diabetes, Oral Health, Overall health, Substance Abuse/Tobacco, and Violence/Injury Prevention. Sharp Grossmont Hospital Community Health Needs Assessment Page 20

HASD&IC 2016 CHNA: Hospital Emergency Department and Hospitalization Discharge Analysis

California's OSHPD is responsible for collecting data and disseminating information about the utilization of health care in California. As part of the 2016 CHNA data collection process, 2013 OSHPD discharge data for hospital inpatient, ED, and ambulatory care encounters from all hospitals within SDC were analyzed through the SpeedTrack© California Universal Patient Information Discovery (CUPID) application (http://www.speedtrack.com). Patients included in the analysis were those who were discharged from an SDC hospital and reported an SDC ZIP code of residence, or were discharged and described as a homeless patient. Those patients who entered through the ED and then were admitted into the hospital were counted as an inpatient discharge. ICD-9 codes for each health need were chosen based on ICD-9 codes used by the County of San Diego Community Health Statistics Unit and hospital service line recommendations. ICD-9 codes are a standardized classification of disease, injuries and cause of death which allow clinicians and others to speak a common language and bill insurance.

The top 10 discharges by principal and secondary diagnosis were pulled for both ED and inpatient hospitalization discharge data at the body system level4. A principal diagnosis is defined as the condition established after examination to be chiefly responsible for the admission. A secondary diagnosis can be defined as other diagnoses that coexisted in addition to the diagnosis reported as the principal diagnosis. It is important to assess principal diagnoses using ED discharge and hospitalization data in order to understand the downstream impact of different health conditions on the health system. Evaluating secondary diagnoses helps to describe existing comorbidities which may be exacerbating poor health outcomes, including chronic conditions such as hypertension and diabetes.

Clinic data was also gathered from OSHPD’s website and incorporated in order to provide a more holistic view of health care utilization in SDC, as hospital discharges may not represent all the health conditions in the community.

HASD&IC 2016 CHNA: Additional Quantitative Data

To supplement KP’s CHNA Data Platform and the analysis described above, additional health data was collected to capture a comprehensive picture of the health of SDC. This included 2012 mortality data from California Department of Public Health (CDPH) and health indicator data from local, state, and national agencies including the California Health Interview Survey (CHIS), California Reducing Disparities Project (CRDP) Population Reports, and publications by the HHSA. A Vulnerable Populations Report

4 Developed at the Agency for Healthcare Research and Quality (AHRQ), the Clinical Classifications Software (CCS) is a tool for clustering patient diagnoses and procedures into a manageable number of clinically meaningful categories. The multi-level CCS groups single-level CCS categories (specific diagnoses and procedures) into broader body systems or condition categories (e.g., "Diseases of the Circulatory System," "Mental Disorders," and "Injury").which can be used to explore data on types of conditions.

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was created to provide a more in-depth understanding of the following populations: children; seniors; Asian American/Native Hawaiian and Other Pacific Islander; American Indians/Alaskan Natives; Latinos; African Americans; homeless; lesbian, gay, bisexual, transgender and queer (LGBTQ); and refugees (see Appendix D). These groups were selected based on Centers for Disease Control and Prevention (CDC) guidelines and recommendations from the community about specific populations to include in future assessments.

In addition, to further support these findings the collaborative partnered with local community organizations to obtain more local level data. The data was summarized and used to aid in understanding geographical and neighborhood level differences. The community partners that were engaged were:

 2-1-1 San Diego  North County Health Services  Palomar Health Community Action Council – TODAY Program  Resident Leadership Academy  County of San Diego Health and Human Services Agency

Results from the quantitative data analysis are summarized in Section 5: Findings.

Quantitative Data Collection and Analysis: SGH 2016 CHNA

Employing similar methodologies, SGH analyzed internal inpatient, ambulatory and ED data (OSHPD, 2013) specific to each of the identified health needs from the 2013 CHNA: behavioral health, cardiovascular disease, cancer, Type 2 diabetes, obesity and senior health.

In addition, SGH incorporated data from Sharp’s 2015 Cancer Psychosocial Distress Screening in its CHNA process. The Cancer Psychosocial Distress Screening is a screening provided to a large number of Sharp cancer patients to obtain input on aspects of the treatment process that cause patient psychosocial distress or difficulties. A referral process to both internal and external (community) resources for the provision of psychosocial care occurs for patients as needed. For SGH, more than 450 patients were screened. Sharp hospitals, including SGH, also report data to an oncology registry database, providing current information on the top new cancer diagnosis treated at each hospital. This data in turn is reported to the state of Calif.

In addition, data from 2-1-1 San Diego was collected to analyze referral patterns of community members connected to SGH from 2-1-1 San Diego, an important community resource and information hub. Through its 24/7 phone service and online database, it helps connect individuals with community, health, and disaster services.

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Quantitative Data Analysis: Community Need Index

Recognizing that health needs differ across the regions and that socio-economic factors impact health outcomes, the IPH used the Dignity Health/Truven Health CNI to identify communities with the highest level of health disparities and needs. The CNI score is an average of five different barrier scores that measure various socio-economic indicators of each community using the 2013 source data.

The CNI provides a score for every populated ZIP code in the United States (U.S.) on a scale of 1.0 to 5.0. A score of 1.0 indicates a ZIP code with the least need (dark green in maps – see Figure 10), while a score of 5.0 represents a ZIP code with the most need (bright red in maps – see Figure 10). For a detailed description of the CNI please see Appendix E.

Figure 10: CNI Score and Color Scale

Five barriers used to determine CNI CNI Color Scale: scores:

 Income Barrier  Culture Barrier  Educational Barrier  Insurance Barrier  Housing Barrier

Please refer to Appendix F of this report for a CNI map of SDC and Figure 16 for the CNI map of SDC’s east region, served by SGH. The CNI tool is publicly accessible at: http://www.dignityhealth.org/Who_We_Are/Community_Health/STGSS044508

Community Engagement Activities: HASD&IC 2016 CHNA

Community engagement activities were conducted with a broad range of community members including health experts, community leaders and San Diego residents, in an effort to gain a more complete understanding of the top identified health needs in the San Diego community. Individuals who were consulted included representatives from state, local, tribal or other regional governmental public health departments (or equivalent department or agency) as well as leaders, representatives, or members of medically underserved, low-income and minority populations. For a complete list of individuals who provided input, please refer to the full HASD&IC 2016 CHNA at: http://hasdic.org.

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Community input was gathered through the following activities:

 Community Partner Discussions  Key Informant Interviews  Health Access and Navigation Survey  Collaborative County of San Diego Health and Human Services Agency Survey  Behavioral Health Discussions

Specific objectives of this community input included:

 Gather in-depth feedback to aid in the understanding of the most significant health needs impacting SDC.  Connect the identified health needs with associated social determinants of health.  Aid in the process of prioritizing health needs within SDC.  Gain information about the system and policy changes within SDC that could potentially impact the health needs and social determinants of health.

Each of the discussions and key informant interviews was summarized and themes were extracted. A full list of themes was then aggregated and tallied by the frequency of times they were mentioned across all the community input activities for use in the prioritization process. In addition, the results from the HHSA survey were used in the tally for the prioritization of health needs. The Health Access and Navigation Survey was utilized to further support the findings.

HASD&IC 2016 CHNA: Community Partner Discussions

Community partner discussions were conducted in all regions of the county between July and October of 2015, with 87 total participants. Non-traditional stakeholders were recruited through existing community partnerships in order to solicit input from those who work directly with vulnerable populations. These stakeholders (community partners) comprised individuals from a variety of backgrounds including: care coordinators, outreach workers, community education specialists, wellness coordinators, school nurses, behavioral health managers and workers, CalFresh Outreach Coordinators, and CalFresh Capacity Coordinators (Capacity Coordinators help to build capacity and community support, implement new projects and provide technical support to better address poverty and hunger). See Table 4 for a description of participants in the community partner discussions.

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Table 4: HASD&IC 2016 CHNA Community Partner Discussion Participants

Number of Description of public health Who Participated Title/Organization Participants knowledge/expertise Low-income, medically Behavioral Health Case underserved, minority Case Managers Network 7 Managers population, population with chronic diseases CalFresh Coordinator, Project Coordinator Low-income, medically San Diego Hunger Community Health Access underserved, minority Coalition CalFresh Task 7 Department - Cal-Fresh population, population with Force (food stamps), chronic diseases Case Management Low-income, medically Outreach workers, underserved, minority Community Education San Ysidro Health Center 23 population, population with Specialist chronic diseases Care Coordinator, Special Low-income, medically Populations Health Family Health Centers of underserved, minority 4 Enrollment Specialist, San Diego population, population with Specialist/Care Coordinator chronic diseases Community Health Workers, Refugees, low-income, Health Interpreter, medically underserved, International Rescue Family Support Worker, 7 minority population, Committee Senior Health Program population with chronic Coordinator, diseases Wellness Coordinator Parent and Youth Partners, Youth and children, medically Family & Youth Program Managers and 9 underserved, minority Roundtable Directors population Low-income, medically SDC Office of Education underserved, minority School Nurses School Nurses Resource 30 population, population with Group chronic diseases, youth and children

Results from the community partner discussions are summarized in Section 5: Findings.

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HASD&IC 2016 CHNA: Key Informant Interviews

In response to feedback from the 2013 CHNA, the number of key informant interviews conducted as part of the 2016 CHNA was expanded to include experts working with a wider variety of patient populations. Participants were selected based on their expertise in a specific condition, age group, and/or population. More specifically, individuals who participated in the 2016 CHNA had knowledge in at least one of the following areas: childhood issues, senior health, Native Americans, Latinos, Asian Americans, refugee and families, homeless, LGBTQ population, veterans, alcohol and drug addiction, cardiovascular health, behavioral health, diabetes, obesity, and food insecurity. In addition there was representation across multiple agencies and organizations including the HHSA, local schools, youth programs, community clinics, and community-based organizations. See Table 5 below for a description of the key informants.

Table 5: HASD&IC 2016 CHNA Key Informants

Description of Number of Name Title/Organization public health Participants knowledge/expertise Children, youth and School Nurse, Rosa Parks Martha Bajet 1 families, low-income, Elementary School medically underserved Ellen Schmeding, M.S., Director, Aging & Senior population, low- MFT Independence Service income, medically 2 Brenda Schmitthenner, Aging Program Administrator; underserved, population MPA County of San Diego, HHSA with chronic diseases Steven Jella, MA, MFT, Associate Executive Director, Children, youth and 1 PsyD San Diego Youth Services families, refugees Nutrition Manager, Public Obesity, diabetes, food Naomi Billups Health Services, County of San 1 issues Diego HHSA Low-income, medically Vice President, Collective underserved, minority Cheryl Moder Impact, Community Health 1 population, population with Improvement Partners chronic diseases, obesity Executive Director, North Homeless, behavioral Don Stump 1 County Lifeline health, low-income Chief Executive Officer and Kim Bond, MFT President, Mental Health 1 Behavioral health Systems Executive Director, Interfaith Homeless, veteran Greg Angela 1 Community Services population, housing Vice President and Chief Low-income, medically Maria Carriedo- Medical Officer, San Ysidro 1 underserved, Latino Ceniceros, M.D. Health Center population

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Description of Number of Name Title/Organization public health Participants knowledge/expertise Low-income, medically Director of Program & Fund underserved, minority Fe Seligman Development, Operation 1 population, breast cancer, Samahan Health Centers cardiovascular disease, Type 2 diabetes President and Chief Executive Low-income, medically Irma Cota Officer, North County Health 1 underserved, minority Services population, Latinos Supervising Child and Adolescent Psychiatrist, Children, youth and Laura Vleugels, M.D. 1 Behavioral Health Services, families, behavioral health County of San Diego HHSA Deputy Director, Programs, Refugees, medically Erica Bouris International Rescue 1 underserved Committee Chief Executive Officer, The Delores Jacobs, Ph.D. San Diego LGBT Community 1 LGBTQ population Center Program Development Director; Community Douglas Flaker Engagement Specialist, 2 Native American population Perse Hooper San Diego American Indian Health Center President and Chief Executive Margaret Iwanaga- Officer, Union of Pan Asian 1 Asian American population Penrose Communities Executive Director, San Diego Food systems issues/food Anahid Brakke 1 Hunger Coalition insecurity, low-income Low-income, medically President and Chairman, underserved, population Rodney G. Hood, M.D. MultiCultural Health 1 with chronic diseases, Foundation African American population Low-income, medically Wilma Wooten, M.D., Deputy Health Officer, County underserved, minority 1 M.P.H. of San Diego HHSA population, population with chronic diseases

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important in SDC, including those not directly related to the top four health needs. Results from the HASD&IC 2016 CHNA key informant interviews are summarized in Section 5: Findings.

HASD&IC 2016 CHNA: Health Access and Navigation Survey

The Health Access and Navigation Survey was developed in partnership with the San Diego County Resident Leadership Academy (RLA).5,6 After comparing results of the RLA’s 2014 Community Needs Assessment7 and with the findings from the HASD&IC 2013 CHNA, access and navigation of health care emerged as a common barrier identified by the San Diego community. The CHNA Committee collaborated with the RLAs to design a survey tool that could identify specific barriers residents face when they try to access health care services. RLA leaders agreed to disseminate the Health Access and Navigation Survey to residents in their neighborhoods.

Survey participants were asked to choose the top five barriers they or the population they work with experience, and to rank the five barriers from one to five, with one being the most troublesome. Please see Appendix G for a copy of the Health Access and Navigation Survey. Results from the HASD&IC 2016 CHNA Health Access and Navigation Survey are summarized in Section 5: Findings.

HASD&IC 2016 CHNA: County of San Diego HHSA Survey

In early 2014, HASD&IC and leadership at HHSA began discussing ways to align their efforts to assess community health needs. In recognition of the tremendous opportunity to leverage the work of each entity, HHSA altered their Community Health Assessment (CHA) schedule to align it with the triennial CHNA schedule required by federal regulations. The alignment supported several key goals: improved ability to share information from the different assessments; reduced burden on the communities and organizations surveyed by both assessments; and increased opportunities for partnership and collaboration. For this 2016 CHNA process, the HHSA and HASD&IC partnered in regional presentations as well as an electronic survey.

Data presentations were given at five Live Well San Diego Regional Leadership Team meetings across SDC in October and November 2015. The Regional Leadership Teams comprise community leaders and stakeholders that are active in each of the six HHSA regions (central, east, north central, north coastal, north inland and south). Each meeting included an overview of the HASD&IC 2013 CHNA process and findings followed by a presentation from the County of San Diego Community Health Statistics Unit on current data trends in their region.

5 More information about the San Diego Resident Leadership Academy is here http://www.sdchip.org/initiatives/resident- leadershipacademy. aspx 6 Adapted from San Ysidro Health Center hand out which was adapted from the Centers for Medicare & Medicaid Services, https://www.cms.gov/About-CMS/Agency-Information/OMH/OMH-Coverage2Care.html 7 More information about the RLA assessment completed for the San Diego County’s Community Action Partnership is available here: http://www.sandiegocounty.gov/hhsa/programs/sd/community_action_partnership/

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Following the data presentations, an electronic survey was sent to pre-identified stakeholders and community partners representing all six HHSA regions. HASD&IC and the HHSA worked together to create specific questions assessing community perception of the top health needs, and for which health needs resources are lacking. Results from the HASD&IC 2016 CHNA County of San Diego HHSA Survey are summarized in Section 5: Findings.

HASD&IC 2016 CHNA: Behavioral Health Discussions

Due to the complexity of behavioral health, additional discussions were held specifically to ensure the quantitative data that was gathered accurately reflected current trends and areas of true need. The purpose of the behavioral health discussions was to gather feedback from behavioral health experts to aid in the understanding of the most significant health needs impacting SDC and aid in the process of prioritizing health needs within behavioral health. See Table 6 below for a description of participants in the behavioral health discussions.

Table 6: HASD&IC 2016 CHNA Behavioral Health Discussion Participants

Who Number of Description of public health Title/Organization Participated Participants knowledge/expertise Low-income, medically Physicians, social Hospital Partners underserved, minority workers, case Behavioral Health 30 population, population with workers Workgroup chronic diseases Low-income, medically Physicians, social Healthy San Diego underserved, minority workers, case Behavioral Health ~20 population, population with workers Workgroup chronic diseases Low-income, medically Physicians, social Alpine Special Treatment underserved, minority workers, case 8 Center population, population with workers chronic diseases

Meetings focused on behavioral health were targeted to solicit feedback from stakeholders including patient advocates as well as representatives from hospitals, clinics, HHSA, smaller behavioral or mental health facilities, and health plans. The behavioral health discussion template was developed based on hospital discharge data analysis and incorporated a synthesis of the community partner discussion data. A summary of data as it relates to behavioral health needs was provided to the behavioral health experts prior to gaining their feedback. Three behavioral health discussions took place between December 2015 and January 2016. The combined total number of attendees was roughly 58 people between the two meetings. Results from the HASD&IC 2016 CHNA behavioral health discussions are summarized in Section 5: Findings.

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Community Engagement Activities: SGH 2016 CHNA

In addition to an active role in the collaborative HASD&IC 2016 CHNA process, Sharp contracted with the IPH at SDSU to conduct a number of community engagement activities specific to the patients and community members served by Sharp hospitals.

In recognition of the challenges that health providers, community organizations and residents face in their efforts to prevent, diagnose and manage these chronic conditions, the 2016 CHNA process focused on gaining deeper insight into the top health needs identified in SGH’s 2013 CHNA (behavioral health, cardiovascular disease, Type 2 diabetes, obesity and senior health). In addition, in recognition of the significance of various forms of cancer prioritized in the 2013 CHNA process (see Figure 7), as well as discussion with Sharp team members and priorities observed in their patient population, SGH also identified cancer as a priority health need to analyze further and address in the 2016 CHNA process.

The overall purpose of collecting primary data was to gather information about the health needs and social determinants specific to Sharp patients in SDC. Specific objectives included:

 Gather in-depth feedback to aid in the understanding of the most significant health needs impacting SDC.  Connect the identified health needs with associated social determinants of health.

Community input was collected through three primary methods: case manager discussions, key informant interviews, and the Health Access and Navigation Survey (noted as “Roadmap Survey” in Figure 11 below) utilized in the HASD&IC 2016 CHNA process. Figure 11 below describes the community engagement activities conducted as part of SGH’s 2016 CHNA process by identified health need.

Figure 11: SGH 2016 CHNA Community Engagement Activities by Health Need

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SGH 2016 CHNA Community Engagement: Behavioral Health

In addition to the behavioral health discussions with Alpine Special Treatment Center, and the two Behavioral Health Workgroups, Sharp-specific community input regarding behavioral health was collected through the following activities:

 Key Informant Interviews  Health Access and Navigation Survey

See Table 7 below for a description of participants in the community engagement activities for behavioral health.

Table 7: Sharp Community Engagement: Behavioral Health

Data Collection Number of Description of public health Who Participated Method Participants knowledge/expertise Psychologist, Sharp Key Informant Behavioral Health Social Worker, McDonald Center 1 Interview Substance Use Outpatient Services Counselor, Sharp Key Informant Behavioral Health Social Worker, McDonald Center 1 Interview Substance Use Outpatient Services Health Access Sharp McDonald Patient-specific challenges related to and Navigation Center Aftercare 46 health and access to care Survey Support Group

Key Informant Interviews – Behavioral Health

Two key informant interviews were conducted with staff from Sharp McDonald Center Outpatient Services to obtain the unique perspective and experience of individuals working directly with Sharp patients with behavioral health needs. Please refer to Appendix H for a list of the questions that were asked during the interview. Results from the Behavioral Health Key Informant Interviews are summarized in Section 5: Findings.

Health Access and Navigation Survey – Behavioral Health

As part of Sharp’s specific needs assessment process, attendees of Sharp McDonald Center’s Aftercare support group were asked to fill out the Health Access and Navigation Survey during a meeting. The Aftercare program helps substance abuse patients maintain a sober lifestyle by supporting them through the necessary transitions at home, work and in the community. The purpose of the survey was to gather feedback from community residents to increase understanding of the challenges they experience

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in accessing and navigating the health care system within SDC. Please see Appendix G for a copy of the survey that was distributed.

A total of 46 behavioral health-specific surveys were completed. The majority of survey participants were ‘white’ (92.9 percent) with the majority living in the north central region (46.7 percent), followed by the north coastal and east regions (17.8 percent and 15.6 percent, respectively). Survey participants were asked to choose the top five barriers they experience, and to rank the five barriers from one to five, with one being the most troublesome. Results from the Behavioral Health Access and Navigation Survey are summarized in Section 5: Findings.

SGH 2016 CHNA Community Engagement: Cancer

The cancer-specific community engagement activities included:

 Key Informant Interview  Cancer Patient Navigator Discussion  Health Access and Navigation Survey

See Table 8 below for a description of participants in the community engagement activities for cancer.

Table 8: Sharp Community Engagement: Cancer

Data Number of Description of public health Collection Who Participated Participants knowledge/expertise Method Key Vice President, Informant 1 Cancer expertise at Sharp HealthCare Oncology Interview Low-income, medically underserved, Cancer minority population, population with Patient Cancer Patient 9 chronic diseases including cancer, non- Navigator Navigators English speakers Discussion Regions: south, east, central

Health Access and Community Cancer patient-specific challenges related 31 Navigation Residents to health and access to care Survey

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Cancer Patient Navigator Discussion

A discussion was conducted with Sharp Cancer Patient Navigators (including from SGH) in order to better understand the unique health issues and barriers to health improvement experienced by Sharp’s cancer patients. There were a total of nine participants in the discussion. Oncology discussion participants represented hospitals and clinics and served low-income residents, medically underserved individuals, minority populations including non-native English speakers (i.e., Spanish, Arabic and Tagolog) and populations with chronic diseases in the central, east and south regions. Refer to Appendix I for a copy of the discussion tool that was used. Results from the Cancer Patient Navigator Discussions are summarized in Section 5: Findings.

Key Informant Interview – Oncology

A key informant interview was conducted with the Vice President of Sharp’s Oncology Service Line to obtain the unique perspective and experience of an expert who works with patients at various stages of cancer treatment. Please refer to Appendix H for a list of the questions that were asked during the interview. Results from the Oncology Key Informant Interview are summarized in Section 5: Findings.

Health Access and Navigation Survey – Oncology

To better assess the priorities and needs of community members dealing with cancer, cancer support group participants were asked to fill out the Health Access and Navigation Survey. The survey was facilitated by a Cancer Patient Navigator with the purpose of gathering feedback from community residents to increase understanding of the challenges they experience in accessing and navigating the health care system within SDC. Please see Appendix G for a copy of the survey that was distributed. A total of 31 oncology-specific surveys were completed.

Survey participants were asked to choose the top five barriers they experience, and to rank the five barriers from one to five, with one being the most troublesome. Results from the Oncology Health Access and Navigation Survey are summarized in Section 5: Findings.

SGH 2016 CHNA Community Engagement: Cardiovascular Health

Key Informant Interview – Cardiovascular Health

A key informant interview was conducted with a Senior Cardiac Specialist at SGH to obtain the unique perspective and experience of an expert who works with cardiac patients at Sharp. See Table 9 below for a description of the Cardiovascular Health Key Informant Interview.

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Table 9: Sharp Community Engagement: Cardiovascular Health

Data Number of Description of public health Collection Who Participated Participants knowledge/expertise Method Key Informant Senior Cardiac Specialist, Cardiovascular health; low-income, 1 Interview Heart Failure Nurse vulnerable patient populations

Please refer to Appendix H for a list of the questions that were asked during the interview. Results from the SGH Cardiovascular Health Key Informant Interview are summarized in Section 5: Findings.

SGH 2016 CHNA Community Engagement: Diabetes

Diabetes Health Educators Facilitated Discussion

A discussion was conducted with Sharp’s diabetes educators in order to better understand the unique health issues and barriers to health improvement experienced by Sharp diabetic patients. There were a total of four participants in the discussion. The discussion participants represented hospitals, and served low-income residents, medically underserved individuals, minority populations, and populations with chronic diseases in the central, east, north central and south regions. Please see Table 10 below for a description of the Diabetes Health Educators Discussion.

Table 10: Sharp Community Engagement: Diabetes

Data Who Number of Collection Description of public health knowledge/expertise Participated Participants Method Low-income, medically underserved, minority Diabetes Discussion 4 population, population with chronic diseases, seniors Educators Regions: central, east, north central, south

Refer to Appendix I for a copy of the discussion tool that was used. Results from the Diabetes Health Educator Discussion are summarized in Section 5: Findings.

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SGH 2016 CHNA Community Engagement: High-Risk Patients

The high-risk patient-specific primary data was collected through the following activities:

 Care Transitions Intervention (CTI)/Community-based Care Transitions Program (CCTP) Discussion  Key Informant Interview – Care Transitions Manager

Please see Table 11 below for a description of the community engagement activities for high-risk patients.

Table 11: Sharp Community Engagement: High-Risk Patient Care Providers

Data Number of Description of public health Collection Who Participated Participants knowledge/expertise Method

CTI/CCTP Low-income, medically underserved, minority Case CTI Coaches and 17 population, population with chronic diseases Manager Pharmacists Discussion Regions: central, east, south, north central Key Care Transitions Care transitions expertise at Sharp, high-risk Informant 1 Manager patients Interview

The HHSA Aging & Independence Services (AIS) entered into a Program Agreement with the Centers for Medicare and Medicaid Services (CMS) to implement the CCTP in partnership with 13 hospitals – including Sharp HealthCare.8 CCTP serves low-income, highly vulnerable patient populations. In addition, the CTI program at SGH includes unfunded and Medi-Cal patients. This focus at SGH has resulted in a heightened awareness of the challenges facing more vulnerable community members.

CCTP/CTI Discussion

The goal of the discussion was to collect a deeper understanding from CCTP/CTI staff on the challenges their patients face with maintaining health and accessing care. A discussion was conducted with Sharp’s Care Transitions coaches and pharmacists in order to better understand the unique health issues and barriers to health improvement experienced by Sharp’s high-risk patients. The Care Transitions discussion was held at a Sharp facility with a total of 17 participants. The Care Transitions discussion participants represented hospitals, nonprofits and community pharmacies, and served low-income residents, medically underserved individuals, minority populations, and populations with chronic diseases in the central, east, north central and south regions.

8http://www.sandiegocounty.gov/hhsa/programs/phs/health_services_advisory_board/documents/2013_O ctober_AIS_Update.pdf Sharp Grossmont Hospital Community Health Needs Assessment Page 35

Refer to Appendix I for a copy of the tool that was used during the discussion. Results from the CCTP/CTI Discussion are summarized in Section 5: Findings.

Key Informant Interview – Care Transitions

A key informant interview was held with Sharp’s Care Transitions Manager to provide an alternative perspective to the challenges faced by high-risk patients and additional systematic challenges that impact Sharp. Please refer to Appendix H for a list of the questions that were asked during the interview. Results from the Care Transitions Key Informant Interview are summarized in Section 5: Findings.

SGH 2016 CHNA Community Engagement: Senior Health

The senior-specific community input was collected through the following activities:

 General Senior Health Feedback o Senior Health Discussions o Senior Patient Surveys – Health Access and Navigation Survey Please see Table 12 below for a description of the community engagement activities for senior health.

Table 12: Sharp Community Engagement: Senior Health

Who Number of Description of public health Data Collection Method Participated Participants knowledge/expertise

Social Low-income, medically underserved, Downtown Senior Workers, 4 minority population, population with Health Center Discussion Nurses chronic diseases, seniors Low-income, medically underserved, Clairemont Senior Nurses 3 population with chronic diseases, Health Center Discussion seniors Health Access and Senior Patient-specific challenges related to 27 Navigation Survey Patients health and access to care for seniors

Senior Health Center Discussions

Senior health discussions were held at two different Senior Health Centers, Clairemont Senior Health Center and Downtown Senior Health Center, due to differences in the health needs of the two populations. There were a total of seven participants in the discussions. Senior Health discussion participants represented clinics and nonprofits and served low-income residents, medically underserved individuals, minority populations, and populations with chronic diseases in the central region. Refer to

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Appendix I for a copy of the discussion tool that was used. Results from the Senior Health Discussions are summarized in Section 5: Findings.

Health Access and Navigation Survey – Seniors

As part of Sharp’s specific needs assessment process, seniors were asked to fill out the survey. The purpose of the Health Access and Navigation Survey was to gather feedback from community residents to increase understanding of the challenges they experience in accessing and navigating the health care system within SDC. Please see Appendix G for a copy of the survey that was distributed.

A total of 27 senior-specific surveys were completed. Survey participants were asked to choose the top five barriers they experience, and to rank the five barriers from one to five, with one being the most troublesome. Results from the Senior Health Access and Navigation Survey are summarized in Section 5: Findings.

2016 CHNA Prioritization of Top Four Identified Health Needs

In order to prioritize the four significant health needs in SDC, the HASD&IC 2016 CHNA Committee applied the following five criteria:

1. Magnitude or Prevalence: The health need affects a large number of people in all regions of SDC. 2. Severity: The health need has serious consequences (morbidity, mortality, and/or economic burden). 3. Health Disparities: The health need disproportionately impacts the health status of one or more vulnerable population groups. 4. Trends: The health need is either stable or changing over time, e.g., improving or getting worse. 5. Community Concern: Stakeholders, community members, and vulnerable populations within the community view the health need as a priority.

Using these criteria, a summary matrix translating the 2016 CHNA findings was created for review by the CHNA Committee. Taking into account the results of the quantitative data collection and the findings from the community engagement activities, a rank from one to four, with one being the most significant, was applied to each criterion. An overall score was given to each health need by averaging the rankings across all five criteria. In addition, the social determinants of health were analyzed and identified across all health needs.

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Section

4 Community Defined

The primary communities served by SGH encompass the entire east region of SDC, including the sub-regional areas of Jamul, Spring Valley, Lemon Grove, La Mesa, El Cajon, Santee, Lakeside, Harbison Canyon, Crest, Alpine, Laguna-Pine Valley and Mountain Empire. Approximately five percent of the population lives in remote or rural areas of this region. Table 13 below presents the ZIP codes where the majority of SGH patients reside.

Table 13: Primary Communities Served by SGH

Feedback on community health needs was solicited from both community members and service providers living and working in the east region of SDC, in order to assess priority health issues for the community. See Figure 12 for a map of the primary communities served by SGH. Please refer to Appendix J for a mapping of community and region boundaries in SDC.

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Figure 12: Map of SGH’s Primary Communities

Map created by Sharp HealthCare Strategic Planning Department, July, 2013.

Demographics

In this section, SGH’s community is defined not only by its demographic makeup but also by particular socioeconomic barriers known to contribute to health care access and health outcomes.

Wherever possible, the descriptions that follow will focus on communities served by SGH, however certain secondary data sources are not available at this level of specificity and broader summaries of SDC’s east region are provided in these instances.

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In the next five years, SGH’s service area is projected to grow 4.5 percent which is the same rate as the county as a whole.9 The service area’s two fastest growing ZIP codes are Encanto and Spring Valley, as shown in Table 14 below.

Table 14: Fastest Growing ZIP Codes in SGH’s Service Area, 2015-2020

Population 2015-2020 ZIP Code Community Name 2015 2020 Change 92114 Encanto 69,806 74,785 7.1% 91977 Spring Valley 60,557 63,889 5.5% 92105 City Heights 73,150 77,105 5.4% 91945 Lemon Grove 26,483 27,910 5.4% 91978 Spring Valley 9,148 9,623 5.2% Source: Speedtrack, Inc.; U.S. Census Bureau

SDC’s east region is a large, diverse area including urban, suburban and rural sections. The region is largely white (59.0 percent) and Hispanic (26.7 percent) but also has a strong refugee presence. The California Department of Social Services reported that SDC ranked first among refugee admissions in California from 2010-2014, totaling 13,801, and in 2011, the top cities/communities in which refugees resettled were San Diego (820), El Cajon (677) and Spring Valley (62).

Approximately 71 percent of the population in the east region spoke English only at home, with another 18.9 percent who are bilingual. An increased percentage of individuals reported their highest education as ‘High School Graduate’ in the east region compared to SDC overall, while a decreased proportion of individuals reported having a Bachelor’s Degree compared to SDC overall.

According to 2014 CHIS data, the east region had the second highest percentage of current smokers but the lowest percentage of binge drinkers when compared to other regions in SDC. Furthermore, 59.5 percent of the east region population reported experiencing food insecurity, exceeding the overall rate in SDC of 38.1 percent food insecure. Please see Table 15 for more east region data.

9 Speedtrack, Inc.; US Census Bureau

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Table 15: SDC East Region Demographics, 2014

Age # % Race # % Gender # % 0-4 Years 31,255 6.6% White 279,908 59.0% Male 234,037 49.3% 5 to 14 Years 59,214 12.5% Hispanic 126,786 26.7% Female 240,289 50.7% to 24 Years 68,843 14.7% Black 24,497 5.2% Asian/Pacific 25 to 44 Years 120,326 25.4% 21,799 4.6% Islander 45 to 64 Years 127,274 26.8% Other 21,336 4.5% 65+ Years 66,414 14.0%

Primary Language Spoken Percent Below Poverty Education % % % at Home Level < High School 13.4% English Only 70.7% Population 14.6% Graduate High School Graduate 25.6% Spanish Only 5.4% Families 11.0%

Some College or AA 37.0% Asian/Pacific Islander Only 1.4% Families With Children 16.9% Bachelor Degree 15.8% Other Language Only 3.6%

Graduate Degree 8.3% Bilingual 18.9% Source: County of San Diego HHSA, Public Health Services, Community Health Statistics Unit, 2016. Demographic Profiles, 2014. and the U.S. Census Bureau, American Community Survey. 2010-2014.

Additional Income Barriers

According to Table 16 below, in 2014 the unemployment rate in the east region was 11.2 percent, which is higher than the unemployment rate for SDC overall (9.2 percent).10

Table 16: Unemployment Estimates for SDC’s East Region (2014 American Community Survey, (ACS))

Eligible Labor Force 16+ Years 337,067 Percent Unemployed 11.20% Source: County of San Diego HHSA, Public Health Services, Community Health Statistics Unit, 2016. Demographic Profiles, 2014. and the U.S. Census Bureau, American Community Survey. 2010-2014.

Nearly 9 percent of families in the east region participate in Supplemental Nutrition Assistance Program (SNAP) benefits, while 20 percent of those below 130 percent of the FPL are eligible for such benefits. This participation rate of families is higher than

10 Source: County of San Diego HHSA, Public Health Services, Community Health Statistics Unit, 2016. Demographic Profiles, 2014. and the U.S. Census Bureau, American Community Survey. 2010-2014.

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SDC overall (6.4 percent).10 Please refer to Table 17 for details on poverty estimates and public program participation in the east region.

Table 17: Food Stamps/SNAP Benefit Participation for SDC’s East Region (2014 ACS)

Percent of Food Stamps/SNAP Benefits Population Households 8.90% Families with Children 8.70% Eligibility by Federal Poverty Level (FPL) Population ≤130% FPL 20.10% Population ≤138% FPL 21.80% Population 139% ‐ 350% FPL 34.10% Source: County of San Diego HHSA, Public Health Services, Community Health Statistics Unit, 2016. Demographic Profiles, 2014. and the U.S. Census Bureau, American Community Survey. 2010-2014.

In the east region, 46 percent of the population spends 30 percent or more of their monthly household income on housing costs. This is slightly higher than SDC overall (45.5 percent). See Table 18 below for additional details on monthly housing costs in the east region.

Table 18: Housing Costs, SDC’s East Region (2014 ACS)

Monthly Income Going to Housing Costs Percent of Population Less than 20% per Month 30.00% 20% to 29% per Month 23.90% 30% or more per Month 46.00% Source: County of San Diego HHSA, Public Health Services, Community Health Statistics Unit, 2016. Demographic Profiles, 2014. and the U.S. Census Bureau, American Community Survey. 2010-2014.

Additional Health Insurance/Access Barriers

Tables 19 and 20 provide a summary of key indicators of access to care in SDC’s east region.

Table 19: Health Care Access in SDC’s East Region, 2014

Year 2020 Health Insurance Coverage Rate Target Children 0 to 11 Years 99.2% 100% Children 12 to 17 Years 100% 100% Adults 18 to 64 Years 91.1% 100% Year 2020 Regular Source of Medical Care Rate Target Children 0 to 11 Years 100% 100% Children 12 to 17 Years 100% 100% Adults 18 to 64 Years 89.4% 89.4%

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Not Currently Insured Rate Adults 18 to 64 Years 8.9% Source: 2013–2014 California Health Interview Survey (CHIS)

Table 20: Medi-Cal (Medicaid) Eligibility Among Uninsured in SDC’s East Region (Adults Ages 18 to 64 Years), 2014

Eligibility Rate Medi-Cal Eligible 35.1% Not Eligible 64.9% Source: 2013–2014 CHIS

Lastly, the leading causes of death for SDC’s east region are detailed in Table 21 below.

Table 21: Leading Causes of Death in SDC’s East Region, 2013

Number of Percent of Cause of Death Deaths Total Deaths Malignant neoplasms 908 23.8% Diseases of heart 877 23.0% Alzheimer’s disease 250 6.6% Cerebrovascular diseases 235 6.2% Chronic lower respiratory diseases 201 5.3% Accidents (unintentional injuries) 193 5.1% Diabetes mellitus 120 3.1% Intentional self-harm (suicide) 67 1.8% Chronic liver disease and cirrhosis 52 1.4% Essential (primary) hypertension and hypertensive renal disease 64 1.7% All other causes 846 22.2% Total Deaths 3,813 100.0% Source: County of San Diego HHSA, Public Health Services, Epidemiology & Immunization Services Branch

It is important to note here that for SDC’s east region, cancer (malignant neoplasms) is the leading cause of death. This underscores the importance of SGH’s commitment to programs that help to educate, screen and prevent the incidence of cancer, as well as to programs that offer support and resources for community members impacted by cancer.

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Section

5 Findings

This section describes findings of both the collaborative HASD&IC 2016 CHNA and SGH’s 2016 CHNA processes. As the HASD&IC 2016 CHNA process included strong representation of the community served by SGH (SDC’s east region), a significant proportion of these findings reflect the same health needs of SGH’s community members.

Both CHNA processes included findings from the collection and analysis of currently existing health and socioeconomic data; CNI data identifying vulnerable communities; and primary data from various community engagement activities. These combined analyses, allowed for a deeper dive into the identified health needs for SGH’s patient community.

HASD&IC 2016 CHNA: Hospital, Clinic and Community Partner Data

San Diego County Hospital Data

In 2013, there were a total of 1,166,355 patient encounters at all SDC inpatient, ED and ambulatory facilities among SDC residents. Of these encounters, approximately 60.8 percent were at ED locations, followed by 25.8 percent at inpatient facilities and 13.5 percent at ambulatory centers. See Table 22 for the demographic characteristics of all SDC resident encounters at any point of care location in 2013.

Table 22: Demographic Characteristics of All Hospital Encounters in SDC by SDC Residents, 2013

Age # % Race # %

0-4 Years 126,677 10.9% White 710,209 60.9% 5 to 14 Years 77,785 6.7% Black/African American 90,299 7.7% 15 to 24 Years 129,263 11.1% Asian/Pacific Islander 65,473 5.6% 25 to 44 Years 279,412 24.0% Native Hawaiian/Other Pacific Islander 8,390 0.7% 45 to 64 Years 287,162 24.6% American Indian/Alaskan Native/Eskimo/Aleut 5,026 0.4% 65+ Years 265,974 22.8% Other Race 274,755 23.6% Unknown 12,158 1.0%

Gender # % Ethnicity # %

Male 515,795 44.2% Non-Hispanic/Non-Latino 806,631 69.2% Female 650,501 55.8% Hispanic/Latino 344,791 29.6% Unknown 14,891 1.3%

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San Diego County Clinic Utilization Data

According to 2013 OSHPD data, there are 103 clinics in operation in SDC, of which 77.7 percent are Federally Qualified Health Centers (FQHC). There were roughly 2.1 million encounters reported in 2013. The largest majority of clinic patients are low- income, Hispanic, and Medi-Cal or Self-Pay. More specifically, 68.4 percent of clinic patients reported having an income below 100 percent of the FPL, followed by 15.6 percent earning between 100-200 percent of the FPL. The clinic patient population is largely Hispanic (55.7 percent), and on average (median), approximately 31 percent of patients are best served in a non-English language. A breakdown of clinic utilization by principal diagnosis is shown below (Figure 13).

Figure 13: Clinic Encounters by Principal Diagnosis, Total Encounters in 2013

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Community Partner Data

To further support data findings from the KP Data Platform, the HASD&IC 2016 CHNA collaborative partnered with local community organizations to obtain more local level data. The data was summarized and used to aid in understanding geographical and neighborhood level differences. The community partners that were engaged were:  2-1-1 San Diego  North County Health Services  Palomar Health Community Action Council – TODAY Program  Resident Leadership Academy  County of San Diego Health and Human Services Agency

Findings of community partner data specific to SDC’s east region are outlined in the following pages.

2-1-1 San Diego

Table 23: 2-1-1 San Diego Referrals to SGH by Taxonomy, 2014-2015

Total Taxonomy Health Needs Emergency Medical Care 78 Emergency Room Care 76 Trauma Centers 2 Health Supportive Services 28 Certified Application Counselor Programs 1 CPR Instruction 6 Dental Care Referrals 3 First Aid Instruction 5 General First Aid Instruction 5 General Health Education Programs 1 Health Insurance Marketplaces 1 Infant/Child CPR Instruction 3 Managed Health Care Information 2 Medication Information/Management 1 Human Reproduction 3 Childbirth Education 1

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Postpartum Care 1 Sibling Birth Preparation Programs 1 Inpatient Health Facilities 81 General Acute Care Hospitals 81 Outpatient Health Facilities 11 Community Clinics 4 Hospital Based Outpatient Services 1 Urgent Care Centers 6 Rehabilitation/Habilitation Services 3 Physical Therapy 3 Specialized Treatment 1 Adult Diabetes Management Clinics 1 Specialty Medicine 4 Emergency Dental Care 4 Grand Total 209

2014 Community Action Partnership San Diego Community Health Needs Assessment (Resident Leadership Academy)

The San Diego County Community Action Partnership (CAP San Diego) is a public community action agency, within the HHSA. In 2014, CAP San Diego conducted a Community Needs Assessment as part of the development of their Community Action Plan for 2016 – 2017. The assessment included the identification and analysis of key community indicators, solicitation of direct community input regarding the needs and priorities of low-income communities by local residents, and analysis of quantitative data and community input collected by CAP San Diego staff and the Community Action Board.

To gather community input, CAP San Diego leveraged a model called RLA. The RLAs provide local leaders in low-income neighborhoods with training and tools to take action in their neighborhoods to increase healthy behavior, improve safety, and create vital neighborhoods. In July 2014, CAP San Diego commissioned six regional RLAs (one in each HHSA designated service region) to train 10-15 residents using the RLA curriculum and complete a needs assessment for their designated region. Below is a summary of the 2014 CAP San Diego Community Needs Assessment findings (Figure 14).

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Figure 14: Summary of the 2014 CAP San Diego Community Needs Assessment Findings

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County of San Diego Health and Human Services Agency Community Health Assessment

The Live Well San Diego CHA process began in 2012. During this process, Regional Leadership Teams were formed and each region conducted the following three assessments: 1) Community Health Status Assessment, 2) Forces of Change Assessment, and 3) Community Themes and Strengths Assessment. This process allowed each region to assess the health status of its community by determining the root causes of health including health behaviors, social factors, and health services. The results of these assessments were combined and key priority areas were identified. These priority areas are summarized in Figure 15.

Figure 15: Summary of Key Priority Areas Identified in the County of San Diego HHSA CHA

•Key Priority Areas: North County •Behavioral Health/Substance Abuse, Nutrition, Physical * Activity

•Key Priority Areas: North Central •Physical Activity, Behavioral Health, Preventative Health Care

•Key Priority Areas: East •Active Living, Healthy Eating, Substance Abuse Prevention •Key Priority Areas: •Access to Health Services, Alcohol, Tobacco and Other Central Drugs, Food Equity /Access to Healthy Food, Safety and Built Environment, Worksite Wellness •Key Priority Areas: South •Health Care Access, Improve Security and Decrease Violence, Physical Activity, Healthy Eating

*Note: North County includes both North Inland and North Coastal regions. Source: County of San Diego, Health and Human Services Agency. Live Well San Diego Community Health Assessment. 2014

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Health Conditions Affecting Primary Communities Served by SGH

Modeling the HASD&IC 2016 CHNA process, SGH analyzed inpatient, ambulatory and ED data for the top identified health needs from the 2013 CHNA process (behavioral health, cardiovascular disease, Type 2 diabetes, obesity and senior health). In addition, SGH’s 2016 CHNA process included a deeper dive into the identified health need of cancer, resulting from analysis of the 2013 CHNA hospital data, SDC east region mortality data, and conversations with various Sharp team members.

Calendar year (CY) 2013 data was sourced from OSHPD via the same SpeedTrack software utilized in the HASD&IC 2013 CHNA. This enabled comparison to trends observed specifically at SGH with trends seen at SDC hospitals overall. Data was pulled specifically for SGH patients that reside in the primary communities served by the hospital. Please refer to Table 13 in Section 4: Community Defined for a listing of these primary communities.

Similar to the HASD&IC 2016 CHNA, hospital data provided a foundation for potential health conditions of concern to communities served by SGH. Further, findings from the analysis of SGH’s utilization data reflected the findings from the overall analysis of SDC hospital data conducted as part of the HASD&IC 2016 CHNA. Inpatient, ambulatory, and ED data for the top identified health needs at SGH are detailed in Appendices K – P:

Appendix K: SGH Behavioral Health Hospital Data Appendix L: SGH Cardiovascular Health Hospital Data Appendix M: SGH Diabetes Hospital Data Appendix N: SGH Obesity Hospital Data Appendix O: SGH Senior Health Hospital Data Appendix P: SGH Oncology Hospital Data

Sharp HealthCare Oncology Registry Data

Sharp hospitals report data to an oncology registry database, providing current information on the top new cancer diagnoses treated at each hospital. This data in turn is then reported to the state of Calif. For SGH, the top cancers observed in 2015 were (in rank order):

1. Breast cancer 2. Lung cancer 3. Colorectal cancer 4. Prostate cancer 5. Hematapoietic cancer

Cancer Psychosocial Distress Screening

To provide greater insight into the psychosocial impacts of cancer on its patient community, SGH participates in a process to integrate and monitor on-site psychosocial distress screening and referral for the provision of psychosocial care for cancer patients.

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Important elements of the screening include:

 Timing of the screening – All cancer patients screened at least once during a pivotal medical visit  Methodology of screening administration – Those administering and interpreting must be trained  Tools – Preference given to standardized, validated instruments with established cut-offs  Assessment and Referral – Patient discussion of results are required. If moderate to severe distress, an oncology team member must assess the patient and make the appropriate internal or external referrals to address patient needs

In 2015, 451 SGH cancer patients were screened with the Cancer Psychosocial Distress Screening. Of those screened, 152 patients (33.7 percent of those screened) scored at a range of moderate to severe distress, and were referred to both internal and external (community) resources. Resources include: on-site social worker, physician and/or nurse; as well as American Cancer Society, Susan G. Komen San Diego, CancerCare®, 2-1-1 San Diego, etc.

Identifying SGH’s Vulnerable Communities

SGH service area ZIP codes were analyzed using the same CNI methodology used in the HASD&IC 2016 CHNA to identify the specific high need communities within the SGH service area. Please refer to Section 3: Methodology for details on the CNI and its components.

Table 24 below presents primary communities (by ZIP code) served by SGH with their calculated CNI score. Areas with a lower CNI score (1-3) are identified as having lower need than those areas with higher CNI scores (4-5). Figure 16 presents a mapping of CNI scores across SDC’s east region.

Table 24: CNI Scores for Primary Communities served by SGH

ZIP Code Community 2013 Population 2013 CNI 91941 La Mesa 32,815 3.4 91942 La Mesa 39,618 3.6 91945 Lemon Grove 26,124 4.2 91977 Spring Valley 60,390 4 92019 El Cajon 44,216 3.2 92020 El Cajon 59,722 4.6 92021 El Cajon 62,188 4.2 92040 Lakeside 42,106 3.4 92071 Santee 56,675 3 Source: Dignity Health Community Need Index. 2013.

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Figure 16: CNI Map – SDC’s East Region

In addition, Figures 17 through 19 present CNI maps for SDC’s east region, with SDC hospital discharge data for behavioral health, cardiovascular disease and diabetes overlaid on the map. These maps demonstrate that while these chronic diseases affect communities of varying need, those areas with the highest CNI score (and thus highest vulnerability) often present higher discharge rates for these chronic health conditions. Thus, the maps strongly suggest the connection between rates of chronic disease, health care utilization, and social determinants of health/socioeconomic factors.

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Figure 17: SDC East Region, CNI and Behavioral Health Discharges

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Figure 18: SDC East Region, CNI and Cardiovascular Disease Discharges

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Figure 19: SDC East Region, CNI and Diabetes Discharges

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Community Engagement Activities

This section describes the findings from the community engagement activities for both the HASD&IC 2016 CHNA and the SGH 2016 CHNA, as all data significantly impacted the overall findings of the SGH 2016 CHNA. Community engagement activities included: community partner/case manager discussions; key informant interviews; surveys, including patient/community resident through the Health Access and Navigation Survey; and behavioral health discussions.

HASD&IC 2016 CHNA: Community Partner Discussions

Community partner discussions were conducted in all regions of SDC between July and October of 2015, with 87 total participants. Non-traditional stakeholders were recruited through existing community partnerships in order to solicit input from those who work directly with vulnerable populations. These stakeholders (community partners) comprised individuals from a variety of backgrounds including: care coordinators, outreach workers, community education specialists, wellness coordinators, school nurses, behavioral health managers and workers, CalFresh Outreach Coordinators, and CalFresh Capacity Coordinators (Capacity Coordinators help to build capacity and community support, implement new projects and provide technical support to better address poverty and hunger). Findings from the community partner discussions are summarized in Table 25.

For the full list of survey respondents’ names, organizations and titles of position, please visit www.hasdic.org.

Table 25: HASD&IC 2016 CHNA: Community Partner Discussion Results

1. What are the most common health issues or needs?  Anxiety  Lack of psychiatrists  Depression  Obesity in youth  Drugs/alcohol  Problems with compliance/coverage  High blood pressure  Self-injury/suicidal ideation in youth  High cholesterol  Unhealthy diet 2. What are the challenges clients face to improving health?  Cost  Stigma  Homeless: often difficult to get proof of  Stress appointment; wait times are often longer  Seniors: don’t have support at home or than the amount of time they are allowed forget to take medications, mobility issues to be gone and healthy eating  Lack of access to healthy food  Transportation  Lack of understanding of covered insurance  Time benefits and fear of hidden costs  Youth: Too few behavioral health  Language barriers practitioners/lack of school counselor,  Literacy knowledge, getting parents on board/parent follow-up

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3. Why do patients not adopt behaviors?  Cost  Perceived seriousness  Cultural practices (i.e. unhealthy food,  Prioritization of other needs medicine only for the sick)  The right questions aren’t being asked  Lack of awareness/recognition/education  Youth: Lack of role model, lack of control  Not properly motivated/confident over health behaviors 4. What are top challenges you as case managers, health navigators, etc. face to helping patients?  Compliance and literacy: getting individuals to read/use resources  Elderly: may choose medicine over food  Getting clients to go is difficult (‘I don’t need that’ or ‘I feel fine’)  Long waiting periods and no follow-up appointments  North County: lack of services, only one crisis location  Problems confirming appointments/contacting  Problems with hospital discharges, continuing care and wrong referrals  Patients being signed up for the wrong plans for what they need/want  South region: getting documents/verifications  Youth: difficulties communicating with parents/what is told to parents at discharge does not filter down to the nurses, limited school-based interventions, cultural barriers, denial, unaware of problem 5. What have you found works best with your clients to help them meet their needs?  Emotional support  Reducing stigma  Finding intrinsic motivation  Strengths-based case management  Keeping the phone lines open  Translators  Multicultural providers 6. How could hospitals collaborate with your organizations?  Better referrals, streamlined discharge planning, and timely access to medical records (more details)  Better ways to ask if people need food or other social services  Discharge summary/instructions from hospital/doctor to school sites for kids (what are limitations, needs, modifications), upstream health education curriculum, presentations, and legislation for youth  No discharge to streets or without medications, no discharges without making follow-up appointments with clients

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HASD&IC 2016 CHNA: Key Informant Interviews

The development of the key informant interview tool began with the results from the HASD&IC 2013 CHNA. The interview questions were designed to provide in-depth detail on the top four health needs. Nineteen key informant interviews took place either in-person or via phone interview between July 2015 and February 2016. Each interview lasted no longer than one hour. Six questions were asked during the interviews, with a particular focus on the top four health needs that were identified in the 2013 CHNA. Although there were specific questions asked, the format of the interviews allowed for ample opportunity for open discussion on health needs that the key informants felt were most important in SDC, including those not directly related to the top four health needs. Please see http://hasdic.org for all key informant interview materials.

The most common health needs, important modifiable risk factors, effective strategies, and suggestions for collaboration are summarized in Table 26. Some important strategies that key informants suggested included: behavioral health prevention and stigma reduction; education on disease management and food insecurity; improving cultural competency and diversity; integrating physical and mental health; coordinating services across the continuum; engaging case managers and patient navigators in the community and incorporating them as a routine part of the continuum of care.

In addition, Figure 20 describes key informant recommendations for community resources to address the four identified health needs as well as their associated social determinants of health.

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Table 26: HASD&IC 2016 CHNA Key Informant Questions and Responses Summary

1. What are the most common health issues or needs?  Anxiety  Hypertension: Latinos, African Americans,  Asthma and Asians  Dental health  Increase in developmental disorders in  Depression children  Dementia and Alzheimer’s disease in  Obesity: youth, acculturating refugees, seniors Native Americans, older veterans, low  Depression and diabetes in seniors income individuals and families  Diabetes: low-income and food insecure  Substance Abuse populations, Latinos, Asians 2. What do you think are the most important modifiable risk factors related to the health issues you just mentioned?  Access to nutritious food  Lack of resources for care and housing of  Access to specialty care seriously mentally ill  Childhood and adult traumas  Lack of social support and isolation  Homelessness  Lack of substance abuse treatment  Lack of access to psychiatrists facilities, especially in North County  Lack of physical activity – decreased  Limited access to gyms or safe spaces to physical education in youth, decreased participate in physical activity mobility in seniors 3. What strategies do you think would be most effective for patients, physicians, case managers etc. in addressing the health needs or modifiable risk factors above?  Care integration and coordination  Early identification and prevention  Community and cultural competency  Knowledge/education 4. What resources need to be developed or increased in order to address the health needs or modifiable risk factors above?  See Figure 20 for a list of resources 5. Are there systems, policy, or environmental changes that, if implemented, could help the hospitals address these health needs or modifiable risk factors?  Payment model reforms that include  Increased awareness of available services reimbursements for social services (i.e.  Increased data sharing behavioral health case management,  Increase psychiatrists and nurse wellness/education, community health practitioners workers) 6. Can you recommend any partnerships or collaborations between hospitals and specific organizations that would help to address the health needs or modifiable risk factors above?  City leadership and planning departments  Intergenerational partnerships  Community-based organizations  Internship/workforce training programs  External provider support through with local educational institutions – County technology of San Diego HHSA  Federally Qualified Health Centers  Managed care plans  Information sharing between  San Diego County Mental Health physicians/case managers and community- Contractors based organizations  Warm hand-offs

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Figure 20: HASD&IC 2016 CHNA, Resources Needed to Meet Needs Identified in Key Informant Interviews

•Community wide educational plan on how to use health insurance and create a wellness plan •Population-specific educational forums on mental health Knowledge & •Programs for the whole family Education: •Comprehensive lists of free/no-cost physical activity and nutrition programs for patients and providers •Provider/resident training on food insecurity

•More accessible interpreter services at primary care providers •Resources to support cultural and linguistic competence Community & •Provider training on how to ask questions about patients ability Cultural to comply with their treatment plan Competency: •Build a workforce that understands geriatric care needs •Increasing community-based fellowships •Diversification of staff and social workers in the community

•Expand crisis intervention services •More quality substance abuse specifically for adolescents and transitional age youth •Behavioral health prevention and help for children where they Behavioral congregate (i.e. ,schools, YMCA) Health Services: •More respite care in behavioral health •Increased recuperative care housing programs across San Diego County •Accessible treatment for drugs and alcohol •ED care coordinators to connect people to resources/ED coordination with primary care providers Integration of •Integrated psychiatric navigators in inpatient settings who can Health, Social help patients transition back to community Services, & •Increase health settings’ capacity to apply for CalFresh/SNAP or Behavioral to refer patients to an agency to help with application Health Systems: •Integrated Case Managers/Health Navigators/CHWs/Promotores(as) in the community for different population groups

•After hours urgent care outside of the ED Other resources: •Increase opportunities to act on health behaviors rather than decreasing access to unhealthy behaviors •Worksite wellness - nutrition, physical activity, lactation

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HASD&IC 2016 CHNA: Surveys

Two distinct surveys were developed and disseminated through multiple avenues as part of the HASD&IC 2016 CHNA process – the Health Access and Navigation Survey and the Collaborative County of San Diego HHSA Survey.

Health Access and Navigation Survey

The Health Access and Navigation Survey was developed in partnership with the San Diego County RLA11, 12. After comparing results of the RLA’s 2014 Community Needs Assessment13 and with the findings from the HASD&IC 2013 CHNA, access and navigation of health care emerged as a common barrier identified by the San Diego community. The CHNA Committee collaborated with the RLAs to design a survey tool that could identify specific barriers residents face when they try to access health care services. RLA leaders agreed to disseminate the Health Access and Navigation Survey to residents in their neighborhoods. Please see Appendix G for the Health Access and Navigation Survey.

Survey participants were asked to choose the top five barriers they or the population they work with experience, and to rank the five barriers from one to five, with one being the most troublesome. Most striking was that the top four barriers cited as most troublesome were all precursors to seeing a health care provider, indicating that community members are often struggling to make it past the first steps of accessing health care. Based on the survey responses, the top five barriers to accessing health care are described in Figure 21 below.

Figure 21: Top Five Barriers to Accessing Health Care, Health Access and Navigation Survey Results 4. Knowing 5. Follow-up care 1. Understanding 2. Getting health 3. Using health where to go for and/or health insurance insurance insurance care appointment

As the number of individuals who have health insurance in the nation and within SDC has increased, so has the importance of helping people understand how to obtain health insurance, use health insurance, and access care that is appropriate for their health needs. Residents’ ability to access health care is a critical first step toward improving the overall health of the San Diego community. Table 27 shows the top five barriers countywide. ‘Understanding health insurance’ was the top cited barrier in all regions with the exception of SDC’s east region which found ‘follow-up care and/or

11 More information about the San Diego Resident Leadership Academy is here http://www.sdchip.org/initiatives/resident-leadership-academy.aspx 12 Adapted from San Ysidro Health Center hand out which was adapted from the Centers for Medicare & Medicaid Services, https://www.cms.gov/About-CMS/Agency-Information/OMH/OMH-Coverage2Care.html 13 More information about the RLA assessment completed for the San Diego County’s Community Action Partnership is available here: http://www.sandiegocounty.gov/hhsa/programs/sd/community_action_partnership/ Sharp Grossmont Hospital Community Health Needs Assessment Page 61

appointments’ to be the number one barrier. Within each overarching barrier participants were asked to choose the reasons those barriers were a problem in accessing care. For example, within the overarching barrier ‘Understanding health insurance,’ the top two reasons this barrier was cited as a problem were ‘confusing insurance terms’ and ‘how does Covered California apply to me?’. Eighty-five percent of survey respondents identified themselves as “community member”. The majority of the respondents were Hispanic (68.5 percent) followed by white (26.9 percent), Asian/Pacific Islander and black (3.7 percent and 2.3 percent, respectively). There was representation from all six HHSA regions, with the largest proportion of respondents being from the south region (46.3 percent). Please see Appendix Q for details on the demographics of the survey respondents.

Table 27: HASD&IC 2016 CHNA: Five Most Troublesome Barriers to Accessing Health Care14

Total Respondents* (N=250) Resident Responses n % 1. Understanding health 194 77.6% insurance 2. Getting health insurance 159 63.6%

3. Using health insurance 149 59.6% 4. Knowing where to go for 149 59.6% care 5. Follow-up care and/or 118 47.2% appointment

*Based on the total number of respondents who selected the barrier as being among the top five barriers they experience

Findings specific to SDC’s east region are presented in Table 28.

14 Details and data by region in Table 28.

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Table 28: HASD&IC 2016 CHNA Health Access and Navigation Survey Results – SDC’s East Region

East Region Total SDC Top Five Health Access & Navigation Categories (barriers cited as Respondents Respondents* most troublesome in accessing health care) (n=14) (n=250) n % n % Understanding health insurance 10 71.40% 194 77.60% Getting health insurance 7 50.00% 159 63.60% Using health insurance 6 42.90% 149 59.60% Knowing where to go for care 8 57.10% 149 59.60% Follow-up care and/or appointment 11 78.60% 118 47.20%

East Total Top Five Health Access & Navigation Categories and Responses n % n % Understanding health insurance Confusing insurance terms 8 100% 104 59.4% How does Covered California apply to me? 3 37.5% 92 52.6% Total 8 175 Getting health insurance How to pick a plan 5 71.4% 92 62.2% Eligibility requirements & documentation status 3 42.9% 79 53.4% Total 7 148 Using health insurance Knowing what services are covered 4 66.7% 97 69.3% Understanding health care costs/bills 4 66.7% 70 50.0% Total 6 140 Knowing where to go for care When to use the ED vs urgent care vs clinic 8 100% 80 56.3% No primary care doctor 3 37.5% 59 41.5% Total 8 142 Follow-up care and/or appointment Lack of instructions about necessary follow up care 5 50.0% 50 45.9% Lack of understanding about next steps 4 40.0% 47 43.1% Total 10 109 100% *Note: The total number of surveys completed was 235; however, since participants could identify multiple regions that they work in, duplications were made for those regional responses

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County of San Diego Health and Human Services Agency Survey

For the HASD&IC 2016 CHNA process, the collaborative partnered with the HHSA and HASD&IC in regional presentations as well as an electronic survey.

Data presentations were given at five Live Well San Diego Regional Leadership Team meetings across SDC in October and November 2015. The Regional Leadership Teams comprises community leaders and stakeholders that are active in each of the six HHSA regions. Each meeting included an overview of the HASD&IC 2013 CHNA process and findings followed by a presentation from the County of San Diego Community Health Statistics Unit on current data trends in their region.

The results of the survey as it relates to the top health problems and lack of resources are summarized by region in Table 29. Overall, mental health issues and alcohol and drug abuse were most frequently cited as the most important health problems across all the regions. Additionally, with the exception of SDC’s east region, mental health issues were found to have the least amount of resources to address the problem across SDC.

For SDC’s east region, behavioral health issues, including alcohol and drug abuse, stood out as the number one identified health problems in the community. The remaining concerns – obesity, diabetes, cancer, and aging – are all well-aligned with the needs identified via SGH’s 2013 and 2016 CHNA processes. For more information, please visit HHSA’s Live Well San Diego website at: http://www.livewellsd.org/content/livewell/home/make-an-impact.html.

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Table 29: HASD&IC 2016 CHNA, Collaborative County of San Diego HHSA Survey Results

North Survey Central East North Central South County Question (15) (6) (14) (12) (44) What do you think are the five most important HEALTH PROBLEMS* in your community (those problems that have the greatest impact on overall community health)? Mental Mental Alcohol and Mental Health Issues Mental Health Health Issues Health Issues Drug Abuse (6) (10) Issues (9) (12) (30) Alcohol and Mental Health Aging concerns& (8) Alcohol/Drug Alcohol/Drug Drug Abuse Issues (5) Alcohol/Drug abuse (8) abuse (30) Abuse (7) (9) Aging Diabetes (9) Obesity (4) Heart Disease (6) Concerns& Obesity (7) (23) Diabetes (3) Cancer (3) High Blood Pressure (4) Aging Concerns& Obesity (7) Diabetes (20) Aging Concerns Obesity (4) (7) (3) Heart Disease Obesity (18) Heart disease (6) (6) Cancer (18) Of the top five HEALTH PROBLEMS that you selected above, specify which ONE health problem has the least amount of RESOURCES available to help address the problem. Mental Alcohol/Drug Mental Mental Health Mental Health Issues Health Issues Abuse Health Issues Issues *Problems were ranked based on total number of respondents identifying the problem as being among the top 5 (shown in parenthesis); health problems with an equal number of responses are listed in the same box. & e.g., arthritis, falls, Alzheimer’s, etc.

HASD&IC 2016 CHNA: Behavioral Health Discussions

When participants were asked to respond to the hospital data presented, there was general agreement in the findings at both the Hospital Partners and the Healthy San Diego Behavioral Health Workgroup meetings (see http://hasdic.org for the hospital

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discharge data presented during meetings). There was consensus that the high rates of psychotic discharges in ages 25 to 44 were likely linked to underlying substance abuse problems. Although participants agreed with the findings, it was pointed out that there were additional important conditions that may not come to the surface because of the way hospital data is coded. Because the data is used for billing purposes, physical conditions may often be coded first and potentially underrepresent the prevalence of underlying behavioral health issues. Most notably missing from the data were developmental disorders. The group also pointed out the importance of data trends. In particular, it was pointed out that in recent years participants have been seeing a significant increase in meth-amphetamine discharges (over 100 percent).

The Alpine Special Treatment Center15, an important provider of care to a particularly vulnerable portion in SDC’s east region, referenced a number of additional challenges that should be noted including lack of placements available once patients were ready to leave their facility, overburdened case managers, and difficulty in managing the disability application process. Another frequent challenge cited by the staff at the Alpine Special Treatment Center was the physical health problems of their patients. Discussion participants stated that behavioral health is frequently associated with other chronic conditions and that the majority of their patients fit the diagnosis for all four of the top health needs. Many patients have such serious physical health conditions that they must be sent to facilities that can treat higher acuity patients, though these facilities are generally less appropriate for treatment of their behavioral health conditions. Discussion participants stated that North County in particular lacked available resources to transition their patients. Sufficient step down facilities and improved communication between hospitals, behavioral health facilities, and community based services were some important strategies to success. Understanding the appropriate number and type of facilities needed to rotate this critical population through the health system effectively was said to be key in order to adequately treat patients across the continuum of care.

SGH 2016 CHNA: Case Manager/Care Navigator Discussions

The SGH 2016 CHNA process included multiple case manager/care navigator discussions to dive deeper into the following identified health needs: cancer, Type 2 diabetes, senior health, and high-risk/vulnerable populations. Table 30 outlines these activities.

15 Alpine Special Treatment Center is a locked mental health rehabilitation and transitional care facility. They provide care to voluntary and involuntary adults with acute psychiatric symptoms and those suffering from co-occurring disorders. Their primary goal is to quickly and safely stabilize and transition individuals from acute care to community placement.

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Table 30: SGH 2016 CHNA – Case Manager/Care Navigator Discussions

Data Collection Number of Description of public health Who Participated Method Participants knowledge/expertise

Sharp Cancer Sharp Cancer 9 Low-income, medically underserved, Patient Navigator Patient minority population, population with Discussions Navigators chronic diseases, non-English speakers Regions: south, east, central Low-income, medically underserved, Sharp Diabetes minority population, population with Sharp Diabetes Educators, 4 chronic diseases, seniors Health Educators Registered Dieticians Regions: central, east, north central, south Sharp Downtown Sharp Social 4 Low-income, medically underserved, Senior Health Workers, Nurses minority population, population with Center chronic diseases, seniors Discussions Sharp Clairemont Low-income, medically underserved, Senior Health Sharp Nurses 3 population with chronic diseases, Center Discussion seniors Low-income, medically underserved, CTI Health Sharp CTI/CCTP minority population, population with Coaches, Nurses, Case Manager 17 chronic diseases Social Workers Discussion and Pharmacists Regions: central, east, south, north central

Sharp Cancer Patient Navigator Discussion Findings A discussion was conducted with Sharp Cancer Patient Navigators to better understand the unique health issues and barriers to health improvement experienced by Sharp cancer patients. Oncology discussion participants represented hospitals and served low-income residents, medically underserved individuals, minority populations including non-native English speakers (i.e., Spanish, Arabic and Tagolog) and populations with chronic diseases in the central, east and south regions.

Refer to Appendix I for a copy of the discussion tool that was used. Please see Table 31 for a summary of the discussion results.

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Table 31: SGH 2016 CHNA, Sharp Cancer Patient Navigator Discussions

1. What are the most common health-related issues or needs?  Alcohol/Smoking  Financial issues related to health including  Child/elder care while undergoing insurance treatment  Health literacy  East County: Head and Neck Cancer,  Reliable transportation Methamphetamine and prescription drug  Translation/interpretation, particularly addiction Spanish and Asian languages  Fear and Anxiety  Understanding where to go for care 2. What are the challenges your patients face to improving their health?  Cultural differences between patient and provider  Language barriers- issues at certain office receptions (i.e. disrespect), consent forms for studies or clinical trials; also problems with privacy and translation when family translator used  Refuse or modify treatment based on financial capability 3. When your patients are unable to adopt healthy behaviors, what are their reasons for not adopting changes?  Rejection of chemotherapy because of hair loss; can be a cultural issue 4. What are top challenges you as case managers, health navigators, etc. face to helping patients?  Cultural barriers  End of life conversations are difficult – doctors are not experts on palliative care, particularly in California versus the East Coast and also varies by culture  Few individuals have Advanced Care Directives 5. What have you found works best with your clients to help them meet their needs?  Have an additional person with the  Empowerment: help them regain patient at the appointment who can control help them remember and understand  One on one support: navigation, the information treatment planning, forms (i.e.  Early preparation: preparing their disability and Medicare) house/refrigerator for surgery day,  Reinforcement: share information setting pain and work expectations, verbally and in writing getting a hair packet before hair loss,  Time early referrals

Sharp Diabetes Educator Discussions Findings A discussion was conducted with Sharp Diabetes Educators to better understand the unique health issues and barriers to health improvement experienced by Sharp diabetic patients. The discussion participants represented hospitals, and served low-income residents, medically underserved individuals, minority populations, and populations with chronic diseases in the central, east, north central and south regions.

Refer to Appendix I for a copy of the discussion tool that was used. Please see Table 32 for a summary of the discussion results.

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Table 32: SGH 2016 CHNA, Sharp Diabetes Educator Discussions

1. What are the most common health-related issues or needs?  Diabetic patients with multiple chronic  Gestational diabetes in outpatient settings conditions related to the top health needs  Newly diagnosed diabetic with history of (i.e. cardiovascular disease, behavioral cardiovascular disease including heart health, and obesity) attack or stroke  Drug use increasing – narcotics, heroin,  Pancreatitis methamphetamine among those in their  Renal failure 40s/50s 2. What are the challenges your patients face to improving their health?  Cannot see a physician  Unable to get outpatient needs met (i.e.  Diabetes education not covered under cannot get an appointment with an Medi-Cal endocrinologist or psychologist)  Programs are hard to find 3. When your patients are unable to adopt healthy behaviors, what are their reasons for not adopting changes?  Affordability – strips are costly  Food insecure  Behavioral health needs unmet- diabetes  Knowledge of benefits management can be overwhelming 4. What are top challenges you as case managers, health navigators, etc. face to helping patients?  Communication is a barrier outside of Sharp Rees-Stealy Medical Group  Lack of case managers to help with cases in an outpatient setting (i.e. food insecure patients)  Problems with insurance coverage for diabetes education  Transitioning individuals from discharge to the home is difficult – insurance piece remains separate; it is unknown if insurance will cover high cost drugs and problems with co-pays 5. What have you found works best with your clients to help them meet their needs?  Prescriptions for equipment and  Dedicated disease management staff medications covered by their insurance  Expanded outpatient hours  Understanding how needs differ by  Hours for seniors including early in the location and population including group morning and times with less traffic versus individual education preferences 6. How could your facility collaborate with community based organizations to help you meet the needs of your clients?  Increase diabetes management capabilities/staff particularly for patients in Sharp Community Medical Group  Increase patient and provider understanding on insurance

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Sharp Senior Health Discussions Findings Senior health discussions were held at two different Senior Health Centers, Clairemont Senior Health Center and Downtown Senior Health Center, due to differences in the health needs of the two populations. Senior Health discussion participants represented clinics and nonprofits and served low-income residents, medically underserved individuals, minority populations, and populations with chronic diseases in the central region. Refer to Appendix I for a copy of the discussion tool that was used. Please see Table 33 for a summary of the results.

Table 33: SGH 2016 CHNA, Sharp Senior Health Discussions

1. What are the most common health-related issues or needs?  Anxiety  Hypertension  Cardiac Disease  Increased need for caregivers  Cognitive impairment and Dementia are a  Isolation: contributes to poor diet, bad growing concern habits, depression  Depression  Loss of purpose  Diabetes  Substance abuse – most commonly  Downtown – larger population with prescription drug psychosis and chronic mental illness 2. What are the challenges your patients face to improving their health?  Access to care issues due to aging,  Lack of understanding on instructions decreased driving, loss of their support  Lack of recognition – ‘I don’t feel like my system (particularly limited support for the sugar [blood pressure] is high’ downtown population)  Memory  Inability to purchase medications due to  Perception of normal aging - think normal money issues, transportation, and/or part of growing old is to gain weight and motivation (understanding the real need) be lonely 3. When your patients are unable to adopt healthy behaviors, what are their reasons for not adopting changes?  Buy in – particularly treatment without symptoms, shift toward ‘going natural’  Cost/Income – trying to promote health on a fixed income is difficult  Downtown – lack of trust of providers/medications/pharmacists/friends/caregivers particularly among new chronically mentally ill patients/homeless  Mobility/transportation  Lack of support system and isolation  Limited to no access to places to cook 4. What are top challenges you as case managers, health navigators, etc. face to helping patients?  Accountability – patient must see the value  Disconnect between training (‘treat with medications’) and eastern or homeopathic medicine  Downtown – fragmented care for seniors and poor medical history  Insufficient resources for staff to organize education on conditions as well as lifestyle  Priority of patient vs. the provider- ‘Which medication can I afford not to take?’  Time – limited time to do education in patient healthcare setting

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5. What have you found works best with your clients to help them meet their needs?  Awareness of cultural differences  Availability  Meeting social needs as well as medical  Building rapport and trust needs  Community education at locations like  Time – seniors need more time to settle in senior centers to build familiarity with  Treating patients with respect and dignity clinic staff  Working relationships with a network of  Flexibility – providing help where it’s specialists/outside groups for referrals (i.e. needed (i.e. calling with patients to make psychotherapy, food, housing) appointments) 6. How could your facility collaborate with community based organizations to help you meet the needs of your clients?  Increase opportunities for staff to get to know the right liaisons for community services and specialists to make referrals  Bring together social services case management (i.e. a social worker or key person available) to help provide support outside of appointments  Work with community centers to help expose individuals to healthy food and opportunities for group exercise  Increase volunteer opportunities for seniors with transportation needs

For this patient population, time was emphasized as a crucial component to helping patients meet their health needs. This includes giving patients time to settle in at the clinic, building rapport and trust, communicating in a calm, respectful manner, and helping patients make additional appointments or otherwise being available to help. There is still a need for more education on normal aging and opportunities for groups to gather with similar conditions at places like senior centers to help build familiarity and motivate people to come in. The establishment of working relationships with networks of specialists, outside groups, or social services liaisons to send patients for off-site services would further improve patient care. The importance of providing support for seniors including help with food and housing outside of medical appointments, potentially through on-site social services case management, was stressed.

Care Transitions (CCTP/CTI) Discussion for Vulnerable, High-Risk Populations Findings: The goal of the discussion was to collect a deeper understanding from CCTP/CTI staff on the challenges their patients face maintaining health and accessing care. A discussion was conducted with Sharp’s Care Transition coaches, nurses, social workers and pharmacists in order to better understand the unique health issues and barriers to health improvement experienced by Sharp’s high risk patients. The discussion participants represented hospitals, nonprofits and community pharmacies, and served patients including low-income residents, medically underserved individuals, minority populations, and populations with chronic diseases in the central, east, north central and south regions. Refer to Appendix I for a copy of the tool that was used during the discussion. Please see Table 34 for a summary of the results.

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Table 34: SGH 2016 CHNA, Sharp Community-Based Care Transitions Discussion

1. What are the most common health-related issues or needs?  East County: Cognitive decline, substance  Behavioral health use, renal failure, and need for mental  Congestive heart failure health skilled nursing facilities  COPD  Obesity  Diabetes  Renal insufficiency 2. What are the challenges your patients face to improving their health?  Lack of social support  Complexity of the healthcare system  Language barriers (particularly in East  Financial barriers including the cost of County) medications  May not feel worthy of care  Health literacy  Transportation 3. When your patients are unable to adopt healthy behaviors, what are their reasons for not adopting changes?  Denial  Fear  East and south - cultural barriers, including  Financial barriers and confusion about trust issues, religious belief systems, and insurance reluctance to talk about advance directives  Inconvenient  Expensive  Social determinants 4. What are top challenges you as case managers, health navigators, etc. face to helping patients?

 Communication from hospitals at discharge to primary care provider  Follow-up appointments within 7 days are a challenge, including medical records sharing 5. What have you found works best with your clients to help them meet their needs?  Coaching patients  Providing clients with transportation,  Educating their clients about their disease support, hope, and love and the health care system  Providing patients with a personal health  Patient education tailored to specific record with information about their cultural and linguistic groups medications and available resources 6. How could your facility collaborate with community based organizations to help you meet the needs of your clients?  Increasing community services  Collaborations with Aging and Independent Services, 2-1-1 San Diego, Walmart, food banks, the County of San Diego, Jewish Family Services of San Diego, and Catholic Charities  Having pharmacists and doctors work together to provide medication lists along with the ‘Why’s’

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SGH 2016 CHNA: Key Informant Interviews The SGH 2016 CHNA process included multiple key informant interviews to dive deeper into the following identified health needs: behavioral health (including chemical dependency), cancer, cardiovascular disease and vulnerable populations. Table 35 outlines these activities.

Table 35: SGH 2016 CHNA, Key Informant Interviews

Who Participated Description of public health knowledge/expertise

Psychologist, Sharp McDonald Behavioral Health Social Worker, Substance Use Center Outpatient Services Counselor, Sharp McDonald Behavioral Health Social Worker, Substance Use Center Outpatient Services Vice President, Oncology, Sharp Cancer expertise at Sharp HealthCare HealthCare Senior Cardiac Specialist, Heart Cardiovascular health; low-income, vulnerable populations Failure Nurse , Sharp Grossmont Hospital Care Transitions Manager, Sharp Care transitions expertise at Sharp HealthCare, high-risk Health Care patients

Behavioral Health Key Informant Interviews Findings Two key informant interviews were conducted with staff from Sharp McDonald Center (SMC) Outpatient Services to obtain the unique perspective and experience of individuals working directly with Sharp patients with behavioral health needs. Please refer to Appendix H for a list of the questions that were asked during the interview.

Interview 1

The most important issues for people with substance use issues include active recovery, intoxication and withdrawal, and co-morbidities such as diabetes or hypertension. Risk factors include co-occurring mental disorders, trauma, and positive attitudes regarding drinking or using from family systems. Co-morbidities include infectious diseases such as hepatitis and the Human Immunodeficiency Virus; cirrhosis, and fatty liver. The CDC recently reported an all-time high rate of alcohol related death not including homicides or driving under the influence (DUI).

Strategies that work with people with substance use issues include motivational interviewing, relapse prevention, acceptance and commitment therapy, cognitive behavioral therapy, and cognitive processing therapy.

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Resources that need to be developed to address substance use and related issues include early prevention programs, particularly those starting in grade school, programming that emphasizes the dangers of alcohol, and increasing accessibility of treatment programs. In addition, there should be psychologists in EDs to provide screening, brief intervention, and referrals to people who go to the ED for substance use related reasons.

Systems, policy, or environmental changes that could help hospitals address the needs of people who have substance use issues include: increasing the number of programs using American Society of Addiction Medicine criteria, which includes levels of care and where patients should be placed; integrating the Columbia Suicide Rating Scale to increase interrater reliability in determining who needs care; integrating trauma informed care throughout hospital systems; and using family systems-integrated family therapy.

Recommended collaborations or partnerships include more forums to share best practices, shared early intervention programs, and Screening, Brief Intervention and Referral to Treatment (SBIRT) used throughout larger systems.

Interview 2

The most important issues for people with substance use issues are accepting that they have a problem, getting established with a support group, and getting affiliated with community resources. Risk factors include biology, environment, family of origin, mental illness, and peer group (teens).

Effective strategies for addressing substance use issues include early treatment, easily accessible treatment, and community programs. “You have to get them treatment as soon as they ask for help. Within three days. You have to get them when they are desperate.” In addition, stigma related to chemical dependency needs to be reduced.

Resources that need to be developed include more recovery beds and programs for youth. Systems, policy, or environmental changes that could help hospitals address the needs of people with substance use issues include training for ED staff about chemical dependency so people are treated better; having beds available for people who can’t pay; and providing long-term aftercare.

Cardiovascular Health Key Informant Interview Findings A key informant interview was conducted with a Senior Cardiac Specialist at Sharp Grossmont Hospital to obtain the unique perspective and experience of an expert working with cardiac patients who are also often low-income, highly vulnerable community members, at Sharp. Please refer to Appendix H for a list of the questions that were asked during the interview.

The most important issues for cardiology patients include access to care, getting medications, and understanding diet. It’s critical for patients to understand their symptoms and be able to communicate their needs clearly to their providers. Patients

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also need to understand how to take their medications, how their medications affect their disease, and how diet affects their disease.

Risk factors include diabetes, lack of social support, substance use disorders, financial issues, transportation, and lack of health education. Almost all of the patients under 50 or 55 have substance use issues, but there is no one trained in addictions on staff in cardiology.

Effective strategies with cardiology patients include having more time for teaching patients about their disease and self-management; building relationships with patients; educational materials; back line numbers for providers; education for general practitioners; and a trained addictions specialist on the treatment team.

Resources that need to be developed include cooking classes on non-salt alternatives, classes on healthier choices for frozen foods and label reading, easier processes for accessing doctors, providing health navigators, and including trained addiction counselors on treatment teams.

Systems, policy, and environmental changes that would help hospitals address the needs of cardiology patients include free transportation to the hospital and medical appointments, better communication between inpatient and outpatient providers, providing patients with a two week supply of medications at discharge, and integrating health navigators and addictions specialists on treatment teams.

Cardiology patients are often diabetic or have substance use issues so increased collaboration between cardiology, diabetes, and behavioral health units are recommended.

Cancer Key Informant Interview Findings A key informant interview was conducted with the Vice President of Sharp’s Oncology Service Line to obtain the unique perspective and experience of an expert who works with patients at various stages of cancer treatment. Please refer to Appendix H for the key informant interview questions.

Oncology has become more complicated for both patients and providers as treatment options have increased and treatment outcomes have improved. Providers need to keep up-to-date on the development of new medications, the efficacy of treatment options, and continually changing screening guidelines; determine if the information they have is actionable; and address survivorship and end-of-life issues. End of life is a particular challenge in oncology. Many physicians have not had this in their medical education. It can also be emotionally challenging for providers because cancer has become a chronic condition so often providers have known their patients and families for many years.

Health/health care issues faced by patients include access to insurance, access to appropriate care, and language barriers for non-English speakers. Even if patients have

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insurance, not all providers accept Medi-Cal so patients may not be able to access all of the services they need, such as breast reconstruction. With treatment, patients are at risk for other cancers and additional side effects affecting other organ systems. Patients need additional monitoring by specialists, but health plans often send them back to primary care, where providers may not be up-to-date on screening guidelines.

“Language is a huge challenge. In oncology, it’s not a single point where the challenge happens. You have a whole team of people and the patient’s ability to understand, to give full informed consent, and to comply with treatment is highly dependent on language.” For example, patients may not be able to participate in clinical trials if consent information is not translated. Additional issues include financial issues, legal issues, and issues related to survivorship. Patients with no social network need in home support, transportation, and other resources to ensure they are able to comply with treatment. In addition to health related issues associated with cancer, patients are faced with emotional, sexual, and body image issues.

Effective strategies for addressing the needs of people with cancer include lay navigators; community coordinators who know what the hospital needs and what the community has; and teams within the hospital and through partnerships with community-based organizations to address how to approach barriers to care, capitalize on personnel, and identify and address gaps in services. Navigators need to be integrated into the care process, and infrastructure must be developed with leadership at the physician level

Resources that need to be developed include education for providers on end-of- life issues and palliative care; someone within the health system who can identify resources and answer questions about different contracts; financial assistance for co-pays, prescriptions, childcare, and other barriers, such as the electric bill; survivorship clinics; and a systematic way to identify resources.

Care Transitions Key Informant Interview Findings

A key informant interview was held with Sharp’s Care Transitions Manager to give an alternative perspective to the challenges faced by highly vulnerable patients and additional systematic challenges that impact Sharp. Please refer to H for a list of the questions that were asked during the interview.

Primary issues for CCTP clients include psychosis, depression, anxiety, Chronic Obstructive Pulmonary Disease (COPD) and other chronic diseases. The program tries to empower patients in place to manage care and connect to services. Risk factors include the home environment, transportation, and medication management.

Effective strategies for addressing the health needs and risk factors above include working with patients to transition them from the hospital to home by connecting them to community resources which help patients become independent in their environment. Integrating the CCTP model into the standard of care is critical.

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Resources that need to be developed include connections into the community, expedited services for patients discharged from the hospital with immediate needs, and ways to finance hospital/community partnerships for expedited services. One necessary systems change is a way to access expedited social services from the county without additional payment.

SGH 2016 CHNA: Health Access and Navigation Surveys

The SGH 2016 CHNA process included the distribution of Health Access and Navigation Surveys (the same survey utilized in the HASD&IC 2016 CHNA). See Appendix G to dive deeper into the following identified health needs for community residents: behavioral health (including chemical dependency), cancer and senior health. Table 36 outlines these activities.

Table 36: SGH 2016 CHNA, Health Access and Navigation Surveys

Number of Who Participated Description of public health knowledge/expertise Participants

Sharp McDonald Center Patient-specific challenges related to health and 46 Aftercare Support Group access to care Community Residents - 31 Cancer patient-specific challenges related to health cancer patients and access to care Community Leaders Senior Patients Patient-specific challenges related to health and 27 access to care

Behavioral Health Access and Navigation Survey Findings As part of Sharp’s specific needs assessment process, attendees of Sharp McDonald Center’s Aftercare support group were asked to fill out the survey during a meeting. The purpose of the Health Access and Navigation Survey was to gather feedback from community residents to increase understanding of the challenges they experience in accessing and navigating the health care system within SDC. Please see Appendix G for a copy of the survey that was distributed.

A total of 46 behavioral health-specific surveys were completed. The majority of survey participants were ‘white’ (92.9 percent) with the majority living in north central region (46.7 percent), followed by north coastal and east regions (17.8 percent and 15.6 percent, respectively). Survey participants were asked to choose the top five barriers they experience, and to rank the five barriers from one to five, with one being the most troublesome. Based on the survey responses, the top five barriers to accessing health care are outlined in Figure 22.

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Figure 22: Top Five Barriers to Accessing Health Care, Health Access and Navigation Survey Results – Behavioral Health

4. Making an 1. Using health 2. Understanding 3. Knowing where 5. Getting health appointment for insurance health insurance to go for care insurance care

Within each overarching barrier participants were asked to choose the reasons those barriers were a problem in accessing care. Among the top challenges that survey participants faced, knowing what services are covered, confusing insurance terms, knowing when to use the ED, urgent care or clinic, no available appointments, and knowing how to pick a plan were the most commonly selected. Please see Table 37 below for more survey details regarding specific challenges identified by support group attendees.

Table 37: Sharp Behavioral Health Access and Navigation Survey, Specific Challenges

1. Using health insurance Total Respondents n % Knowing what services are covered 29 82.9% Understanding health care costs/bills 20 57.1% Total** 35

2. Understanding health insurance Total Respondents n % Confusing insurance terms 31 88.6% How does Covered California apply to me? 9 25.7% Total** 35

3. Knowing where to go for care Total Respondents n % When to use the emergency department vs. urgent care vs. clinic 15 60.0% No primary care doctor 6 24.0% Total** 25

4. Making an appointment for care Total Respondents n % No available appointments 12 63.2%

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Wait time issues 12 63.2% Total** 19

5. Getting health insurance Total Respondents n % How to pick a plan 17 81.0% Eligibility requirements and documentation status 9 42.9% Total** 21

**Total refers to the number of survey participants who chose to rank specific challenges within a major category. Only the top two challenges are listed and participants were asked to select all that apply so columns should not be added downwards to determine the total.

Survey participants were also given the opportunity to elaborate on specific challenges and opportunities. General “other” comments and suggestions for improvement are summarized in Table 38 below.

Table 38: Sharp Behavioral Health Access and Navigation Survey, “Other” Comments

 A need for specialty doctors that are  Not understanding financing easily accessible through public transit  Not understanding insurance coverage  Continued care specifics  “Covered California is impossible”  Understanding what facility best meets  Lack of recovery options the patients’ needs  Not understanding exclusions  Remembering to refill prescriptions

Demographics on behavioral health survey respondents can be found in Appendix R, Table 1.

Cancer Health Access and Navigation Survey Findings

As part of Sharp’s specific needs assessment process, cancer support group participants were asked to fill out the Health Access and Navigation Survey. The survey was facilitated by a Cancer Patient Navigator with the purpose of gathering feedback from community residents to increase understanding of the challenges they experience in accessing and navigating the health care system within SDC. Please see Appendix G for a copy of the survey that was distributed. A total of 31 oncology-specific surveys were completed.

Survey participants were asked to choose the top five barriers they experience, and to rank the five barriers from one to five, with one being the most troublesome. Most striking was that four out of the top five barriers cited as most troublesome were all precursors to seeing a health care provider, indicating that community members are

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often struggling to make it past the first steps of accessing health care. Based on the survey responses, the top five barriers to accessing health care are outlined in Figure 23 below:

Figure 23: Top Five Barriers to Accessing Health Care, Health Access and Navigation Survey Results – Cancer

4. Making an 5. Knowing 1. Understanding 2. Using health 3. Picking up appointment for where to go for health insurance insurance prescriptions care care

Within each overarching barrier participants were asked to choose the reasons those barriers were a problem in accessing care. Among the top challenges that survey participants faced, confusing health insurance terms, knowing what services are covered, knowing what pharmacy to use, knowing when to use the ED, urgent care or clinic, and lack of available appointments were the most commonly selected. Please see Table 39 below for more survey details regarding specific challenges identified by SDC residents.

Table 39: Sharp Cancer Health Access and Navigation Survey, Specific Challenges

1. Understanding health insurance Total Respondents n % Confusing Insurance Terms 10 55.60% How does Covered California apply to me? 5 27.80% Total** 18

2. Using health insurance Total Respondents n % Knowing what services are covered 15 93.80% Understanding health care costs/bills 10 62.50% Total** 16

3. Picking up prescriptions Total Respondents n % What pharmacy to use 2 25.00% Understanding costs 2 25.00% Lack of Transportation 2 25.00% Total** 8

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4. Making an appointment for care Total Respondents n % No available appointments 8 66.70% Wait time issues 8 66.70% Total** 12

5. Knowing where to go for care Total Respondents n % When to use the emergency department vs. urgent care vs. clinic 10 71.40% Other (clinic locations, doctor or clinic) 4 28.60% Total** 14

Survey participants were also given the opportunity to elaborate on specific challenges and opportunities. Suggestions for improvement are summarized below.

More time with doctors More comprehensive educational groups A Navigator staff member or a case manager for all oncology patients, not just newly diagnosed Help navigating which health insurance option provides the best coverage for your needs A tour specific to patients who have a serious illness and will be needed multiple treatments

Demographics on cancer survey respondents can be found in Appendix R, Table 2.

Senior Health Access and Navigation Survey Findings

As part of Sharp’s specific needs assessment process, older adult patients at Sharp’s Senior Health Centers (Clairemont and Downtown locations) were asked to fill out the Health Access and Navigation Survey. The purpose of the survey was to gather feedback from community residents to increase understanding of the challenges they experience in accessing and navigating the health care system within SDC. Please see Appendix G for a copy of the survey that was distributed.

A total of 27 senior-specific surveys were completed. The majority of survey participants identified as white (72.0 percent) and live in the central region (48.1 percent) followed by the east and north central region (25.9 percent and 18.5 percent, respectively). Survey participants were asked to choose the top five barriers they experience, and to

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rank the five barriers from one to five, with one being the most troublesome. Based on the survey responses, the top five barriers to accessing health care are outlined in Figure 24 below:

Figure 24: Top Five Barriers to Accessing Health Care, Health Access and Navigation Survey Results – Senior Health

2. Knowing 5. Follow-up care 1. Understanding 3. Using health 4. Getting health where to go for and/or health insurance insurance insurance care apointments

Within each overarching barrier participants were asked to choose the reasons those barriers were a problem in accessing care. Among the top challenges that survey participants faced, confusing insurance terms, knowing when to use the ED, urgent care or clinic, understanding health care costs/bills, hearing back about your insurance after signing up, and lack of understanding of next steps following an appointment were the most commonly selected. Please see Table 40 below for more survey details regarding specific challenges identified by senior residents in SDC.

Table 40: Sharp Senior Health Access and Navigation Survey, Specific Challenges

1. Understanding health insurance Total Respondents n % Confusing Insurance Term 17 73.9% How does Covered California apply to me? 9 39.1% Total** 23

2. Knowing where to go for care Total Respondents n % When to use the emergency department vs. urgent care vs. clinic 8 57.1% Lack of health insurance 5 35.7% Total** 14

3. Using health insurance Total Respondents n % Understanding health care costs/bills 10 83.3% Knowing what services are covered 9 75.0% Total** 12

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4. Getting health insurance Total Respondents n % Hearing back after signing up 6 54.5% Eligibility requirements and documentation status 6 54.5% Total** 11

5. Follow-up care and/or appointment Total Respondents n % Lack of understanding about next steps 6 50.0% No available follow-up appointments 4 33.3% Total** 12

Survey participants were also given the opportunity to elaborate on specific challenges and opportunities. The general comments and suggestions were:

Too much information

Understanding Medicare coverage

A need for referrals

Location of office not convenient to home. Too far to travel for covered health plan.

Demographics on senior health survey respondents can be found in Appendix R, Table 3.

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2016 CHNA: Prioritization Results

As detailed in Section 3: Methodology, the CHNA Committee applied the following five criteria to prioritize the four significant health needs (behavioral health, cardiovascular disease, Type 2 diabetes and obesity) in SDC:

1. Magnitude or Prevalence 2. Severity 3. Health Disparities 4. Trends 5. Community Concern

Using these criteria, a summary matrix translating the 2016 CHNA findings was created for review by the CHNA Committee. Through examination of the combined results and in review of all data, a clear ranking within the top four health needs emerged (Table 41 below).

Table 41: HASD&IC 2016 CHNA, Ranking Results from Quantitative Data Collection and Community Input

Behavioral Cardiovascular Diabetes Obesity Data Health Rank Disease Rank Rank Rank

1. Magnitude or Prevalence: 3.0 1.0 4.0 2.0

2. Severity: 2.0 1.0 3.0 4.0

3. Health Disparities: 1.0 1.0 1.0 1.0

4. Trends: 2.0 4.0 3.0 1.0

5. Community Concern: 1.0 3.3 2.7 3.0 Key Informants 1.0 2.0 3.0 4.0 Discussions 1.0 4.0 2.0 3.0 County HHSA 1.0 4.0 3.0 2.0 Average Ranking Among 5 1.8 2.1 2.7 2.2 Criteria

The CHNA Committee identified behavioral health as the number one health need in SDC. In addition, cardiovascular disease, Type 2 diabetes and obesity were identified as having equal importance due to their interrelatedness. Please see Figure 25.

Health needs were further broken down into priority areas due to the overwhelming agreement among all data sources and in recognition of the complexities within each health need. Within the category of behavioral health, Alzheimer’s disease, anxiety, drug and alcohol issues, and mood disorders are significant health needs within SDC.

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Among the other chronic health needs, hypertension was consistently found to be a significant priority area related to cardiovascular disease, uncontrolled diabetes was an important factor leading to complications related to diabetes, and obesity was often found to co-occur with other conditions and contribute to worsening health status. The impact of the top health needs differed among age groups; with Type 2 diabetes, obesity, and anxiety affecting all age groups, drug and alcohol issues affecting teens and adults, and Alzheimer’s disease, cardiovascular disease, and hypertension affecting older adults.

Figure 25: HASD&IC 2016 CHNA Top Health Needs

Behavioral Health Alzheimer’s disease, Anxiety, Drug & Alcohol Issues, Mood Disorders

Cardiovascular Disease • Hypertension

Type 2 Obesity Diabetes • Co-occurence w/ other • Uncontrolled chronic diabetes disease

A description of the impact of the prioritized health needs on the morbidity and mortality of SDC residents can be found in the full CHNA report. A complete analysis of disparities among different population groups with respect to the top four health needs can be found in the Vulnerable Populations Report (see Appendix D). In addition, Geographic Information System (GIS) maps were created, overlaying the rate of primary diagnosis for hospital discharge data with CNI data for the health needs: diabetes, cardiovascular disease, and behavioral health. GIS maps were not created for obesity due to the fact that obesity is not a common primary diagnosis but rather a secondary condition that contributes to the primary reason for a hospital visit. For the full HASD&IC 2016 CHNA or the GIS maps of hospital discharge rates and CNI data, please visit http://hasdic.org.

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As the HASD&IC 2016 CHNA process included robust representation from the communities served by SGH, the findings of the prioritization process also apply to the same four priority health needs identified for SGH (behavioral health, cardiovascular disease, Type 2 diabetes and obesity). In addition, SGH will continue to examine and address the health needs of seniors and community members impacted by cancer through its community health programming. Please refer to Section 6: Description of Identified Community Health Needs and Social Determinants of Health for additional information on the priority health needs identified for SGH.

To better understand the important barriers, modifiable risk factors, and potential strategies to address these health needs, please see the Social Determinants of Health section below.

Social Determinants of Health

In addition to the health outcome needs that were identified, social determinants of health were a key theme in all of the 2016 CHNA community engagement activities. Analysis of results from the community partner discussions and key Informant interviews revealed the most commonly associated social determinants of health for each of the top health needs above. Ten social determinants were consistently referenced across the different community engagement activities. The importance of these social determinants was also confirmed by quantitative data. Hospital programs and community collaborations have the potential to impact these social determinants, which are outlined in Figure 26 in order of priority.

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Figure 26: 2016 CHNA, Social Determinants of Health

• Cited most often as a social determinant of health across all Food Insecurity & Access to community engagement activities. Healthy Food • Lack of access to healthy food poses a challenge that contributes to diabetes and obesity.

• Overarching barriers to access included transportation, Access to Care or Services language barriers, health literacy, insurance coverage, cost, time, and legal status.

• Frequently mentioned as barriers to addressing health needs Homeless/Housing issues and improving health status, particularly behavioral health.

• For youth, concerns included decreased physical education, limited access to gyms and safe spaces for actitivities. Physical Activity • For seniors, lack of excercise was attributed to reduced mobility.

• Educational efforts on behavioral health & stigma reduction, Education/Knowledge food insecurity awareness and patient, caregiver, & family empowerment are needed to improve health.

• The changing demographics of San Diego County require a Cultural Competency culturally competent workforce.

• Transportation problems make it difficult to obtain services. Transportation • There are often no providers within a reasonable travel distance.

• Residents reported challenges understanding, securing and Insurance Issues using health insurance, which impede ability to access care.

• Frequently mentioned as a barrier that hindered individuals Stigma from seeking help with behavioral health. • Also mentioned with reference to seeking food assistance.

• Linkages between low-income levels and diabetes, obesity and cardiovascular disease were cited. Poverty • Behavioral health issues were mentioned as barriers to employment and financial stability.

Feedback from Sharp’s 2016 CHNA community engagement activities was also strongly aligned with these social determinants of health, particularly access to care, food insecurity and insurance issues.

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HASD&IC 2016 CHNA: Community Recommendations

Following the completion of the community engagement activities in the HASD&IC 2016 CHNA, all of the different types of feedback were combined and analyzed. Four key categories emerged: overarching strategies to address the top health needs; resources that must be increased or developed to meet the health needs; system, policy and environmental changes that could support better health outcomes; and possible collaborations to improve access and quality of care for vulnerable populations. The overarching recommendations are summarized in Figure 27 below.

Figure 27: HASD&IC 2016 CHNA, Summary of Community Recommendations

Strategies to address the top health needs fell into four major categories

Community and cultural Early identification and Care integration and Knowledge/education competency prevention coordination

Resources that must be developed or increased to address the top health needs

Integration Community and Behavioral health health/social After hours urgent Worksite wellness cultural competency services services/behaviora care l health systems

System, policies and environmental changes required to support better health outcomes

Reimbursement for Increased number of Increased awareness of social and supportive Data sharing psychiatrists and nurse available services services & care practitioners management

Collaborations that could improve community health outcomes

Warm hand-offs Increased Partnerships with and information internship and External support community Collaboration sharing between workforce training for providers collaboratives & between provider health providers & programs with through the use of Intergenerational and community community based local educational technology Partnerships organizations institutions

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Again, feedback from Sharp’s 2016 CHNA community engagement activities echoed many of these same suggestions, including increased staffing, care integration and coordination, community and cultural competency, etc. Please refer to the findings of SGH’s specific community engagement activities for details.

Although one of the recommendations references the need to add and develop additional services, we want to acknowledge that there are many excellent existing resources available to SDC residents. In order to provide an overview of the type and number of resources currently available to address the top health needs, a list of local assets was compiled using 2-1-1 San Diego’s Directory of Services (Appendix S). 2-1- 1 San Diego is an important community resource and information hub. Through its 24/7 phone service and online database, it helps connect individuals with community, health, and disaster services. Considering that available programs and services continuously change, the community is encouraged to access the most available data through 2-1-1 San Diego.

In addition to citing the resources available through 2-1-1 San Diego, a list of existing health initiatives and public policy efforts was also created. The next phase of this CHNA will likely include an expansion of the current list. Please refer to Section 7: Conclusion/Community Assets for additional information on this list of identified resources.

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Section Description of Identified Community Health Needs and 6 Social Determinants of Health

A description of the impact of the prioritized health needs on the morbidity and mortality of SDC residents is provided in the following pages. Mortality data was gathered by HHSA using the CDPH Statistical Master files for the year 2012. Morbidity was assessed using 2013 OSHPD hospital discharge data, the KP Data Platform, and other available community data sources. To better understand the important barriers, modifiable risk factors, and potential strategies to address these health needs, please see the Social Determinants of Health section.

For additional information about the top health needs identified through the HASD&IC 2016 CHNA (behavioral health, cardiovascular disease, Type 2 diabetes and obesity) please see the Health Need Profiles in Appendix T. A complete analysis of disparities among different population groups with respect to the top four health needs can be found in the Vulnerable Populations Report (see Appendix D).

Identified Community Health Needs

Behavioral Health Behavioral health is an important health need because it impacts an individual’s overall health status and is a comorbidity often associated with multiple chronic Mental Health can be defined conditions, such as diabetes, obesity and asthma. as “a state of complete physical, mental and social well-being, and not merely the Behavioral health encompasses many different areas absence of disease”.* including mental health, mental illness and substance Mental illness is defined as abuse. Because of its broadness, it is often difficult to “collectively all diagnosable capture the need for behavioral health services with a single mental disorders” or “health measure. conditions that are characterized by alterations in thinking, mood, or behavior An analysis of mortality data in SDC found that in 2013, (or some combination thereof) Alzheimer’s was the third leading cause of death and associated with distress intentional self-harm (suicide) was the eighth. In SDC’s east and/or impaired functioning”.* region, Alzheimer’s disease was the third leading cause of See the Health Need Profile in death. Hospital ED encounters and inpatient discharge data Appendix T for more details for SDC patients with a primary diagnosis of a behavioral health-associated ICD-9 code in 2013 was used to provide an overview of main reasons individuals sought care related to

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behavioral health by age group. A complete analysis of the behavioral health OSHPD data is available in the HASD&IC 2016 CHNA located at: http://hasdic.org.

A summary of the trends found were as follows:

 OSHPD ED discharge data: Anxiety disorders were the top primary diagnosis for ED discharge among those age 5 through 44 and those 65 and older. For those aged 45-64, the top ED discharge for behavioral health was alcohol-related disorders followed by anxiety and mood disorders. Alcohol related disorders was the number two primary diagnosis for discharge for those aged 15 through 44 and those 65 years and older.

 OSHPD inpatient discharge data revealed that when examining the ICD-9 codes related to behavioral health, ‘mood disorders’ was the top primary diagnosis for inpatient discharge for ages 5 through 24 and 45 and over. For those aged 25 through 44, the top behavioral health primary diagnosis was ‘schizophrenia and other psychotic disorders’ followed by ‘mood disorders.’

 Feedback from the behavioral health discussions found that high rates of psychotic discharges in ages 25 to 44 were likely linked to underlying substance abuse problems. Although participants agreed with the findings, it was found that hospital coding may potentially underrepresent the prevalence of underlying issues and miss certain conditions. Most notably missing from the OSHPD data was developmental disorders. The groups also pointed out the importance of emerging data trends. In recent years, discussion participants cited a significant increase in drug-related discharges, particularly meth-amphetamine (over 100 percent).

 Mental health issues and alcohol/drug abuse issues were consistently selected by the highest number of HHSA survey participants in all regions as health problems that have the greatest impact on overall community health. In addition, aging concerns including Alzheimer’s disease was cited among the top five most important health needs in all regions in SDC except the central region. The following categories were found to be important health needs within behavioral health in SDC:

o Alzheimer’s disease (seniors) o Anxiety (all age groups) o Drug and alcohol issues (teens and adults) o Mood disorders (all age groups)

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Anxiety: Anxiety is a normal reaction to stress but can become excessive, difficult to control, and ultimately interfere with normal day-to-day living.16 There are a wide variety of anxiety disorders including post-traumatic stress disorder, generalized anxiety disorder, panic disorder, and social anxiety disorder. National prevalence data estimates that 18 percent of the population has an anxiety disorder, with phobias and generalized anxiety being the most common. In SDC, there has been a steady increase in the rate of ED discharges with a primary diagnosis of anxiety. In particular, there has been a 64.2 percent increase in children up to age 14 from 25.0 per 100,000 in 2010 to 41.0 per 100,000 in 2013.

Substance Abuse: The Substance Abuse and Mental Health Services Administration (SAMHSA) defines substance use disorders as the recurrent use of alcohol and/or drugs which causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home.17 The percentage of adults age 18 and older in SDC who self-report heavy alcohol consumption (defined as more than two drinks per day on average for men and one drink per day on average for women) is 17.2 percent; additionally, 12.1 percent reported currently smoking cigarettes some days or every day according to the Behavioral Risk Factor Surveillance System (BRFSS). Acute substance abuse hospitalization rates increased 37.4 percent from 2010 to 2013 and increased most among 15-24 year olds (58.0 percent). Acute alcohol hospitalization rates grew most among 25-44 year olds with a 45.9 percent increase between 2010 and 2013. Finally, chronic alcohol ED visits among seniors age 65 and older increased 89.7 percent during the same time period.

Alzheimer’s disease: Alzheimer’s is the most common form of dementia although all dementias are characterized by a decline in memory, thinking skills, and ability to perform everyday activities.18 According to the 2015 San Diego County Senior Health Report19, roughly 60,000 individuals in SDC are living with Alzheimer’s disease or other dementia (ADOD) in 2012. It is projected that the number of SDC adults age 55 and older with ADOD will increase by 55.9 percent between 2012 and 2030. The largest majority of individuals live in the east region though the largest percentage increase is projected in the north central region. ADOD also affects caregivers physically and emotionally so significant increases in the number of people living with ADOD will have an impact that extends beyond those affected.

Mood Disorders: Mood disorders are particularly prevalent in the community and increasing. Data from the CMS show that among the fee-for-service population, 14.5 percent suffer from depression compared to 13.4 percent in California in 2012. In

16 Substance Abuse and Mental Health Services Administration. Mental Disorders. Retrieved from http://www.samhsa.gov/disorders/mental 17 Substance Abuse and Mental Health Services Administration. Substance Use Disorders. Retrieved from http://www.samhsa.gov/disorders/substance-use 18 Alzheimer’s Association. What is Alzheimer’s?. Retrieved from http://www.alz.org/alzheimers_disease_what_is_alzheimers.asp 19 County of San Diego, Health and Human Services Agency, Public Health Services, Community Health Statistics Unit. (2015).San Diego County Senior Health Report. Retrieved from www.SDHealthStatistics.com. Sharp Grossmont Hospital Community Health Needs Assessment Page 92

addition, an analysis of OSHPD data shows that the rate of ED discharges per 100,000 individuals with a primary diagnosis of mood disorders increased by 38.7 percent from 2010 to 2013 for children up to age 14; hospitalizations also went up by 26.8 percent in this age group. Mood disorders are often associated with comorbidities including diabetes, obesity and asthma. Suicide is also an indicator of poor mental health and is one of the major complications of depression. In SDC, the suicide rate according to the CDPH is 11.3 per 100,000 population which is above the state suicide rate of 9.8 per 100,000 (Table 42) and above the Healthy People 2020 (HP 2020) benchmark of 10.2 per 100,000 population. It is also the eighth leading cause of death in SDC. When adjusting for race/ethnicity, non-Hispanic whites are more likely to commit suicide followed by Native Hawaiian/Pacific Islander. Comparing suicide rates by race, non- Hispanic whites, black, Asian, Native Hawaiian/Pacific Islander, and those of multiple races were all above state levels. Please see Table 43 for additional trend data.

Table 42: Suicide Mortality and Poor Mental Health Indicators

San Diego County California United States

Poor Mental Healtha 12.75% 14.3% NA Suicide Mortality, Age-Adjusted Rate (per 11.29 9.8 NA 100,000)b HP 2020 Target for Suicidec <=10.2 <=10.2 <=10.2 aSource: University of California Center for Health Policy Research, California Health Interview Survey. 2011-2012. bSource: California Department of Public Health, CDPH – Death Public Use Data. University of Missouri, Center for Applied Research and Environmental Systems. 2010-2012. cSource: Healthy People 2020 . https://www.healthypeople.gov

Table 43: Mental Health SDC Trends over Time, 2009-2013

California Health Interview Survey Trends 2009 2011-2012 2012-2013

Serious psychological distress in the past year (Adults 18-64 years old)

% based on 6 questions, known as the “Kessler 6”, to assess symptoms of distress during a 30-day period in the past year. 5.3% 7.7% 7.6% Often used as a proxy measure for severe mental illness.

*Source: California Health Interview Survey, 2009, 2011-2012, and 2012-2013

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Cardiovascular Disease The World Health Organization defines cardiovascular disease ‘Diseases of the heart’ were the second leading cause (CVD) as a group of disorders of of death in SDC in 2013. In addition, ‘Cerebrovascular the heart and blood vessels that Diseases’ were the fourth leading cause of death, and include coronary heart disease, cerebrovascular disease, ‘Essential (primary) hypertension and hypertensive renal peripheral arterial disease, disease’ was the tenth. In SDC’s east region, ‘Diseases rheumatic heart disease, of the heart’ were the second leading cause of death, congenital heart disease, deep vein thrombosis and pulmonary ‘Cerebrovascular Diseases’ were the fourth leading cause of death, and ‘Essential (primary) hypertension and embolism.* hypertensive renal disease’ was the tenth. Coronary heart disease is the most common form of heart Hospital ED encounters, inpatient discharges, and clinic disease and the leading cause of utilization data for SDC patients with a primary death in the U.S. High blood diagnosis of a cardiovascular disease-related ICD-9 pressure, high cholesterol, and smoking are all risk factors that code in 2013 was analyzed in order to provide an could lead to CVD and stroke.* overview of the main reasons individuals sought care *See the Health Need Profile in related to cardiovascular disease by age group. A Appendix T for more details summary of the trends found were as follows:

 ‘Essential hypertension’ was the top primary diagnosis from the ED for ages 25 and up related to cardiovascular disease.  ‘Congestive heart failure; non-hypertension’ was the top primary diagnosis for inpatients ages 25 and older. Sixty-seven percent of inpatients discharged for a cardiovascular primary diagnosis had Medicare insurance.

The 2011-2012 CHIS estimates that 135,000 adults, or 5.8 percent of the adult population, in SDC have ever been told by a doctor that they have coronary heart disease or angina. Data gathered from North County Health Services, a local FQHC, found that ‘Hypertension Unspecified Essential’ ranked sixth out of the top eight primary diagnosis in 2014 among seniors and adults who visited their clinic.

Table 44 provides a summary of the quantitative data relevant to cardiovascular disease. While the mortality rates due to ischemic heart disease and stroke were lower for SDC than in California, the rate of death is still above the HP 2020 benchmark. Additionally, mortality rates for ischemic heart disease and stroke were particularly high for African Americans and Native Hawaiian/Pacific Islanders. Unmanaged high blood pressure is also a problem in SDC. According to the 2006-2010 BRFSS, roughly a third of adults reported that they are not taking medication for their high blood pressure. Please see Table 45 for additional hypertension trend data.

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Table 44: Cardiovascular Disease Indicators

San Diego United California County States

Percentage with Heart Diseasea 5.80% 6.30% NA Stroke Age-Adjusted Death Rate (per 32.8 37.38 NA 100,000)b Ischemic Heart Disease Age-Adjusted 148.27 163.18 NA Death Rate (per 100,000)b HP 2020 Target for Ischemic Heart Disease <=100.8 <=100.8 <=100.8 Death Ratec aSource: University of California Center for Health Policy Research, California Health Interview Survey. 2011-2012. bSource: CDPH – Death Public Use Data. University of Missouri, Center for Applied Research and Environmental Systems. 2010- 2012. cSource: Healthy People 2020 . https://www.healthypeople.gov

Table 45: Hypertension SDC Trends Over Time, 2009-2013

California Health Interview Survey Trends 2009 2011-2012 2012-2013

Ever diagnosed with hypertension (Adults 18-64 years old) % Diagnosed 26.3% 25.8% 26.4% *Source: California Health Interview Survey, 2009, 2011-2012, and 2012-2013

Finally, an assessment of health needs by HHSA region found that heart disease was cited as being among the top five most important health problems in the central, north central, and south regions. Additionally, high blood pressure was selected as a problem that has a substantial impact on overall community health in the north central region.

Hypertension was found to be a major contributor to poor cardiovascular disease- related outcomes and a significant area of need in SDC overall.

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Cancer In 2013 cancer was the leading cause of death in SDC’s east region, responsible for 23.8 percent of deaths. There were 908 deaths due to cancer (all sites) in SDC’s east region in 2013. The region’s age-adjusted death rate due to cancer was 172.9 deaths per 100,000 population, higher than the SDC age-adjusted rate of 155.6 deaths per 100,000 population.20

According to a 2016 report from the American Cancer Society, California Cancer Facts & Figures, cancer survival is more likely to be successful if the cancer is diagnosed at an early stage. Such diagnosis is an indication of screening and early detection. Regular screenings that allow for the early detection and removal of precancerous growths are known to reduce mortality for cancers of the cervix, colon, and rectum. Five-year relative survival rates for common cancers, such as breast, prostate, colon and rectum, cervix, and melanoma of the skin, are 93 percent to 100 percent if they are discovered before having spread beyond the organ where the cancer began. In 2013, the percentage of cancer cases diagnosed at an early age is lowest among African American women for breast and Hispanic males for prostate in SDC.

Although community members are impacted by a variety of cancers, the statistics below focus on two particular types of cancer: breast and prostate, given their distinction as the most common cancers among women and men (respectively), no matter their race or ethnicity. For statistics on additional types of cancer, please refer to the HASD&IC website at: www.hasdic.org. Further, resources provided in the community asset list in Section 7: Conclusion/Community Assets, address various types of cancer, beyond breast and prostate.

Breast Cancer

Breast cancer is defined as any cancerous growth that inhabits the tissues in the breast. Though breast cancer is mostly found in women, in rare cases it is also found in men. In the U.S. alone, one out of every eight women (12 percent) will develop this disease during their lifetime.

Not counting some kinds of skin cancer, breast cancer in the U.S. is the most common cancer in women, despite race or ethnicity. Compared to all deaths from cancer, breast cancer deaths are most common among Hispanic women; second most common among white, black, and Asian/Pacific Islander women; and third most common among American Indian/Alaska Native women.21 Table 46 presents breast cancer incidence in SDC.

20 County of San Diego HHSA, Public Health Services, Community Epidemiology Branch 21 https://www.cdc.gov/cancer/breast/statistics/

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Table 46: Age-Adjusted Breast Cancer Incidence (Rate Period 2009-2013)

Geographic Area Annual Incidence Ratea,b, (95% CI) United States 123.3 (123.1 – 123.5) California 121.4 (120.8 – 122.1) SDC 128.3 (125.8 – 130.7) Imperial County 100.7 (91.3 – 110.9) aIncidence Rates per 100,000 Population. bAdjusted rates are adjusted to 2000 U.S. Standard Population. Source: CDC's National Program of Cancer Registries Cancer Surveillance System November 2015 data submission and SEER November 2015 submission as published in United States Cancer Statistics.

SDC has higher breast cancer incidence rates for females (128.6 per 100,000) compared to California (122.0 per 100,000) and the U.S. (43.7 per 100,000).22 Although the incidence of breast cancer in white, non-Hispanic females is greater than that of black females, mortality rates among black females is much greater than that of white, non-Hispanic females. African American women have the highest death rates (27.7), followed by Caucasian women (23.9), Latina women (17.3), and then Asian/Pacific Islander women (13.2).23 Table 47 presents breast cancer mortality rates for SDC.

Table 47: Age-Adjusted Female Breast Cancer Mortality Rates, 2013

Geographical Area Death Ratea,b (%) United States24 20.7% California25 20.0% SDC26 20.1% San Diego Regions Central 16.3% East 19.7% North Central 20.7% North Coastal 18.8% North Inland 23.2% South 20.1%

HP 2020 Target 20.6%

D Death rates per 100,000 Population. bAdjusted rates are adjusted to 2000 U.S. Standard Population.

22 CDC's National Program of Cancer Registries Cancer Surveillance System November 2015 data submission and SEER November 2015 submission as published in United States Cancer Statistics. 23 2015 Susan G. Komen for the Cure® San Diego Affiliate Community Profile Report 24 U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2013 Incidence and Mortality Web- based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2016. Available at: www.cdc.gov/uscs. 25 U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2013 Incidence and Mortality Web- based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2016. Available at: www.cdc.gov/uscs. 26 County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology and Immunization Services Branch, California Department of Public Health, Center for Health Statistics, Office of Health Information and Research, Death Statistical Master Files; Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology and Immunization Services Branch, 3/4/14. SANDAG January 1 population estimates (2001-2013 estimate released January 2014)

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In 2013, 71.7 percent of white women in SDC were diagnosed with breast cancer at an early stage (stage 1) compared to 66.4 percent of African Americans, 69.7 percent of Hispanics, and 68.5 percent of Asian/Pacific Islanders.27 Detection in the earliest stages of breast cancer has a 99 percent survival rate. Data suggests that early detection resources were needed in minority communities, especially the African American and Hispanic communities. Table 48 below presents details on breast cancer diagnosis in SDC.

Table 48: Percent of Women Diagnosed with Breast Cancer at Early Stage (Stage 1)

Non-Hispanic Asian/Pacific African American Hispanic White Islander Cases % Early Cases % Early Cases % Early Cases % Early San Diego 1,837 71.7% 113 66.4% 495 69.7% 314 68.5% California 18,543 73.6% 2,037 65.1% 6,127 66.4% 4,507 71.5% Source: Cancer Facts and Figures, 2013. Reprinted in the Community Profile Report, Susan G. Komen for the Cure® San Diego Affiliate, 2015

Findings from the 2015 Susan G. Komen for the Cure® San Diego Affiliate Community Profile Report identified the following barriers for San Diego community members in accessing breast health care: cultural and language barriers; socioeconomic status, education and awareness; financial barriers including insurance, Health Maintenance Organization authorization, transportation and childcare; lack of self-care, fear of screening or other aspects of the medical system; homelessness and joblessness. The study findings indicate a critical need for culturally competent outreach, especially for Hispanic, Middle Eastern, and African American women. Community efforts should also focus on improving transportation and education to reduce fear and uncertainty.

Findings from the study also proposed the following recommendations from stakeholders and breast cancer survivors: increased advocacy and education including breaking down cultural and trust barriers and increasing breast health resource awareness; increased funding for services, particularly transportation and access to care for uninsured/undocumented and Health Maintenance Organization patients and screening; and increased knowledge and training for providers. In addition, the 2015 Susan G. Komen for the Cure® San Diego Affiliate Community Profile Report found the following barriers for the south region: cultural and socioeconomic factors, lack of awareness, and transportation. The focus group participants indicated that along with all of the barriers, social support systems are vital to recovery. Prostate Cancer

The NCI defines prostate cancer as a cancer that forms in tissues of the prostate, a gland in the male reproductive system found below the bladder and in front of the rectum.28 Prostate cancer usually occurs in older men, and in the U.S. and California, is

27 American Cancer Society, Inc., California Division and the California Cancer Registry of the California Department of Public Health. California Cancer Facts and Figures, 2016. Retrieved from: file:///C:/Users/sinan_000/Downloads/California%20Cancer%20Facts%20and%20Figures_ACS_2016_FF.pdf 28 http://www.cancer.gov/types/prostate

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the most common form of cancer in men (not counting certain forms of skin cancer). In 2013, 18,655 new cases of prostate cancer were diagnosed in California.29

Nationally, prostate cancer is the second most common cause of death from cancer among white, African American, and Hispanic men and the third most common cause of death from cancer among American Indian/Alaska Native men. Prostate cancer is more common in African American men. In addition, a man with a father, brother or son who has had prostate cancer is two to three times more likely to develop the disease himself.30 Tables 49 and 50 present incident and mortality data for prostate cancer in SDC.

Table 49: Age-Adjusted Prostate Cancer Incidence Rates, 2009-2013

Geographic Area Annual Incidence Ratea,b, (95% CI) United States 123.1 (122.8 – 123.3) California 118.7 (118.0 – 119.5) SDC 115.8 (113.2– 118.3) Imperial County 127.1 (115.7 – 139.3) aIncidence Rates per 100,000 Population. bRates are adjusted to 2000 U.S. Standard Population. Source: CDC's National Program of Cancer Registries Cancer Surveillance System (NPCR-CSS) November 2015 data submission and SEER November 2015 submission as published in United States Cancer Statistics.

Table 50: Age-Adjusted Prostate Cancer Mortality Rates, 2013

Geographical Area Death Ratea,b (%) United States31 19.2% California32 19.5% SDC33 22.7% San Diego Regions Central 21.3% East 21.5% North Central 23.0% North Coastal 22.7%

29 American Cancer Society, California Department of Public Health, California Cancer Registry. California Cancer Facts & Figures 2016. Oakland, CA: American Cancer Society, Inc., California Division; 2016. 30 CDC. Retrieved from: http://www.cdc.gov/cancer/prostate/basic_info/risk_factors.htm. 31 U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2013 Incidence and Mortality Web- based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2016. Available at: www.cdc.gov/uscs. 32 U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2013 Incidence and Mortality Web- based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2016. Available at: www.cdc.gov/uscs. 33County of San Diego Health and Human Services Agency (HHSA), Public Health Services, Epidemiology & Immunization Services Branch, California Department of Public Health, Center for Health Statistics, Office of Health Information and Research, Death Statistical Master Files; Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology and Immunization Services Branch, 3/4/14. SANDAG January 1 population estimates (2001-2013 estimate released January 2014)

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North Inland 21.9% South 26.7%

HP 2020 Target 28.8% aDeath Rate per 100,000 Population. bRates are adjusted to 2000 U.S. CDPH Department of Public Health, Center for Health Statistics, Office of Health Information and Research, Death Statistical Master Files; SANDAG January 1 population estimates (2001-2013 estimate released January 2014)

Patient Navigators

According to the American Medical Association, a patient navigator provides personal guidance to patients and families as they move through the health care system. According to a 2013 study published in the Journal of Clinical Oncology of newly diagnosed cancer patients, receiving support from a patient navigator led to higher satisfaction of care and fewer problems with psychological and social care, coordination of care, and health information.34 Patients reported feeling better emotionally, more involved in their care, more informed and better prepared for the future.35

According to the National Breast Cancer Foundation, Inc., patient navigation helps guide patients through and around barriers in complex health care systems to help ensure timely diagnosis, treatment and support. In addition, it was found that patient navigation is critical to survival and early detection.35

Type 2 diabetes Type 2 diabetes, once known as adult-onset or noninsulin- Type 2 diabetes is an important health need because of its dependent diabetes, is a chronic prevalence, its impact on morbidity and mortality, and its condition that affects the way preventability. An analysis of mortality data for SDC found the body metabolizes sugar that in 2013 ‘Diabetes mellitus’ was the seventh leading (glucose), which is the body's cause of death for SDC overall as well as for SDC’s east main source of fuel. With Type 2 diabetes, the body either resists region. The percentage of adults aged 20 and older who the effects of insulin — a have ever been diagnosed with diabetes was 7.2 percent in hormone that regulates the 2012 in SDC and has been steadily rising since 2005 movement of sugar into the cells according to the National Center for Chronic Disease — or doesn't produce enough Prevention and Health Promotion (Table 51). Type 2 insulin to maintain a normal glucose level. If left untreated, diabetes is an important target for intervention because Type 2 diabetes can be life- hospitalizations due to diabetes-related complications are threatening.* potentially preventable with proper management and a *See the Health Need Profile in healthy lifestyle. In San Diego, approximately 1.5 percent of Appendix T for more details discharges in the black patient population were attributable to diabetes compared to 0.7 percent of discharges among whites.

34 Nurse Navigators in Early Cancer Care: A Randomized, Controlled Trial. Published early online November 25, 2013 in Journal of Clinical Oncology. First author Edward H. Wagner, MD, MPH, Group Health Research Institute, Seattle, Wash. 35 The National Breast Cancer Foundation, Inc. http://www.nationalbreastcancer.org/breast-cancer- patient-navigator

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Hospital ED encounters, inpatient discharges, and clinic utilization data for SDC patients with a primary diagnosis of a diabetes-related ICD-9 code in 2013 was used to provide an overview of the main reasons individuals sought care related to diabetes by age group. A summary of the trends found were as follows:

 ‘Diabetes … Uncontrolled’ was the top inpatient primary diagnosis related to Type 2 diabetes for those age 15-24 and 45 and older. For individuals age 25-44, the top inpatient primary diagnosis was ‘Abnormal Glucose Tolerance of Mother with Delivery’ followed by ‘Diabetes…Uncontrolled.’

Data gathered from North County Health Services, a local FQHC, found that ‘Diabetes mellitus’ and ‘Abnormal glucose of mother antepartum’ ranked fourth and fifth respectively out of the top eight primary diagnosis in 2014 among seniors and adults who visited their clinic. Please see Table 52 for additional trend data.

Table 51: Diabetes Indicators

San Diego United California County States Population with Diagnosed Diabetes Age- 7.20% 8.05% 9.11% Adjusted Ratea Diabetes Age-Adjusted Discharge Rate (per 8.96 10.4 NA 10,000)b aSource: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2012. bSource: California Office of Statewide Health Planning and Development, OSHPD Patient Discharge Data. 2011.

Table 52: Diabetes SDC Trends over Time, 2009-2013

California Health Interview Survey Trends 2009 2011-2012 2012-2013 Ever diagnosed with diabetes (Adults 18-64 years old) % Diagnosed. Excludes ever been diagnosed with gestational 7.8% 7.9% 8.0% diabetes

*Source: California Health Interview Survey, 2009, 2011-2012, and 2012-2013

Finally, an assessment of health needs by HHSA region found that Type 2 diabetes was cited as being among the top five most important health problems in the central, east, north coastal and north inland regions. Uncontrolled Type 2 diabetes was found to be a major contributor to poor diabetes-related outcomes and a significant area of need in SDC overall.

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Obesity

Obesity is an important health need due to its high prevalence in the U.S. and SDC and although it is not a leading cause of death, it is a significant Obesity is a medical condition in which contributor to the development of other chronic excess body fat has accumulated to the conditions. extent that it may have an adverse effect on health. Overweight and obesity ranges are determined using weight and height to Adults: 36.3 percent of adults aged 18 and older calculate a number known as "body mass self-reported that they have a body mass index index" (BMI). * (BMI) between 25.0 and 30.0 (overweight) in SDC For adults: according to 2011-2012 BRFSS data (Table 53). An  BMI between 25 and 29.9 is additional 20.1 percent of adults aged 20 and older considered overweight. self-reported that they have a BMI greater than 30.0  BMI of 30 or higher is considered (obese) in SDC. The percentage of residents who obese. are obese was higher slightly among men (21.3 For children and adolescents (ages 2-19):  BMI at or above the 85th percentile percent) than women (18.8 percent). Excess weight and lower than the 95th percentile may indicate an unhealthy lifestyle and puts for children of the same age and individuals at risk for further health issues including sex is considered overweight th obesity, heart disease, diabetes, and other health  BMI at or above the 95 percentile issues. for children of the same age and sex is considered obese. Youth: FITNESSGRAM is the required physical *See the Health Need Profile in Appendix T for more details fitness test that school districts must administer to all California students in grades 5, 7, and 9. The percentage of children in grades 5, 7, and 9 ranking within the "health risk" category (overweight) for body composition on the FITNESSGRAM physical fitness test was 17.7 percent in SDC for the years 2013-2014. Furthermore, approximately 15.9 percent of children in grades 5, 7, and 9 were ranked within the "high-risk" category (obese). Rates of overweight and obese youth were highest among Hispanic/Latino and African American youth.

Obesity is largely categorized as a secondary diagnosis in hospital discharge data. An analysis of the primary diagnoses associated with a secondary diagnosis of an obesity- related ICD-9 code in 2013 was used to provide an overview of the main reasons individuals with abnormal weight seek care by age group. In addition, local program data were summarized to provide additional perspective on the impact of obesity on morbidity in SDC. A summary of the trends found were as follows:

 When examining inpatient hospital discharge data with obesity as a secondary diagnosis, it was found that the most common primary diagnosis of those patients were nonspecific chest pain in ages 25-64, abdominal pain for those ages 15-24, and for those over 65 years their primary diagnosis was osteoarthritis, septicemia followed by congestive heart failure.

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Local data from Palomar Health’s TODAY program demonstrated a decrease in the percentage of children screened who were obese in 2014 compared to 2008. While the program screens different youth each year, this decrease may represent a decreasing trend in childhood obesity, particularly in North County. Please see Table 54 for additional adult obesity trend data.

Table 53: Adult and Youth Overweight and Obese Indicators

San Diego California United County States

Percent Adults Overweighta 36.28% 35.85% 35.78%

Percent Adults with BMI > 20.10% 22.32% 27.14% 30.0 (Obese)b

Percent Youth Overweightc** 17.74% 19.30% NA

Percent Youth Obesec** 15.89% 18.99% NA aSource: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. 2011-2012. bSource: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 2012. cData Source: California Department of Education, FITNESSGRAM®; Physical Fitness Testing. 2013-2014. ** The thresholds for youth overweight and obese are based on the CDC's BMI-for-age growth charts, which define an individual as overweight when his or her weight is between the "85th to less than the 95th percentile".

Table 54: Obesity SDC Trends over Time, 2009-2013

2011- California Health Interview Survey Trends 2009 2012-2013 2012 Obese (Adults 18-64 years old)

Defined as body mass index (weight [kg]/height [m2]) greater than 21.9% 22.1% 23.1% or equal to 30.0 *Source: California Health Interview Survey, 2009, 2011-2012, and 2012-2013

Table 55 presents self-reported obesity prevalence rates for all SDC regions. SDC’s east region has the fourth-highest obesity prevalence rate when compared to the rest of the regions, and has a lower prevalence rate of obesity when compared to SDC overall.

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Table 55: Age-Adjusted Self-Reported Obesity Prevalence Rates, 2014

Geographical Area Prevalence Rate (%) United States36 37.9% California37 27.0% San Diego County22 24.8% Central 25.5% East 20.9% North Central 20.0% North Coastal 18.8% North Inland 31.3% South 33.2%

HP 2020 Target 30.5% aDeath Rate per 100,000 Population. bRates are adjusted to 2000 U.S. Standard Population. Source: California Department of Public Health, Center for Health Statistics, Office of Health Information and Research, Death Statistical Master Files; SANDAG January 1 population estimates (2001-2013 estimate released January 2014)

Finally, an assessment of health needs by HHSA region found that obesity was consistently cited as being among the top five most important health problems across all the regions, though it ranked highest in the east and south regions. Obesity and its contribution to other chronic and co-occurring diseases was found to be a significant area of need in SDC overall.

Senior Health

Older adults are among the fastest growing age groups in the U.S.38 In 2011, the first of more than 70 million baby boomers (adults born between 1946 and 1964) turned 65, and in the next two decades, another 79 million baby boomers will move into this demographic.23,39,40

In SDC overall, there were 416,568 residents (13.0 percent of the SDC population) aged 65 years or older in 2015.41 For every age group of adults aged 65 years or older in SDC, females outnumber males, with the proportion of females increasing with each

36 CDC Website: National Center for Health Statistics. 2013-2014. National Health and Nutrition Examination Survey. http://www.cdc.gov/nchs/data/hestat/obesity_adult_13_14/obesity_adult_13_14.htm . U.S. rate is calculated for ages 20 and older. 37 UCLA Center for Health Policy and Research. 2014 California Health Interview Survey. AskCHIS. http://ask.chis.ucla.edu/AskCHIS/tools/_layouts/AskChisTool/home.aspx#/geography. CA and SDC rates are calculated for ages 18 and older. 38 American Hospital Association; First Consulting Group. When I’m 64: How boomers will change health care. Chicago: American Hospital Association; 2007. 23 p 39 Baby Boomers Approach 65 – Glumly. Pew Research Center Social & Demographic Trends, 2010. 40 America’s Health Ranking Senior Report: A Call to Action for Individuals and Their Communities. United Health Foundation; 2013. 41 Speedtrack, Inc. US Census Bureau

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older age group. This trend is projected to continue through 2030.42 In 2015, 67.9 percent of seniors in SDC were white, while 16.1 percent were Hispanic.26 The percentage of white seniors in SDC is projected to decrease between now and 2030, primarily because of an increase in the number of Hispanic seniors (up to an expected 22.9 percent in 2030).43 Seniors made up 14.4 percent of the east region population (73,489 residents aged 65 or older) in 2015. Similar to SDC overall, white seniors outnumber seniors of all other race/ethnicities in the east region.44 Between 2015 and 2020 the east region’s senior population is expected to grow by 20.7 percent, lower than the growth rate of seniors for SDC overall (22.0 percent).29 In SDC, most seniors speak only English (69.3 percent) while 19.2 percent of seniors are unable to speak English very well.28

In 2013, 16.2 percent of SDC seniors aged 65 years or older were in the labor force – an increase from 2011– and the mean household income was $59,830. More than 49 percent of SDC seniors had no retirement income, 2.8 percent received Food Stamps/SNAP Benefits, and 1.5 percent received Cash Public Assistance Income. Moreover, 98.4 percent of SDC seniors had health insurance in 2013.45

In the east region in 2013, nearly 27 percent of seniors were 200 percent below the Federal Poverty Level (FPL).5 This is an increase of nearly four percent from the 2011 ACS study. See Table 56 for additional details on the older adult population in the east region.

Table 56: Older Adult Population of SDC’s, East Region (2013 ACS)

Total Population 65+ Years Old 63,901 Household Type Married-Couple Family 52.66% Family Household, No Spouse Present 14.40% Non-Family Household 4.03% Group Quarters 5.00% Male, Living Alone 7.38% Female, Living Alone 16.54% Poverty Percent Below 100% FPL 8.76% Percent Below 200% FPL 26.92% Source: 2013 County of San Diego HHSA, Public Health Services, Community Epidemiology Branch

42 County of San Diego, Health and Human Services Agency, Public Health Services, Community Health Statistics Unit. (2015). San Diego County Senior Health Report. 2015. 43 County of San Diego, Health and Human Services Agency, Public Health Services, Community Health Statistics Unit. (2015). San Diego County Senior Health Report. 2015. 44 Speedtrack, Inc. US Census Bureau 45 County of San Diego HHSA, Public Health Services, Community Health Statistics Unit Sharp Grossmont Hospital Community Health Needs Assessment Page 105

Adults age 65 and older are the largest consumers of health care services, as the process of aging brings upon the need for more frequent care.46 Seniors in SDC use the 9-1-1 system at higher rates than any other age group. In 2012, 71,655 calls were made to 9-1-1 for seniors in need of pre-hospital care in SDC, representing a call for one out of every five seniors.47

Seniors are at high-risk for developing chronic illnesses and related disabilities, and chronic conditions are the leading cause of death among older adults.48 Nationwide, about 80 percent of seniors are living with at least one chronic condition, while 50 percent of seniors have two or more chronic conditions, thus increasing their need for care.32,49

Significant health issues for seniors include obesity, diabetes mellitus, stroke, chronic lower respiratory diseases, influenza and pneumonia, mental health issues including dementia and Alzheimer’s disease, and cancer and heart disease, which were the top two leading causes of death for seniors in SDC in 2013.50,34 In addition, seniors are at high-risk for falls, which is the leading cause of death due to injury for San Diegan’s ages 65 and older.51 See Tables 57 – 59 for details on the leading causes of death for seniors in SDC.

Table 57: Leading Causes of Death for Ages 65-74 Years in SDC, 2013

Number of Percent of Total Cause of Death Deaths Deaths Malignant neoplasms 1,152 37.3% Diseases of heart 622 20.1% Chronic lower respiratory diseases 230 7.4% Cerebrovascular diseases 155 5.0% Diabetes mellitus 124 4.0% Accidents (unintentional injuries) 75 2.4% Alzheimer's disease 66 2.1% Chronic liver disease and cirrhosis 64 2.1% Intentional self-harm (suicide) 41 1.3% Parkinson’s disease 34 1.1% All other causes 525 17.0% Total Deaths 3,088 100.0%

Source: County of San Diego HHSA, Public Health Services, Community Epidemiology Branch

46 American Hospital Association; First Consulting Group. When I’m 64: How boomers will change health care. Chicago: American Hospital Association; 2007. 23 p. 47 County of San Diego, Health and Human Services Agency, Public Health Services, Community Health Statistics Unit. (2015). San Diego County Senior Health Report. 2015. 48 Centers for Disease Control and Prevention and The Merck Company Foundation. The State of Aging and Health in America 2007. Whitehouse Station, NJ: The Merck Company Foundation; 2007. 49 County of San Diego, Health and Human Services Agency, Public Health Services, Epidemiology & Immunization Services Branch 50 County of San Diego, Health and Human Services Agency, Public Health Services, Community Health Statistics Unit. (2013). San Diego County Senior Health Report: Update and Leading Indicators. 51 County of San Diego, Health and Human Services Agency, Public Health Services, Community Health Statistics Unit. (2012). San Diego County Senior Falls Report Sharp Grossmont Hospital Community Health Needs Assessment Page 106

Table 58: Leading Causes of Death in Ages 75-84 Years in SDC, 2013

Number of Percent of Total Cause of Death Deaths Deaths Malignant neoplasms 1,354 28.0% Diseases of heart 1,118 23.1% Chronic lower respiratory diseases 378 7.8% Alzheimer's disease 295 6.1% Cerebrovascular diseases 274 5.7% Diabetes mellitus 178 3.7% Parkinson's disease 98 2.0% Accidents (unintentional injuries) 89 1.8% Influenza and pneumonia 78 1.6% Essential (primary) hypertension and hypertensive renal disease 71 1.5% All other causes 897 18.6% Total Deaths 4,830 100.0% Source: County of San Diego HHSA, Public Health Services, Community Epidemiology Branch

Table 59: Leading Causes of Death for Ages 85+ Years in SDC, 2013

Number of Percent of Total Cause of Death Deaths Deaths Diseases of heart 2,311 30.6% Malignant neoplasms 1,067 14.1% Alzheimer's disease 914 12.1% Cerebrovascular diseases 532 7.0% Chronic lower respiratory diseases 367 4.9% Essential (primary) hypertension and hypertensive renal disease 204 2.7% Accidents (unintentional injuries) 179 2.4% Influenza and pneumonia 178 2.4% Diabetes mellitus 159 2.1% Parkinson's disease 110 1.5% All other causes 1,540 20.4% Total Deaths 7,561 100.0% Source: County of San Diego HHSA, Public Health Services, Community Epidemiology Branch

In 2012, 108,745 seniors were treated and discharged from SDC EDs, representing nearly one out of every three senior residents. In addition, 95,679 seniors aged 65 and over were hospitalized in SDC in 2012.52 SDC’s east region had the second-highest hospitalization rate for seniors when compared to other regions of SDC.53

52 2011 County of San Diego HHSA, Public Health Services, Community Health Statistics Unit 53 County of San Diego, Health and Human Services Agency, Public Health Services, Community Health Statistics Unit. (2015). San Diego County Senior Health Report. 2015. Sharp Grossmont Hospital Community Health Needs Assessment Page 107

In 2013, seniors in the east region experienced higher rates of hospitalization for falls, coronary heart disease, stroke, pneumonia, COPD, diabetes mellitus, Alzheimer’s disease and influenza when compared to SDC overall. Additionally, seniors in SDC’s east region experience higher ED discharge rates for falls, coronary heart disease, COPD and Alzheimer’s disease in comparison to SDC overall. Falls are a substantial reason for hospitalization and ED discharge among older adults, and San Diego hospitals emergently treat or admit two older adults for falls every hour.54

See Table 60 for hospitalization and ED discharge rates for important health issues among seniors in SDC and the east region.

Table 60: Hospitalization and ED Discharge Rates for Ages 65+ Years in SDC and the East Region (2013)

San Diego County East Region

Hospitalization ED Discharge Hospitalization ED Discharge Health Condition Rate Rate Rate Rate

Falls 1,916.1 4,386.2 2,012.4 4,686.9 Coronary Heart 1,004.3 149.6 1,067.2 184.6 Disease Stroke 1,158.9 300.4 1,352.1 269.1 Pneumonia 828.7 357.9 959.3 353.6 Chronic Obstructive 510.4 596.6 737.0 669.7 Pulmonary Disease Diabetes Mellitus 313.1 347.5 389.6 323.9 Alzheimer’s Disease 208.4 183.8 261.3 217.5 Influenza 126.1 95.8 129.8 84.5 Source: County of San Diego HHSA, Public Health Services, Community Epidemiology Branch

Care at the end of life is another critical issue for the senior population. End of life is when health care providers anticipate a patient’s death within approximately six months.55 According to a 2012 survey, 70 percent of Californians would prefer to die at home. However, new data shows that compared to the national average, Californians at the end of life experience more deaths in hospitals and spend more time in the ICU than at home – these aggressive forms of care are not considered beneficial to dying patients. The data also revealed wide variation across California regions and hospitals in the use of hospice, hospital and ICU services during the last six months of life. Factors such as age, sex, race and level of education are likely to affect whether patient

54 County of San Diego, Health and Human Services Agency, Public Health Services, Community Health Statistics Unit. (2012). San Diego County Senior Falls Report 55 What Are Older Adults Mental Health Needs Near the End of Life? American Psychological Association, 2013. http://www.apa.org/pi/aids/programs/eol/end-of-life-factsheet.aspx

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treatment preferences are followed, while differences in medical culture and the availability of medical resources across hospitals and regions can strongly determine the level of care that is delivered.56

Improving the quality and availability of medical and social services for patients and their families could not only enhance quality of life through the end of life, but may also contribute to a more sustainable care system. The number of older Americans with some combination of frailty, physical and cognitive disabilities, chronic illness and functional limitations is rapidly increasing. The U.S. population is also quickly becoming more culturally diverse, increasing the need for responsive, patient-centered care. In addition, America’s health care system is increasingly burdened by factors that hamper the delivery of high-quality care near the end of life, including but not limited to barriers in access to care that disadvantage certain groups, and misalignment between the services patients and families need and those they can obtain.57

The Institute of Medicine has identified a need for public education and engagement about end-of-life planning at several levels, including: the societal level, to build support for public and institutional policies that ensure high-quality, sustainable care; the community and family levels, to raise awareness and elevate expectations about care options, the needs of caregivers, and the hallmarks of high-quality care; and the individual level, to motivate and facilitate advance care planning and meaningful conversations with family members and caregivers.41

Hospice care is considered the model for quality compassionate care for people facing a life-limiting illness. Hospice provides expert medical care, pain management, and emotional and spiritual support that is tailored to the patient’s needs and wishes. There has been substantial growth in the number of hospice programs and patients served over the last decade. In 2014, an estimated 1.6 to 1.7 million patients received services from hospice. More than half of these patients were female, approximately 84 percent were 65 years of age or older (with 41.1 percent being 85 years or older), and approximately 93 percent were of non-Hispanic or Latino origin. Non-Caucasian patients accounted for approximately one-quarter of hospice patients.58

In addition, it is critical to provide resources and support to caregivers of older adults. An estimated 34.2 million American adults have served as an unpaid caregiver to someone age 50 or older in the prior 12 months.59 Today, families remain the most important source of assistance and support to loved ones with a chronic illness or disability.60 Those caring for a close relative, such as a spouse or parent, are at a much

56 End-of-Life Care in California: You Don’t Always Get What You Want. California Healthcare Foundation, 2013. http://www.chcf.org/topics/end-of-life-and-palliative 57 Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Institute of Medicine. 2014. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2014/EOL/Report%20Brief.pdf 58 NHCPO’s Facts and Figures: Hospice Care in America 2015 Edition. National Hospice and Palliative Care Organization. 2015. http://www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Figures.pdf 59 Caregiving in the United States 2015. National Alliance for Caregiving and AARP Public Policy Institute. 2015. http://www.aarp.org/content/dam/aarp/ppi/2015/caregiving-in-the-united-states-2015-report-revised.pdf 60 Valuing the Invaluable: 2011 Update The Growing Contributions and Costs of Family Caregiving. Lynn AARP Public Policy Institute. http://assets.aarp.org/rgcenter/ppi/ltc/i51-caregiving.pdf

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greater risk of declining health as a result of caregiving.61 One in three caregivers of someone age 50 or older says a health care provider, such as a doctor, nurse, or social worker, has asked about what was needed to care for their recipient, while only 16 percent say a health care provider has asked what they need to care for themselves.45 More than eight out of ten of these caregivers say they could use more information or help on caregiving topics, including keeping their loved one safe at home and managing their own stress, while one in four would like more information about making end-of-life decisions.45 In addition, one in four caregivers report it is very difficult to get affordable care services in their loved one’s community to help with their care.45

Social Determinants of Health

Food Insecurity and Access to Healthy Food Food insecurity and access to healthy food were cited most often as a social determinant of health across all community engagement activities. In addition, high levels of food insecurity and the food environment in SDC supports this as an important social determinant of health. An unhealthy diet was among the most commonly cited modifiable risk factors for the top identified health needs. Community discussion participants stated that lack of access to healthy food, including availability and cost, continue to pose a challenge that contributes to diabetes and obesity. Education, cultural practices, and transportation also play an important role in diet and food access. Key informant interview participants stated that inexpensive ‘junk food,’ food access/food insecurity issues, and food assistance stigma were perpetuating forces that increased the onset of chronic diseases such as diabetes, obesity and cardiovascular disease. According to 2014 CHIS data, 38.1 percent of adults with an income less than 200 percent of the FPL in SDC were food insecure, defined as not being able to afford enough food. Conversely, only 17.7 percent of adults reported currently receiving Cal Fresh benefits. In addition, SDC has more fast food restaurants per 100,000 population in 2012 than both California and the U.S. (81.9 vs 74.5 and 72.0 respectively) according the U.S. Census Bureau County Business Patterns.

Access to Care or Services Access to care was cited as an important social determinant of health throughout the community engagement activities and is supported by quantitative data which demonstrates shortages of health care services in and around SDC. Overarching access to care barriers that were highlighted during community partner discussions included issues with transportation, language barriers, health literacy, insurance coverage, cost, time, and legal status. Transportation and insurance issues were specifically called out separately as important social determinants of health and are described further below. Both discussion and survey participants stated that knowing where to go for care was also a factor that impacted access to care. Key informants

61 Caregiving in the United States 2015. National Alliance for Caregiving and AARP Public Policy Institute. 2015. http://www.aarp.org/content/dam/aarp/ppi/2015/caregiving-in-the-united-states-2015-report-revised.pdf Sharp Grossmont Hospital Community Health Needs Assessment Page 110

highlighted that certain populations are struggling to access services as they need them, and that access to ‘good’ services, defined as a provider where the patient feels comfortable and understood, were important for increased compliance. Overburdened case managers and lack of access to clinics, primary care providers, and specialists including psychiatrists were also areas of concern. Fragmentation of care and lack of available placements for behavioral health patients are additional problems that were described during key informant interviews. Qualitative data shows that roughly 15.4 percent of the SDC population is living in a geographic area designated as a "Health Professional Shortage Area" by the U.S. Health Resources and Services Administration. This is defined as having a shortage of primary medical care, dental or mental health professionals.

Homeless/Housing Issues Housing and homelessness is an important social determinant of health in SDC with both quantitative and community input pointing to a continued problem. According to 2015 Point-in-Time counts, the homeless population in SDC is the fourth highest in the U.S. at 8,742 individuals. Key informants highlighted that homelessness and housing issues are barriers to the successful treatment of health needs, and that this is particularly true of behavioral health. Key informants pointed out that individuals often do not have the resources to get off the street and treat mental illness. Of the unsheltered homeless in SDC, the 2015 WeALLCount report estimates that 17 percent have problems with substance/alcohol abuse and 19 percent self-reported having severe mental illness, defined as a mental illness that is severe, long term, and inhibits their ability to live independently. The homeless population also has unique challenges that may prevent them from accessing care; discussion participants found that individuals who are involved with programs often struggle to get proof of their appointment and stated that long wait times can negatively impact their status in the program. Finally, discussion participants emphasized the importance of meeting basic needs first including housing, a safe environment, sleep and food.

Physical Activity Lack of physical activity in children and adults was revealed as a major social determinant of health during the community engagement activities. The prevalence of physical inactivity was confirmed by quantitative data, supporting a need to increase adult and youth physical activity. Community input elaborated on the specific challenges faced in the SDC area related to physical activity. Based on key informant interviews, lack of exercise was attributed to decreased mobility in seniors, decreased physical education for youth, and limited access to gyms, resources, and safe spaces to participate in physical activity. Discussions with community partners highlighted that physical education avoidance among youth also contributes to physical inactivity. According to the CDC’s National Center for Chronic Disease Prevention and Health Promotion, 14.9 percent of adults in SDC aged 20 and older self-reported that they perform no leisure time physical activity in 2012. For youth, results of the FITNESSGRAM physical fitness test show that 29.4 percent of children in grades 5, 7,

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and 9 ranked within the "High-Risk" or “Needs Improvement” zones for aerobic capacity for the 2013-2014 year.

Education/Knowledge Education in some capacity was mentioned during all community engagement activities and is supported by quantitative data which shows disparities in educational attainment across SDC regions. Community input provided insight into important areas related to education that drive poor health outcomes and could be targeted in future health programs. Based on information gathered from key informant interviews and community partner discussions, educational efforts focused on behavioral health and stigma reduction, food insecurity awareness (for both providers and residents), and patient, caregiver, and family empowerment would have a positive impact on health. In addition, modified messaging based on culture and literacy level is important. Within SDC, almost 15 percent of the total population aged 25 and older have no high school diploma (or equivalency) or higher based on 2013 ACS data. An assessment of educational attainment by SDC region found that the percentage of adults who had less than a high school diploma were highest in the south (22.4 percent) and central (21.1 percent) regions and lowest in the north central region (5.7 percent).

Cultural Competency Cultural competency was reiterated as a social determinant of health across all community engagement activities. In addition, quantitative data highlights the changing demographics of the population in SDC and the need for a culturally competent workforce. Cultural competence in health care can be described as “the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs.” In order to understand the cultural needs of the community, it is important to consider the changing demographics of the population, potential language barriers, and how different cultural practices and lack of cultural competency in health care drives disparities in health outcomes.

Among community partners, low motivation and health literacy were cited as behavioral factors that contribute to poorer health outcomes. Key informant interviews also illuminated strategies for improvement that would help eliminate disparities. These strategies included: understanding the environment patients are coming from and their ability to comply with treatment plans; increasing provider comfort and knowledge working with different populations and their needs; providing culturally and linguistically appropriate services, including accessible interpreter services; developing trusting relationships between providers and patients; and diversifying of staff and social workers in the community.

Quantitative data shows a dramatic change in demographics in the SDC population. According to the U.S. Census Bureau Decennial Census, between 2000 and 2010, SDC has experienced a 32.0 percent increase in the Hispanic population and a change in composition by race where the greatest percentage increases were among Asians (34.5

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percent), followed by individuals of multiple races (20.1 percent). Changes in racial and ethnic composition also points to potential language barriers. From this information, it can be determined that there is a significant need for a diversified health care workforce.

Transportation Transportation was cited as a social determinant of health across different community engagement activities. More specifically, transportation was mentioned as a problem that made it difficult to obtain services and that too few practitioners and distance to services heighted the problem. Transportation issues also impacted access to healthy foods. Discussion participants highlighted the need for better Medi-Cal education on which plans have available services to better meet their transportation needs. According to 2010-2014 ACS estimates, roughly 6.1 percent, or 66,596, of households in SDC have no motor vehicle. Households without access to a vehicle may lack access to health care or other services that may improve health.

Insurance Issues The percentage of the population without insurance is a powerful predictor of health that was cited as a continued problem within SDC during the community input activities. Insurance issues were found to be the cause of three out of five of the top barriers to accessing care according to the 2016 CHNA Health Access and Navigation Survey. Residents reported challenges understanding insurance, getting insurance, and using health insurance which impeded their ability to access care. Within these categories, survey participants stated that confusing insurance terms, knowing how to pick a plan, and knowing what services are covered were the top problems they faced. These sentiments were echoed in the key informant interviews and community partner discussions. Key informants stated that many individuals don’t understand their benefits, including what’s available or how to access it. Others stated that lack of insurance and affordability remain problems in certain groups in SDC and that it resulted in the delay of medication. Discussion participants cited that a lack of understanding of covered benefits and fear of hidden costs plays a key role in the decision to seek care. In addition, current coverage may not be sufficient to meet specific needs, including behavioral health treatment.

According to the ACS, the uninsured rate in SDC decreased from 16.3 percent in 2013 to 12.3 percent in 2014 following the implementation of the Affordable Care Act. While it is important to recognize the proportion of uninsured individuals that remain, as more people become insured, it will become increasingly more important to address challenges individuals face with their insurance.

Stigma The CDC defines stigma as “the prejudice, avoidance, rejection and discrimination directed at people believed to have an illness, disorder or other trait perceived to be undesirable.” The CDC describes the negative consequences of stigma as “needless

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suffering, potentially causing a person to deny symptoms, delay treatment and refrain from daily activities. Stigma can exclude people from access to housing, employment, insurance, and appropriate medical care”.62 Stigma was mentioned in two contexts during the community engagement activities – behavioral health stigma and food assistance stigma. Strong stigma associated with behavior health was a frequently mentioned barrier that hindered individuals from seeking help. Discussion participants stated that fear of that disclosure resulting in repercussions such as job loss also creates a barrier to accessing needed care for behavioral health issues. Reducing stigma related to mental health, building relationships with patients, and teaching families about the signs and symptoms of mental health issues were important concepts expressed during community partner discussions. Community residents may also experience stigma that prevents them from accessing needed food assistance. Discussion participants found that some individuals may not give the correct answer when asked if they need food. Working on different ways to ask or refer individuals to food assistance programs that avoids confusion or embarrassment was suggested by participants as a way to decrease the stigma barrier. According to a study conducted by Sarkin et al., who examined 2009 data on individuals who had used mental health services in SDC, 89.7 percent reported experiencing some type of discrimination with relation to their mental health problems.63

Poverty

Poverty is one of the most powerful predictors of population health. Community input activities cited poverty as a continued problem within SDC as well as data from the ACS showing disparities by race and ethnicity. Key informants highlighted the link between Type 2 diabetes, obesity and cardiovascular disease as it related to low-income individuals and families. Behavioral health issues were also mentioned as a barrier to employment and financial stability. In addition, key informants emphasized that prevention is hard for those living in poverty. During community partner discussions, participants described the impact of poverty on their clients’ ability to manage their chronic conditions. Lifestyle change and treatment for chronic conditions can be unaffordable for individuals and families living in poverty. For example, for many low- income families healthy food options are not readily available or are unaffordable. In addition, low-income families often struggle to purchase medications even when utilizing insurance. Data from the ACS found that within SDC between 2009 and 2013, 14.5 percent or 441,648 individuals were living in households with income below 100 percent of the FPL. An analysis of poverty by race and ethnicity showed that a greater proportion of Latinos, African Americans, Native Americans, and individuals of some other race were in poverty compared to the overall SDC population. For children 0-17, the percentage living 100 percent below the FPL (which for a family of three is $20,090 per year) increases to 18.8 percent. Poverty creates barriers to accessing services that

62 Centers for Disease Control and Prevention, Mental Health. Stigma and Mental Illness. http://www.cdc.gov/mentalhealth/basics/stigma-illness.htm. Accessed May 2016. 63 Sarkin, A. , Lale, R. , Sklar, M. , Center, K. , Gilmer, T. , et al. (2015). Stigma experienced by people using mental health services in san diego county. Social Psychiatry and Psychiatric Epidemiology, 50(5), 747-756. DOI 10.1007/s00127-014-0979-9

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promote well-being including health services, healthy food, and other necessities that contribute to improved health status.

Data Limitations and Information Gaps: The 2016 CHNA Process

Limitations of 2016 CHNA processes for both SGH and the collaborative HASD&IC effort are discussed here, in order to potentially benefit future CHNA processes and reports.

Regarding the collaborative HASD&IC 2016 CHNA process, the KP data platform utilized in the initial quantitative data analysis includes approximately 150 secondary indicators that provide timely, comprehensive data to identify the broad health needs faced by a community. However, there are some limitations with regard to these data, as is true with any quantitative data. Some data were only available at a county level, making an assessment of health needs at a neighborhood level challenging. Furthermore, disaggregated data around age, ethnicity, race, and gender are not available for all data indicators, which limited the ability to examine disparities of health within the community. Lastly, data are not always collected on a yearly basis, meaning that some data are several years old.

In order to offset these limitations, additional health data was collected and utilized. This data included SDC hospital data, county mortality data, health indicators from the CHIS, clinic data, and vulnerable population data. In order to gain an in-depth look into smaller communities, the collaborative partnered with local community organizations to obtain regional and local neighborhood data.

To conduct a comprehensive CHNA, a mixed method approach was required, including the collection and analysis of quantitative data and community input from a variety of sources. The collaborative 2016 CHNA process involved conducting 19 key informant interviews, conducting seven community partner discussions, three behavioral health discussions, and collecting 235 Health Access and Navigation Surveys from community residents which provided a large volume of comprehensive community input. One limitation to the 2016 CHNA process was that the population and disease-specific key informant interviews may not have captured all of the challenges faced by the groups represented. Additionally, while there was representation from all regions and ethnicities based on the participants who completed the survey, smaller sample sizes among certain groups may limit its generalizability to subsections of the population.

Similarly, while community partner discussions were chosen to be as representative as possible of high need communities in SDC, due to time constraints only seven dialogues were completed as part of the assessment. These included high need neighborhoods identified in the CNI data. While these dialogues were only held in seven locations, there was representation from many additional cities due to the recruitment of participants from different SDC communities. Given the existence of regional

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differences and population-specific challenges, these seven discussions may not be completely representative of SDC or of high need neighborhoods as a whole.

Additionally, the age of the data used throughout this CHNA process is worth noting as a limitation. Much of the quantitative data used in both the HASD&IC and SGH 2016 CHNA processes was based on a number of different sources at the state and county level, often over different time periods that were not current to 2013. For example, the most recent period available for hospital discharge data used in the report was CY 2013, and more current data (2014) will not be available until later in 2016.

Relatedly, lack of obesity data at the ZIP code level demonstrates another limitation. This lack of data presents an obstacle for community programs designed to target the issue of obesity within specific communities below the county level. To help reduce the impact of this limit, data and statistics regarding obesity-related illnesses (e.g., diabetes, cardiovascular disease) are included in this CHNA.

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Section

7 Conclusion/Community Assets

The results of this CHNA revealed significant priority health needs impacting communities served by SGH, particularly those most vulnerable communities, as well as provided insight from direct conversations with the community. These findings will assist in the design and implementation of community benefit efforts provided at SGH for its community members.

Community Assets

Assets, capacities and resources within a community are integral to addressing the full spectrum of health needs that exist in the population. In recognition of the various levels of intervention and health improvement, the community assets (i.e., programs, initiatives and organizations) that are currently available to address the top health needs are separated based on the following categories:

 Programmatic and/or organizational resources  Health initiatives and public policy

2-1-1 San Diego is an important community resource and information hub. Through its 24/7 phone service and online database, it helps connect individuals with community, health, and disaster services. Considering that available programs and services continuously change, the community is encouraged to access the most available data through 2-1-1 San Diego. In order to provide an overview of the type and number of resources currently available to address the top health needs, a list of local assets were compiled using on 2-1-1 San Diego’s Directory of Services (Appendix S).

Data was pulled by searching the 2-1-1 San Diego taxonomy using relevant search terms for each condition. The number of resources that were located for each condition were as follows:

 Behavioral Health (190),  Diabetes (118),  Obesity (382), and  Cardiovascular Disease (161).

Please note, this is an assessment of the type and number of services available as of February 2016 but it is not an exhaustive list of resources available in SDC. Due to the interconnectedness of chronic conditions, organizations and programs may be repeated if they provide more than one service and if they are located in more than one location. For more specific information about the programs within each category, please contact 2-1-1 San Diego or visit their website at: http://www.211sandiego.org.

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In addition to the resources available at 2-1-1 San Diego there are community and countywide initiatives, partnerships, collaborations, and public policy that address the top health needs (Table 61 below). Please note this is a survey of local assets and is not an exhaustive list of the initiatives, partnerships, collaborations, or public policy available in SDC.

Table 61: HASD&IC 2016 CHNA - SDC Initiatives, Partnerships, Collaborations and Public Policy that Address Behavioral Health, Cardiovascular, Diabetes, and Obesity

Health Initiatives Website Be There San Diego, Preventing Heart Attacks and http://betheresandiego.org Strokes http://www.chcf.org/~/media/MEDIA%20LIBRARY% California’s Health Care Coverage Initiative 20Files/PDF/PDF%20C/PDF%20CountyIndigentCareIn itiative.pdf http://www.sdchip.org/initiatives/suicide- CHIP Suicide Prevention Council prevention-council.aspx

Chula Vista Community Collaborative http://chulavistacc.org https://healthykidshealthyfuture.org/links/san- Farm to School Taskforce diego-county-school-taskforce/ HASD&IC Behavioral Health Continuum of Care http://hasdic.org/

Healthy Chula Vista Initiative http://www.chulavistaca.gov

Healthy Weight Collaborative http://www.ncbi.nim.nih.gov It's Up to Us Campaign http://www.up2sd.org/ Live Well Food System Initiative http://www.livewellsd.org/ Live Well San Diego http://www.livewellsd.org/ National Diabetes Prevention Program (National http://www.cdc.gov/diabetes/prevention/index.htm

DPP) l Regional Continuum of Care Collaborative http://www.sandiegococ.org/ https://www.cdph.ca.gov/programs/cpns/Pages/Ret Re-Think Your Drink

hinkYourDrink-Resources.aspx http://www.sandag.org/index.asp?projectid=404&fu Safe Routes to School

seaction=projects.detail San Diego County Childhood Obesity Initiative

http://ourcommunityourkids.org (COI) San Diego County Stroke Consortium (HHSA and http://search.usa.gov/search?utf8=%E2%9C%93&affi San Diego County hospitals) liate=cosd&query=stroke+consortium San Diego Family Military Collaborative http://sdmilitaryfamily.org/ San Diego Food System Alliance http://www.sdfsa.org/ http://www.sandiegocounty.gov/content/sdc/hhsa/ The Alzheimer's Project (HHSA) programs/phs/community_health_statistics/Alzheim

ers.html

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Sharp conducted additional research to identify community assets that address senior health and cancer in the community, which are detailed on the following pages.

Note: Please note this is a survey of local assets and is not an exhaustive list of those resources available in SDC. The resources were gathered based on responses to a question in the electronic survey asking the health experts and community leaders to provide information on assets for each condition they addressed in their response.

The health care safety net in SDC is highly dependent upon hospitals and community health clinics to care for the uninsured and medically underserved communities. Finding more effective ways to coordinate and enhance the safety net is a critical policy challenge. Hospitals and their community partners will use this list to identify gaps in regions and neighborhoods.

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COMMUNITY ASSET LIST:

I. CANCER

 Every Woman Counts Every Woman Counts provides free clinical breast exams, mammograms, pelvic exams, and Pap tests to California’s underserved women. The mission of Every Women Counts is to save lives by preventing and reducing the devastating effects of cancer for Californians through education, early detection, diagnosis and treatment, and integrated preventive services, with special emphasis on the underserved. Every Woman Counts is part of the Department of Health Care Service's Cancer Detection and Treatment Branch.

Address San Diego & Imperial Counties Regional Contractor 1625 E. Shaw Avenue Fresno, CA 93711-3504 Phone 844-496-6366 or 800-511-2300 for general information Email NA Website http://www.dhcs.ca.gov/services/Cancer/ewc/Pages/default.aspx

 Reach to Recovery, American Cancer Society, Border Sierra Region (Offers Education and Screening Services)

Provides trained volunteers to assist women in adjusting emotionally and physically before and after breast cancer treatment. Volunteers provide peer- to-peer moral support and mentorship, as well as information about resources. Services are provided on a one-to-one basis, in the hospital, over the phone, or at home.

Address 2655 Camino del Rio North, Suite 100 San Diego, CA 92108 Phone 800-227-2345 Email NA Website www.cancer.org or http://www.cancer.org/myacs/california/areahighlights/patient- support

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 Man To Man, American Cancer Society, Border Sierra Region Provides community-based education and support to men with prostate cancer and their family members. Peer support for prostate cancer patients and their caregivers include one-on-one visitations and support and self-help groups, which are led by a trained facilitator. Address 2655 Camino del Rio North Suite 100 San Diego, CA 92108 Phone 800-227-2345 or 619-682-7410 Email NA Website www.cancer.org or http://www.cancer.org/myacs/california/areahighlights/patient- support

 Informed Prostate Cancer Support Group, Inc.

The Informed Prostate Cancer Support Group comprises both men and women, survivors, newly diagnosed and people who want more information about prostate cancer and treatments. The monthly support groups are open to the public to join. The group’s goal is to raise awareness and provide mentorship and resources.

Address P.O. Box 420142 San Diego, CA 92142 Phone 619-890-8447 Email [email protected] Website www.ipcsg.org

 Prostate Cancer Research and Education Foundation

The Prostate Cancer Research and Education Foundation is a research and education foundation dedicated to empowerment of prostate cancer patients through education and support. The foundation is committed to fundraising to support prostate cancer research. Periodic support groups offer a space for both survivors and spouses with peer support, coaching and information regarding prostate cancer treatments.

Address Alvarado Hospital 6655 Alvarado Road San Diego, CA 92120 Phone (619)-906-4700 Email [email protected] or [email protected] Website www.pcref.org

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 San Diego LGBT Community Center: Prostate Cancer Support Group

A group to support members of the LGBT community who are dealing with prostate cancer.

Address San Diego LGBT Community Center 3909 Centre Street San Diego, CA 92103 Phone 619-692-2077

Email [email protected] Website http://www.thecentersd.org/programs/mens-services/

 Leukemia & Lymphoma Society: Family Support Group

The Family Support Groups are designed to offer emotional support and education throughout your cancer journey. Under professional guidance, patients and family members can discuss their anxieties and concerns with others who share a similar experience. This sharing opportunity facilitates improved communication and helps enhance the ability to cope with a cancer diagnosis. Please join us for informative discussions and have your concerns addressed by survivors, family members, and trained facilitators. Our groups are designed for both patients and their family members.

Address The Leukemia & Lymphoma Society 9150 Chesapeake Drive, Suite #100 San Diego,CA 92123 Phone 858-277-1800

Email NA Website https://www.lls.org/

 Sharp Grossmont Hospital: Breast Cancer Support Group

This is a free support group for women with breast cancer. At the group, women can share their concerns and experiences of living with breast cancer and exchange ideas to discover new coping strategies in a friendly, informational atmosphere. The support group is open to women in all stages of breast cancer — from recent diagnosis to treatment to cancer survivor — but is not meant for those with metastatic disease.

Address Long Cancer Center 5555 Grossmont Center Drive La Mesa, CA 91942 Phone 1-800-82-SHARP

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Email NA Website www.Sharp.com

 Sharp Grossmont Hospital: Lung Cancer Support Group

This monthly support group is designed to meet the educational and emotional needs of people living with or caring for someone with lung cancer. It offers encouragement and hope in a safe environment to explore important issues that matter when coping with any phase of treatment for this disease. Registration is required prior to attending.

Address Long Cancer Center 5555 Grossmont Center Drive La Mesa, CA 91942 Phone 1-800-82-SHARP Email NA Website www.Sharp.com

 Sharp Grossmont Hospital: Art and Chat Cancer Support Group

Join other cancer patients, survivors and their loved ones to chat and create art at this free support group. Each week you will learn relaxing drawing methods that help increase focus, creativity and an increased sense of self-confidence and personal well-being. All projects will be accessible and simple. No previous art experience is necessary. Registration is preferred but walk-ins are welcome.

Address Long Cancer Center 5555 Grossmont Center Drive La Mesa, CA 91942 Phone 1-800-82-SHARP Email NA Website www.Sharp.com

 Sharp Grossmont Hospital: Chemo Brain Workshop – Improving Memory and Concentration

This free workshop is open to patients who are experiencing memory problems related to chemotherapy and other cancer treatments. We will explore what chemo brain is, why it occurs and what can be done about it. You will also gain tips and strategies for managing and improving your memory during and after cancer treatment. Advanced registration is recommended but not required. Loved ones are also encouraged to attend.

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Address Long Cancer Center 5555 Grossmont Center Drive La Mesa, CA 91942 Phone 1-800-82-SHARP Email NA Website www.Sharp.com

 Sharp Grossmont Hospital: Lunch and Learn Cancer Education Series

This free educational series is open to current cancer patients and survivors as well as their caregivers. Each month a different topic on how to live with and survive cancer will be discussed. Previous topics include the benefits of yoga, creating a wellness plan, life beyond cancer, stress management and wills and advance directives. A licensed clinical social worker facilitates this group with help from a variety of guest speakers such as dietitians, physicians and pharmacists. A question-and-answer period is also included. Lunch is provided and registration is preferred.

Address Long Cancer Center 5555 Grossmont Center Drive La Mesa, CA 91942 Phone 1-800-82-SHARP Email NA Website www.Sharp.com

 Sharp Grossmont Hospital: Relaxation and Quieting the Mind Workshop for Cancer Patients

This class offers cancer patients and their loved ones different ways to manage the stress and anxiety that accompanies a cancer diagnosis. A licensed clinical oncology social worker will give you proven tips and strategies for quieting the voice of worry in your head and show you how to manage difficult emotions, fears and nerves. Advanced registration is recommended but not required.

Address Long Cancer Center 5555 Grossmont Center Drive La Mesa, CA 91942 Phone 1-800-82-SHARP Email NA Website www.Sharp.com

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I. SENIOR HEALTH

 Caregiver Coalition of San Diego

The Caregiver Coalition of San Diego is an alliance of agencies that provide services for family caregivers, and is dedicated to supporting them through education and advocacy. The Coalition's mission is to identify and address the needs of caregivers through advocacy efforts and collaboration of a broad coalition membership in order to improve the overall quality of life for caregivers, their families and the community. The Coalition hosts family caregiver conferences, webinars and distributes an e-newsletter, as well as partners with others on programs of interest to caregivers and advocates for family caregivers. General coalition meetings are held monthly. Committees include Education, Community Outreach, Publicity and Marketing and Speakers Bureau. Free. Public welcome.

Burn Institute Address 8825 Aero Drive San Diego 92123 Phone Martin Dare, Coordinator, 858-505-6300 Email [email protected] http://www.caregivercoalitionsd.org/; Website https://www.facebook.com/pages/Caregiver- Coalition/142346875794950?v=wall

 AIS Health Promotion Committee

The AIS Health Promotion Committee’s mission is to improve the health and wellness of older adults in SDC so that they may remain independent. The committee provides programs specifically for older adults to manage chronic conditions, improve physical functioning, increase socialization and prevent falls. Representatives from a network of senior, health and community organizations meet monthly. Free. Public welcome.

5560 Overland Avenue Address San Diego, CA 92123 Contact Kari Carmody, AIS Health Promotion Manager Email [email protected] Website NA

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 Long Term Care Integrated Project (LTCIP)

Part of the HHSA, LTCIP's mission is to develop a comprehensive, consumer-centered, integrated continuum of care (health and social services) that maintains individual dignity, and allows consumers of long term care services to remain an integral part of their family and community life, and pools funding to minimize process and maximize resources.. Quarterly stakeholder meetings. Free. Public welcome.

Address Consult website as location varies. Phone Kristen Smith, Manager of LTCIP, 858-495-5853 Email [email protected] Website www.sdltcip.org

 San Diego Community Action Network (SanDi-CAN)

SanDi-CAN's mission is to be the community based action partnership of providers, volunteers and consumers of services dedicated to improving quality of life for older adults and adults with disabilities living in the City of San Diego. SanDi-CAN advocates for seniors and dependent adults in San Diego. Meetings held monthly. Free. Public welcome.

Balboa Park War Memorial Bldg. Address 3325 Zoo Drive San Diego, CA 92101 Phone Brian Rollins, 858-505-6305 Email [email protected] www.localcommunities.org/lc/sandican; Website https://211sandiego.communityos.org/zf/profile/agency/id/17 0198

 San Diego County Coalition for Improving End-of-Life Care

San Diego County Coalition for Improving End-of-Life Care's mission is to educate and raise awareness within San Diego County about end-of- life issues and to provide resources to help people make informed choices. The goal is to bring open conversations and increased awareness to the inevitable process we face in the process of living and dying. Meets monthly. Public welcome.

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Burn Institute Address 8825 Aero Drive San Diego, CA 92124 Phone 858-635-1224 Email [email protected] Website http://www.sdcoalition.org/

 San Diego County Council on Aging

The San Diego County Council on Aging is a multidisciplinary organization that promotes education, awareness, and networking in SDC to enhance the quality of life for seniors. Goals include: Protecting the rights and lifestyles of the senior population; Remaining informed regarding the fair allocation of government and private resources to serve the needs of seniors; Providing education for professionals and the community to improve the quality of life for the senior population; Collaborating with other senior organizations. Membership available on website. Meets monthly.

Vibra Hospital of San Diego 555 Washington St. Address San Diego, CA 92103 Phone Susan Phan, 619-462-2273 [email protected]; Email [email protected] Website www.sdccoa.com

 San Diego Dementia Consortium

The San Diego Dementia Consortium (SDDC) is organized exclusively for charitable, scientific and educational purposes and more specifically to advance public knowledge and awareness of dementia and cognitive health as well as to develop and promote clinical and research programs to benefit those patients with dementia and cognitive disease. One of SDDC's goals is to initiate new programs and projects hands-on which benefit the welfare of elderly cognitive impaired patients in our community. SDCC also sponsors activities which promote cognitive health among seniors and across the lifespan. Members welcome.

San Diego Dementia Consortium Address 12463 Rancho Bernardo Rd., #268 San Diego, CA 92128-2143

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Phone 858-412-7337 Email  [email protected] http://www.sddementiaconsortium.org/ Website https://www.facebook.com/dementiaconsortium/

 San Diego Regional Home Care Council

The San Diego Regional Home Care Council’s (Home Care Council) mission is to restore, maintain and promote optimal health. The Home Care Council provides professional networking and education, while promoting standards of practice for the home care community. Members are made up of health care professionals in San Diego looking to improve the quality of health care. Meetings held monthly.

General Meetings are held at: First United Methodist Church Address 2111 Camino Del Rio South San Diego, CA 92108 Phone NA Email [email protected] http://www.sdrhcc.org/ Website https://www.facebook.com/San-Diego-Regional-Home-Care- Council-281488061869663/

 Senior Specialists Networking Group

The Senior Specialist Networking Group is a unique, extensive organization of professional men and women dedicated to the highest standards of service, integrity and competency. The group meets monthly to exchange up-to-date information and ideas about how best to serve senior clients.

Address Monthly Networking Luncheons at different facilities: Phone Janette Beck, 760-497-1150

Email [email protected]

https://www.facebook.com/Senior-Specialists-Networking- Website Group-170495069650585/

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 Serving Seniors Networking Breakfast The Serving Seniors Networking Breakfast is a non-exclusive networking organization for professionals serving the senior population in any capacity. Our purpose is to educate one another on our products, services, facilities and to build better relationships through monthly meetings. We can then make better recommendations to our senior clients who deserve professionals with integrity, knowledge, and a dedication to excellent services.

Address Meetings travel. See website for upcoming locations. Phone NA Email [email protected] Website http://www.servingseniorsnetworkingbreakfast.com/

 East County Action Network for Older Adults & Adults with Disabilities (ECAN)

The mission of ECAN is to be the East County community based network that takes action and advocates for Older Adults and Adults with Disabilities. ECAN is the largest County Action Network in San Diego County and is affiliated with the County of San Diego, Aging and Independent Services.

ECAN Coordinator: 389 N. Magnolia Ave. Address El Cajon, CA 92020Schedule can vary. Confirm meeting dates with Coordinator. Phone Loren Goldstein (619) 401-3994 Email [email protected] Website www.localcommunities.org/ecan

 East County Senior Service Providers

East County Senior Service Providers works to identify, educate and advocate for issues relating to the quality of life of older adults residing in the East San Diego County area. Their goal is to develop and maintain a communication link for senior service providers, provide education on senior issues and resources, advocate for quality of life issues for the older adults of San Diego’s East County, host a senior health fair annually, and make donations to selected non-profits each year. Annual Dues: $25 per organization.

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El Cajon Salvation Army Address 1011 E Main St. El Cajon 92020 Bill Mathis, Chair, 619-757-1114, or Phone Marian Mann, Co-Chair, 619-447-8782 Email [email protected], or [email protected] http://www.facebook.com/pages/East-County-Senior-Service- Website Providers/185953294773601

 AIS Fall Prevention Task Force

With a mission to reduce falls and their devastating consequences in San Diego County, 2013 projects include educating health care providers and seniors on community fall prevention resources and best practices for fall prevention. Free. Public welcome. Members play an active role and in addition to meetings, work on projects outside of the meetings.

Central Region North Central Region SDC Operations Center Tri-City Wellness Center Address 5500 Overland Ave 6250 El Camino Real San Diego, CA 92123 Carlsbad, CA 92009 Kari Carmody, AIS Health Promotion Manager, 858-495- Phone 5998 Email [email protected] Website www.SanDiegoFallPrevention.org

HASD&IC 2016 CHNA: Next Steps

Hospitals and health care systems that participated in the HASD&IC 2016 CHNA process have varying requirements for next steps. Private, not for profit (tax-exempt) hospitals and health care systems are required to develop hospital or health care system community health needs assessment reports and implementation plans to address selected identified health needs. The participating public hospitals and health care systems do not have federal or state CHNA requirements, but work very closely with their patient communities to address health needs by providing programs, resources, and opportunities for collaboration with partners. Every participating hospital and health care system will review the CHNA data and findings in accordance with their own patient communities and principal functions, and evaluate opportunities for next steps to address the top identified health needs in their respective patient communities.

The CHNA report will be made available as a resource to the broader community to solicit additional feedback on findings and may serve as a useful resource to both

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residents and health care providers to further communitywide health improvement efforts.

The CHNA Committee is in the process of planning Phase 2 of the 2016 CHNA, which will include gathering community feedback on the 2016 CHNA process and strengthening partnerships around the identified health needs and social determinants. The complete summary of the HASD&IC 2016 CHNA is available online at: www.hasdic.org. Paper copies or electronic files are also available upon request, as well as items provided in the HASD&IC 2016 CHNA developed by IPH. Please contact Lindsey Wade at the HASD&IC with any questions.

Lindsey Wade Vice President, Public Policy Hospital Association of San Diego & Imperial Counties 5575 Ruffin Road, Ste 225 • San Diego, CA 92123 P: 858.614.1553 [email protected]

SGH 2016 CHNA: Next Steps

SGH has developed its FY 2017 – FY 2020 Implementation Plan to address the needs identified through the 2016 CHNA process for the primary communities it serves. In addition, the SGH CHNA Planning Team, Sharp Community Benefit team, Sharp service line leaders and other team members across Sharp are committed to an ongoing exploration of partnerships and collaborations to provide programs and services that address the needs of SGH’s community members.

Tools such as the asset map of currently existing resources within SDC, as well as the CNI data, will be utilized to help continue to identify gaps in community resources and provide insight into further program development.

The SGH FY 2017 – FY 2020 Implementation Plan is available on sharp.com at: http://www.sharp.com/about/community/health-needs-assessments.cfm. In addition, the implementation plan is submitted along with the IRS Form 990, Schedule H, and will be publicly available on Guidestar (http://www.guidestar.org/) in the coming months.

Sharp will continue to work with HASD&IC and IPH as part of the CHNA Committee to develop and implement Phase 2 of the 2016 CHNA. Phase 2 will focus on continued engagement of community partners to analyze and improve the CHNA process, as well as the hospital programs provided to address the 2016 CHNA findings (i.e., implementation plans). In this way, our CHNA work will continue to evolve to meet the needs of our ever-changing community. Phase 2 of the CHNA will focus on the development of a multi-hospital and health system collaborative effort to address priority health needs, including a policy agenda to focus and strengthen the role of hospitals as advocates for community health.

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There is broad recognition that all regions of SDC will continue to experience changes that may directly affect the health of the communities served by SGH. This uncertainty in the general environment continues to be a serious issue and key consideration for the health care community. While this CHNA provides a high-level view of health in the communities served by SGH, hospital community benefit and community relations efforts must also stay mindful of and responsive to emerging trends and needs in health care as they arise.

Conclusion

The SGH 2016 CHNA focused on highlighting the health needs of its community members. In particular, meeting the unmet health needs of vulnerable community members is a continuing concern of hospitals and hospital community benefit efforts throughout SDC. Although community benefit programs have accomplished much in SDC, there is of course, still work to be done.

With the challenging and uncertain health care landscape before us, community well- being is a prevalent concern. SGH and the Sharp system remain committed to the care and improvement of health for all San Diegans amidst these challenges. Many of the issues identified in this CHNA – access to care, affordable insurance and health care, education and information for all community members – will take time, patience and perseverance to improve. Sharp remains committed to the challenges ahead and welcomes the exploration of new opportunities to better the health and well-being of the San Diego community.

The information collected throughout the SGH 2016 CHNA process, as published here, is publicly available to the community. Readers are invited to read and download this CHNA report (http://www.sharp.com/about/community/health-needs-assessments.cfm), and to utilize the data findings in both this report and the HASD&IC 2016 CHNA to positively impact the health of community members throughout SDC.

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Appendix

A SGH Programs and Services

. 24-hour emergency services with heliport and paramedic base station – designated STEMI Center . Acute care . Ambulatory care services, including infusion therapy . Behavioral Health Unit . Breast Health Center, including mammography . Cardiac services, recognized by the American Heart Association – Get With The Guidelines . Cardiac Training Center . Computed Tomography scan . David and Donna Long Center for Cancer Treatment . Electroencephalography . Electrocardiogram . Endoscopy unit . Grossmont Plaza Outpatient Surgery Center . Group and art therapies . Home health64 . Home infusion therapy . Hospice65, including BonitaView, LakeView and ParkView hospice homes . Hyperbaric treatment . ICU . Neonatal Intensive Care Unit . Orthopedics . Outpatient diabetes services, recognized by the American Diabetes Association . Pathology services . Pediatric services66 . Pulmonary services . Radiology services . Rehabilitation Center . Robotic surgery . Senior Resource Center . Sleep Disorders Center . Spiritual care services . Stroke Center . Surgical services . Transitional Care Unit . Van services

64 Provided through Sharp Memorial Hospital Home Health Agency 65 Provided through Sharp HospiceCare 66 Inpatient services are provided through an affiliation with Rady Children’s Hospital

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. Vascular services . Women’s Health Center . Wound Care Center

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Appendix

B An Overview of Sharp HealthCare

FOUR ACUTE CARE HOSPITALS:

Sharp Chula Vista Medical Center (343 licensed beds) The largest provider of health care services in SDC’s rapidly expanding South Bay, Sharp Chula Vista Medical Center (SCVMC) operates the South Bay’s busiest ED and is the closest hospital to the busiest international border in the world. SCVMC is home to the region’s most comprehensive heart program, services for orthopedic care, cancer treatment, women and infants, and the only bloodless medicine and surgery center in SDC.

Sharp Coronado Hospital and Healthcare Center (181 licensed beds) Sharp Coronado Hospital and Healthcare Center (SCHHC) provides services that include acute, sub-acute and long-term care, rehabilitation therapies, joint replacement surgery, hospice, and emergency services.

Sharp Grossmont Hospital (509 licensed beds) Sharp Grossmont Hospital (SGH) is the largest provider of health care services in San Diego’s East County and has one of the busiest EDs in SDC. SGH is known for outstanding programs in heart care, orthopedics, rehabilitation, robotic surgery, stroke care, and women's health.

Sharp Memorial Hospital (656 licensed beds) A regional tertiary care leader, Sharp Memorial Hospital (SMH) provides specialized care in trauma, oncology, orthopedics, organ transplantation, cardiology, and rehabilitation. SMH houses San Diego's largest emergency and trauma center.

THREE SPECIALTY CARE HOSPITALS:

Sharp Mary Birch Hospital for Women & Newborns (206 licensed beds) A freestanding women’s hospital specializing in obstetrics, gynecology, gynecologic oncology, and neonatal intensive care, Sharp Mary Birch Hospital for Women & Newborns (SMBHWN) delivers more babies than any other private hospital in California.

Sharp Mesa Vista Hospital (158 licensed beds) The largest private freestanding psychiatric hospital in SDC, Sharp Mesa Vista Hospital (SMV) is a premier provider of behavioral health services.

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Sharp McDonald Center (16 licensed beds)67 Sharp McDonald Center (SMC) is SDC’s only licensed chemical dependency recovery hospital.

Collectively, the operations of SMH, SMBHWN, SMV and SMC are reported under the not-for-profit public benefit corporation of SMH and are referred to herein as the Sharp Metropolitan Medical Campus (SMMC). The operations of Sharp Rees-Stealy Medical Centers are included within the not-for-profit public benefit corporation of Sharp, the parent organization. The operations of SGH are reported under the not-for-profit public benefit corporation of Grossmont Hospital Corporation. The operations of Sharp HospiceCare are reported within SGH.

Please refer to Appendix U for a map of Sharp HealthCare locations in SDC.

Mission Statement

It is Sharp’s mission to improve the health of those it serves with a commitment to excellence in all that it does. Sharp’s goal is to offer quality care and services that set community standards, exceed patients’ expectations and are provided in a caring, convenient, cost-effective and accessible manner.

Vision

Sharp’s vision is to become the best health system in the universe. Sharp will attain this position by transforming the health care experience through a culture of caring, quality, safety, service, innovation and excellence. Sharp will be recognized by employees, physicians, patients, volunteers and the community as the best place to work, the best place to practice medicine and the best place to receive care. Sharp will be known as an excellent community citizen, embodying an organization of people working together to do the right thing every day to improve the health and well-being of those it serves.

Values

. Integrity – Trustworthy, Respectful, Sincere, Authentic, Committed to Organizational Mission and Values

. Caring

67 As a licensed chemical dependency recovery hospital, SMC is not required to file a community benefit plan. However, SMC is committed to community programs and services and has presented community benefit information in Section 11: SMV and SMC.

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– Compassionate, Communicative, Service Oriented, Dedicated to Teamwork and Collaboration, Serves Others Above Self, Celebrates Wins, Embraces Diversity

. Safety – Reliable, Competent, Inquiring, Unwavering, Resilient, Transparent, Sound Decision Maker

. Innovation – Creative, Drives for Continuous Improvement, Initiates Breakthroughs, Develops Self, Willing to Accept New Ideas and Change

. Excellence – Quality Focused, Compelled by Operational and Service Excellence, Cost Effective, Accountable

Culture: The Sharp Experience

For more than 15 years, Sharp has been on a journey to transform the health care experience for patients and their families, physicians and staff. Through a sweeping organization-wide performance-and-experience-improvement initiative called The Sharp Experience, the entire Sharp team has recommitted to purposeful, worthwhile work and creating the kind of health care people want and deserve. This work has added discipline and focus to every part of the organization, helping to make Sharp one of the nation’s top-ranked health care systems. Sharp is San Diego’s health care leader because it remains focused on the most important element of the health care equation: the people.

Through this extraordinary initiative, Sharp is transforming the health care experience in San Diego by striving to be:

. The best place to work: Attracting and retaining highly skilled and passionate staff members who are focused on providing quality health care and building a culture of teamwork, recognition, celebration, and professional and personal growth. This commitment to serving patients and supporting one another will make Sharp “the best health system in the universe.”

. The best place to practice medicine: Creating an environment in which physicians enjoy positive, collaborative relationships with nurses and other caregivers; experience unsurpassed service as valued customers; have access to state-of-the- art equipment and cutting-edge technology; and enjoy the camaraderie of the highest-caliber medical staff at San Diego’s health care leader.

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. The best place to receive care: Providing a new standard of service in the health care industry, much like that of a five-star hotel; employing service-oriented individuals who see it as their privilege to exceed the expectations of every patient – treating them with the utmost care, compassion and respect; and creating healing environments that are pleasant, soothing, safe, immaculate, and easy to access and navigate.

Through this transformation, Sharp will continue to live its mission to care for all people, with special concern for the underserved and San Diego’s diverse population. This is something Sharp has been doing for more than half a century.

Pillars of Excellence

In support of Sharp’s organizational commitment to transform the health care experience, Sharp’s Pillars of Excellence serve as a guide for its team members, providing framework and alignment for everything Sharp does. In 2014, Sharp made an important decision regarding these pillars as part of its continued journey toward excellence.

Each year, Sharp incorporates cycles of learning into its strategic planning process. In 2014, Sharp’s Executive Steering and Board of Directors enhanced Sharp’s safety focus, further driving the organization’s emphasis on its culture of safety and incorporating the commitment to become a High Reliability Organization (HRO) in all aspects of the organization. At the core of HROs are five key concepts:

• Sensitivity to operations • A reluctance to simplify • Preoccupation with failure • Deference to expertise • Resilience

Applying high-reliability concepts in an organization begins when leaders at all levels start thinking about how the care they provide could become better. It begins with a culture of safety.

With this learning, Sharp is a seven-pillar organization − Quality, Safety, Service, People, Finance, Growth, and Community. The foundational elements of Sharp’s strategic plan have been enhanced to emphasize Sharp’s desire to do no harm. This strategic plan continues Sharp’s transformation of the health care experience, focusing on safe, high-quality and efficient care provided in a caring, convenient, cost-effective, and accessible manner.

The seven pillars listed below are a visible testament to Sharp’s commitment to become the best health care system in the universe by achieving excellence in these areas:

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Demonstrate and improve clinical excellence to set industry standards and exceed customer expectations.

Keep patients, employees and physicians safe and free from harm.

Create exceptional experiences at every touch point for customers, physicians and partners by demonstrating service excellence.

Create a values-driven culture that attracts, retains, and promotes the best and brightest people, who are committed to Sharp’s mission and vision.

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Achieve financial results to ensure Sharp’s ability to provide quality health care services, new technology and investment in the organization.

Achieve consistent net revenue growth to enhance market dominance, sustain infrastructure improvements and support innovative development.

Be an exemplary public citizen by improving the health and well- being of the community and supporting the stewardship of our environment.

Awards

Sharp has received the following recognition:

Sharp is a recipient of the 2007 Malcolm Baldrige National Quality Award, the nation’s highest presidential honor for quality and organizational performance excellence. Sharp was the first health care system in California and eighth in the nation to receive this recognition.

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In 2013, 2014, and 2016, Sharp was recognized as one of the World's Most Ethical Companies by the Ethisphere Institute, the leading business ethics think tank. The World’s Most Ethical Companies are those that truly embrace ethical business practices and demonstrate industry leadership, forcing peers to follow suit or fall behind.

Sharp was ranked No. 16 out of 500 large employers on Forbes America’s Best Employers 2016 list. Sharp was also given the No. 2 spot on the newcomer’s list.

Sharp was named the No. 1 “best integrated health care network” in California and No. 12 nationally by Modern Healthcare magazine in 2012. The rankings are part of the “Top 100 Most Highly Integrated Healthcare Networks,” a survey conducted by health care data analyst IMS Health. This was the 14th consecutive year that Sharp placed among the top in the state.

Sharp was named “Best Hospital Group” by U-T San Diego readers participating in the paper’s 2015 “Best of San Diego” Readers Poll. In 2015, SMBHWN was named “Best Hospital,” while SGH and SMH were ranked second and third “Best Hospitals.” Sharp Community Medical Group and Sharp Rees-Stealy Medical Group were ranked first and second, respectively, in 2015 as San Diego’s “Best Medical Group.”

SGH, SMBHWN and SMH have received MAGNET® Designation for Nursing Excellence by the American Nurses Credentialing Center. The Magnet Recognition Program is the highest level of honor bestowed by the American Nurses Credentialing Center and is accepted nationally as the gold standard in nursing excellence. SMH was redesignated in March 2013.

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Sharp was named one of the nation’s “Most Wired” health care systems from 1999 to 2009, and again from 2012 to 2016 by Hospitals & Health Networks magazine’s annual Most Wired Survey and Benchmark Study. “Most Wired” hospitals are committed to using technology to enhance quality of care for both patients and staff.

In 2014, SCVMC and its on-site Birch Patrick Convalescent Center became the first co-located hospital and skilled nursing facility in the nation to be designated as a Planetree Patient-Centered Organization. SCVMC joined both SMH and SCHHC in Planetree distinction. In 2012, SMH was designated as a Planetree Patient-Centered Hospital, and is the largest hospital-only designated facility in the U.S. In 2014, SMH achieved Planetree Designation with Distinction and was redesignated as a Planetree Patient-Centered Hospital in 2015. SCHHC was originally designated in 2007 and is the only hospital in the state to be re-designated twice, occurring in both 2010 and 2013. Additionally, SCHHC was named a Planetree Hospital with Distinction for its leadership and innovation in patient-centered care. Planetree is a coalition of more than 100 hospitals worldwide that is committed to improving medical care from the patient’s perspective.

In 2013, both SCHHC and SCVMC received Energy Star designation from the U.S. Environmental Protection Agency for outstanding energy efficiency. Buildings that are awarded use an average of 40 percent less energy than other buildings and release 35 percent less carbon dioxide into the atmosphere. SCHHC first earned the Energy Star certification in 2007 and then again each year from 2010 through 2013, while SCVMC received the Energy Star certification in 2009, 2010, 2011, 2013 and 2015.

San Diego Gas & Electric recognized Sharp for outstanding results in energy efficiency and conservation. Sharp was named San Diego's "Healthcare 2014 Energy Champion" for its successes in energy conservation.

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In 2013, Sharp was named a “Recycler of the Year” at the City of San Diego’s annual Waste Reduction and Recycling Awards for a successful and extensive recycling program. SMH and SMBHWN were honored for their comprehensive waste reduction programs.

Sharp was named the Crystal Winner of the 2011 Workplace Excellence Awards from the San Diego Society for Human Resource Management. This designation recognizes Sharp’s Human Resources Department as an innovative and valuable asset to overall company performance.

From 2013 to 2015, the Press Ganey organization recognized multiple Sharp entities with Guardian of Excellence AwardsSM. Based on one year of data, this designation recognizes recipients for having reached the 95th percentile for patient satisfaction, employee engagement, physician engagement surveys or clinical quality. Awards for Sharp entities included SCVMC, SCHHC, SGH, SMBHWN, SMH, SMH Outpatient Pavilion, SMV, Sharp HealthCare, Sharp HospiceCare, Sharp Rees-Stealy Medical Group, Sharp Community Medical Group and Sharp Home Health for Employee Engagement; SMBHWN and the Sharp Senior Health Centers at SMH for Patient Satisfaction; and SCHHC, SMBHWN and SMV for Physician Engagement.

In 2013, the Press Ganey organization recognized multiple Sharp entities for achievement of the Beacon of Excellence AwardsSM. This designation recognizes those who maintain consistent high levels of excellence in patient satisfaction (based on a three-year period), employee engagement, or physician engagement (the latter two based on the two most recent survey periods). Awarded entities included Sharp HealthCare for Employee Engagement; SMH for Patient Satisfaction; and SCHHC and SMV for Physician Engagement.

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Sharp Health Plan (SHP) was ranked a top 100 U.S. health plan and a top three California health plan based on the National Committee for Quality Assurance’s (NCQA) Private Health Insurance Rankings 2014–2015, which rated health insurance plans based on clinical quality, member satisfaction and NCQA Accreditation Survey results. SHP also received the highest level "Excellent" Accreditation status from the NCQA for the third year in a row (2013–2015). The NCQA awards accreditation status based on compliance with rigorous requirements and performance on Healthcare Effectiveness Data and Information Set and Consumer Assessment of Healthcare Providers and Systems measures. SHP was also rated highest in California among reporting California Health Plans for Rating of the Health Plan, Rating of Health Care, Rating of Personal Doctor, and Rating of Health Promotion and Education in NCQA’s 2015 Quality Compass/Consumer Assessment of Healthcare Providers and Systems survey, which provides state, regional and national benchmarks as well as individual plan performance.

In 2015, Sharp was ranked fourth in the large employers category as one of the “Best Places to Work” for Information Technology professionals by the International Data Group’s Computerworld survey. The list is compiled by the following criteria: benefits, training, retention, career development, average salary increases, employee surveys, workplace morale and more.

SGH received the Women’s Choice Award® as one of America’s Best Hospitals for cancer care in 2015 and for obstetrics in 2016. SMBHWN also received the award in 2015 for obstetrics. The Women’s Choice Award® is a symbol of excellence in customer experience awarded by the collective of women.

For the third year in a row, and the fourth time in five years, Sharp won the top spot in the Mega Employer category in the Rideshare 2015 Challenge. The month-long challenge encouraged the replacement of solo drivers with sustainable carpool, vanpool, bike, walk, or transit commutes. Powered by San Diego Association of Governments (SANDAG) and in cooperation with the 511 transportation information

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service, iCommute is the Transportation Demand Management program for the San Diego region and encourages use of transportation alternatives to help reduce traffic congestion and greenhouse gas emissions.

Sharp was named the 2015 Medical Provider of the Year at the International Travel & Health Insurance Journal Awards. The International Travel & Health Insurance Journal honors companies that have made an outstanding contribution to the global travel and health insurance industry over the past year. Sharp’s Global Patient Services program coordinates patient transfers and evacuations for medical emergencies from around the world to a Sharp hospital.

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Appendix Description of Partnering C Organizations – HASD&IC and IPH

The Hospital Association of San Diego and Imperial Counties

The Hospital Association of San Diego and Imperial Counties (HASD&IC) was established in 1956 (then the Hospital Council) and is a nonprofit organization representing over 35 hospitals and integrated health systems in the two-county area. HASD&IC's mission is to support its members by advancing the organization, management and effective delivery of affordable, medically necessary, quality health care services for the communities of San Diego and Imperial counties. HASD&IC's board of directors represents all member sectors and provides policy direction to ensure the interests of member hospitals and health systems are preserved and promoted. HASD&IC contracted with San Diego State University’s Institute for Public Health (IPH) to conduct a hospital-based Community Health Needs Assessment (CHNA) throughout the region.

The Institute for Public Health at San Diego State University

The Institute for Public Health (IPH) at San Diego State University (SDSU) was founded in 1992 as a unit of SDSU’s Graduate School of Public Health (http://iph.sdsu.edu/). The mission of the IPH is to bridge academic research and real-world practice by working with public and private community-based agencies, hospitals and health care organizations and the people they serve, assisting them to define their needs, improve their programs, and better serve their communities. The IPH specializes in community- engaged scholarship activities involving applied research and evaluation, teaching and service. Their research and evaluation strategies include community based participatory research, applied research, evaluation, and the integration and dissemination of research in equal partnership with community organizations and their members. Their goal is to translate evidence-based best practice from journal articles in the library to the highest quality public health interventions capable of creating positive health outcomes in a wide variety of community settings and in a diverse number of content areas.

Tanya Penn, MPH, CPH

Tanya Penn is an Epidemiologist for the Institute for Public Health in the Graduate School of Public Health, at San Diego State University. Trained in public health with an emphasis in Epidemiology, Ms. Penn also holds a nationally recognized Certification in Public Health. Ms. Penn has been with the IPH since 2011 and is currently the Principal Investigator on the 2016 HASD&IC Community Health Needs Assessment working collaboratively with the Hospital Association of San Diego and Imperial Counties (HASD&IC) and the CHNA Committee. Her expertise includes: statistical analysis, data

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management and manipulation, and utilizing large public-use data sets. Her primary research interests include health disparities in underserved populations, health education and community based participatory research. Before joining the IPH, Ms. Penn was part of a team that helped start one of the first free Diabetic Clinics for indigent patients in Wilmington, North Carolina in which Ms. Penn was ultimately the Clinic Director.

Amy Pan, PhD

Dr. Amy Pan is a research associate at the Institute for Public Health (IPH) at San Diego State University. Dr. Pan provides program evaluation and grant writing support for the IPH. Her primary research interests include violence prevention and other preventative health issues in immigrant and refugee communities. Prior to working at the IPH, Amy worked at the Center for Community Solutions, the Tahirih Justice Center, and the Center for Child Welfare at George Mason University.

Nicole Delange, MPH, CPH

Nicole Delange holds a MPH degree with an emphasis in Epidemiology from San Diego State University. She has served as a research assistant at the IPH since May of 2015, and provided literary and data research support for Phase II of the 2013 HASD&IC Community Health Need Assessment prior to her involvement in this 2016 CHNA. Her research interests include health disparities, community-based participatory research methods and access to care issues.

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Appendix D Vulnerable Populations Report

Vulnerable Populations

Children

Seniors

Asian American and Native Hawaiian and Other Pacific Islander

American Indians/Alaskan Native

Latinos

African American

Homeless

LGBTQ

Refugee Population

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Vulnerable Populations

According to the 2013 CDC Health Disparities and Inequities Report, “health disparities and inequalities are gaps in health or health determinants between segments of the population.” In particular the CDC's Office of Minority Health & Health Equity highlights ‘Racial and Ethnic Minorities’ and ‘Other At-Risk/Vulnerable Populations’ including those defined by age and risk status related to sex and gender as potentially vulnerable populations. Using these guidelines and recommendations from the community about specific populations to include, reports were compiled to provide a more in-depth understanding of the following populations: Children, Seniors, Asian American/Native Hawaiian and Other Pacific Islander, American Indians/Alaskan Natives (AI/ANs), Latinos, African Americans, Homeless, LGBTQ, and Refugees.

Children

The Life Course Perspective emphasizes the importance of looking at health across the lifespan rather than as distinct, disconnected stages. This is due to the complex interplay of biological, behavioral, psychological, social, and environmental factors that contribute to health outcomes across the course of a person’s life. Evidence of the connection between childhood and adulthood as it relates to health status has become increasingly clear. In a large San Diego study of Adverse Childhood Events (ACE), greater exposure to abuse or household dysfunction during childhood was linked to an increase in risk factors for several leading causes of illness such as heart disease, substance abuse, obesity and depression.

Chronic Conditions

Many trends in childhood predict future health status in adulthood. For example, reports show that 80% of children who are overweight at ages 10-15 were obese by the age of 25 and at an increased risk of high blood pressure, high cholesterol, and Type 2 diabetes. In San Diego, a lower proportion of school age students 5th, 7th, and 9th grade were at high risk/obese compared to California. Childhood poverty is also associated with adverse conditions in adulthood including chronic stress and mental health conditions, obesity, heart disease, and increases in hospitalizations. Poor children are disproportionately exposed to inadequate nutrition, child abuse and neglect, trauma, parental depression or substance abuse, and violence. Furthermore, teens in poor families are more likely to engage in risky behaviors such as smoking and alcohol and drug abuse. In a recent issue brief released by the California Budget & Policy Center, researchers found that while children only make up about a quarter of the Californian population, roughly 32.7% are in deep poverty. Furthermore, studies have found that being born into poverty more than doubles a child’s chance of having a lower income as an adult. According to the 2013 San Diego Report Card on Children and Families, there is a worsening trend for the percentage of children 0-17 living in poverty. Recognizing disparities such as these and how they contribute to poor health is an important first step to addressing the needs of vulnerable populations in the San Diego community.

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Mental/Behavioral Health The life course of unmet mental health needs from childhood to adulthood has a significant impact on the individual, family and society as a whole. Focusing on mental and behavioral health issues in children and youth is particularly important because it is estimated that half of all lifetime cases of mental disorders begin by age 14 and three-quarters by age 24. Early identification and intervention has the potential to improve both short and long term health outcomes.

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Table 1. Selected Indicators from 2013 San Diego County Report Card on Children & Families Trend San Diego California % of mothers who initiate breast feeding 95.2 92.3 Ages 6-12 (School Age) % of children ages 2-11 who have never visited a dentist 6.5 10.3 % of students not in the Healthy Fitness Zone (at high risk/obese) Grade 5 30.7 33.7 Grade 7 27.2 30.1 Grade 9 23.1 26.2 Ages 13-18 (Adolescents) % of students who report using cigarettes in the past 30 days Grade 7 4.5 NA Grade 9 7.6 NA Grade 11 9.8 NA % of students who report using alcohol in the past 30 days Grade 7 10.8 NA Grade 9 18.8 NA Grade 11 27.5 NA % of students who report using marijuana in the past 30 days Grade 7 7.1 NA Grade 9 14.3 NA Grade 11 19.3 NA % of male students (grades 9-12) who report they attempted suicide in the previous 12 months NA 6.5 NA % of female students (grades 9-12) who report they attempted suicide in the previous 12 months NA 10.1 NA Community and Family (Cross Age) % of children ages 0-17 living in poverty 19.8 23.8 # of eligible children receiving Food Stamps 135,487 NA % of children ages 0-17 without health coverage 6.3 4.2 Rate of domestic violence reports per 1,000 households 15 12.5 Rate of substantiated cases of child abuse and neglect per 1,000 children ages 0-17 7.6 8.9 Adult Indicators % of adults 18 or older that are obese 22.1 24.8 % of adults 18 or older that reported smoking 12.8 13.6 % of adults 18 -64 living in poverty 14.3 15.6 *The Children’s Initiative San Diego County Report Card on Children and Families 2013 Edition. www.thechildrensinitiatve.org *NA refers to Not Available FOOTNOTE Fine, Amy, Kotelchuck, Milton, Adess, Nancy, & Pies, Cheri. (2009). A New Agenda for MCH Policy and Programs: Integrating a Life Course Perspective. http://cchealth.org/lifecourse/pdf/2009_10_policy_brief.pdf Felitti, Vincent J et al. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults, American Journal of Preventive Medicine, 14 (4), 245 – 258. Alissa Anderson. (2015). Five Facts Everyone Should Know About Deep Poverty. California Budget & Policy Center. http://calbudgetcenter.org/wp-content/uploads/Five-Facts-Everyone-Should-Know-About-Deep-Poverty_Issue-Brief_06.05.2015.pdf The Children’s Initiative. (2013). San Diego County Report Card on Children & Families. www.thechildrensinitiatve.org The Children’s Initiative. (2013). San Diego County Report Card on Children & Families. www.thechildrensinitiatve.org

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Seniors

The following data is from the 2015 San Diego County Senior Health Report and provides information on the senior population in SDC. As significant users of the health system, it is important to understand the demographic composition of the senior population and forecast potential changes in utilization.

Seniors age 65 and older (65+) represented approximately 12% (374,535) of the San Diego population in 2012 according to SANDAG population estimates. This percent is expected to almost double by 2030 to 23%.The racial and ethnic composition of this group is also anticipated to change. Currently 69.4% of seniors are white followed by Hispanic (16.0%), Asian/Pacific Islander (10.3%), black (2.8%) and Other/2+ (1.6%). By 2030, the demographic composition of seniors is projected to be 55.7% white, 22.9% Hispanic, 13.5% Asian/Pacific Islander, 4.3% black, and 3.7% Other/2+ races. Of those aged 65 and older, a significant percentage (23.8%) are Veterans.

It is also important to understand the current burden of disease. Overall, a greater percentage of San Diego seniors compared to California overall reported their health status as good or better for all age groups 55 and older. More specifically, 79.4% of San Diego residents 65 years or older reported being in good to excellent health compared to just 72.6% in California. Similarly, a smaller percentage (48.0%) reported having a physical, mental or emotional disability compared to the state overall (51.9%). To better understand morbidity and mortality, Table 2. describes the leading causes of death by age in SDC, followed by a more detailed description of how the top four health needs affect seniors.

Table 2. Top Five Leading Causes of Death by Number of Death Due to Disease, San Diego County, 2012* Rank 55-64 Years 65-75 Years 75-84 Years 85+ Years

1 Cancer Cancer Cancer Diseases of the Heart

2 Diseases of the Heart Diseases of the Heart Diseases of the Heart Cancer

Chronic Lower Chronic Lower 3 Unintentional Injury Alzheimer’s Respiratory Diseases Respiratory Diseases

Chronic Liver Disease 4 Diabetes Alzheimer’s Disease Stroke & Cirrhosis

Chronic Lower 5 Diabetes Stroke Stroke Respiratory Diseases *Adapted from the 2015 San Diego County Senior Health Report; Source: Death Statistical Master Files (CDPH), County of San Diego, Health & Human Services Agency, Epidemiology & Immunization Services Branch; SANDAG, Current Population Estimates, 2012.

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Behavioral Health

According to 2012 CHIS data, 15.0% of individuals age 55-64 and 8.1% of individuals age 65 and older reported needing help for an emotional/mental health problem or for use of alcohol/drugs in San Diego County. Approximately a third of seniors 65 and older who reported needing help sought support from a professional for their problems.

Mental Health Rates of anxiety disorder, mood disorders, schizophrenia and other psychotic disorders, and self-inflicted injury were consistently highest among those age 55-64 compared to those 65+ in both ED and Inpatient settings in 2012. Among those 65+, rates of anxiety-related discharges were highest living in South in 2012. Mood disorder discharge rates were highest among those 65+ in Central, for both ED and Inpatient hospitalization. Central and East region had the highest ED and hospitalization rates for Schizophrenia and other psychotic disorders and North Inland experienced the highest rates of suicide and self-inflicted injury.

Substance Abuse A higher percentage of San Diego seniors reported binge drinking (defined as 5 or more drinks for men or 4 or more drinks for women) in the past year compared to California overall (12.8% vs 9.3%). Similarly, a slightly higher percentage of San Diego seniors reported smoking than in California (8.6% vs. 6.5%) but this is still under the HP 2020 goal of less than 12%. In San Diego County, a higher rate of acute alcohol-related discharges were found among those 55-64 compared to those 65+. Of those 65 years or older, the highest rate of hospitalization and ED discharges was seen in Central. ED discharges for acute substance-related disorder were highest among 55-64 year olds, but hospitalization was highest among those 85 years or older.

Diabetes

In 2012, approximately 14.3% of seniors reported having ever been told they have pre-diabetes or borderline diabetes. It is estimated that roughly 15-30% of individuals with pre-diabetes will progress to Type 2 diabetes within 5 years. A further 16.0% reported that they have diabetes according to 2012 CHIS data. Deaths due to diabetes were highest among those 85+, whereas hospitalization and ED discharge rates were highest for those 75-84 years old in 2012. In particular, Central and South region demonstrated a greater burden of diabetes-related deaths and discharges.

Overweight/Obesity

Among those 65 and older in 2012, roughly 37% were overweight and 19% were obese.

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Cardiovascular Disease

Diseases of the heart have been shown to be the leading cause of death among those 65 and older and put a significant burden on the health system. Rates of hospitalization and death due to coronary heart disease were found to increase with age. Regionally, rates of hospitalization for coronary heart disease were found to be highest in South. Similarly, rates of stroke, another form of cardiovascular disease, were also found to increase with age, particularly among those 85+, and also had higher hospitalization rates in South. According to 2012 CHIS data, 60.7% of adults 65 years or older reported having ever been told they had high blood pressure, a significant risk factor for health outcomes such as heart attack and stroke.

Additional Barriers to Care

Poverty is a significant barrier to care. In 2012, roughly 18.9% of seniors estimated to be living at 149% or below the federal poverty level. In 2012, the ACS found that 19.2% of seniors spoke English less than “very well” and the anticipated demographic shift has implications for future demand for a diverse, culturally competent workforce. Seniors also face increased social isolation and physical limitations that may contribute to poorer health outcomes.

FOOTNOTE County of San Diego HHSA. (2015). San Diego County Senior Health Report. Retrieved from http://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/CHS/COSD_SeniorHealthReport_2015.pdf

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Asian American and Native Hawaiian and Other Pacific Islander

According to the 2010 Census, approximately 5.6% (17.3 million) of the U.S. population identified as “Asian alone” or “Asian in combination.” An overwhelming thirty-two percent of this population reported living in California. The Native Hawaiian and other Pacific Islander (NHPI) population accounted for an additional 0.4% (1.2 million) of the U.S. population. San Diego ranked 5th among U.S. counties with the highest number of Asian individuals and also had the 5th highest number of NHPIs. As a percentage of San Diego County’s population, Asians represented roughly 13% and NHPI represented 1% in 2010. Furthermore, Asian Americans were the fastest growing racial group and NHPI were the third fastest from 2000 to 2010 in the county. Finally, within the Asian American population, Filipino Americans made up the largest ethnic group, followed by Chinese and Vietnamese, and the Bangladeshi ethnic group was the fastest growing from 2000 to 2010. There exists a significant amount of variation within these groups, including language, culture, immigration patterns, spirituality, acculturation, education level, and socioeconomic status. To better understand morbidity and mortality, Table 3. describes the leading causes of death by ethnic group in San Diego County, followed by a more detailed description of how the top four health needs affect the Asian American NHPI population. Table 3. Leading Causes of Death by Race and Ethnic Group, San Diego County 2005-2010 Race and Ethnic Group Leading Causes of Death No. 1 Cause No. 2 Cause No. 3 Cause % of Total for Group % of Total for Group % of Total for Group Asian American Cancer 30% Heart Disease 23% Stroke 9% Cambodian Heart Disease Cancer 21% Stroke 12% 29% Chinese Cancer 31% Heart Disease 21% Stroke 9% Filipino Cancer 27% Heart Disease 25% Stroke 8% Indian Heart Disease 32% Cancer 22% Diabetes 7% Japanese Cancer 30% Heart Disease 20% Stroke 9% Korean Cancer 34% Heart Disease 14% Stroke 9% Laotian Cancer 31% Heart Disease 17% Stroke 9% Vietnamese Cancer 36% Heart Disease 17% Stroke 9% NHPI Heart Disease Cancer 21% Diabetes 8% 28% Guamanian or Heart Disease Cancer 20% Diabetes 8% Chamorro 28% Native Hawaiian Heart Disease Cancer 25% Accidents 7% 29% Samoan Heart Disease Cancer 19% Diabetes 8% 25% Total Population Heart Disease Cancer 25% Stroke 6% 25% *Adapted from the ‘A Community of Contrasts: Asian Americans, Native Hawaiians and Pacific Islanders in San Diego County,’ 2015 Report; Source: California Department of Public Health Death Public Use Files 2005–2010. Note: Chinese figures include Taiwanese

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Behavioral Health

According to the Asian Pacific Islander California Reducing Disparities Project (CRDP) Population Report, there exists a significant amount of variation in the rates of behavioral health needs among different ethnic groups. While data finds that typically prevalence of mental illness and service utilization are low among Asians, literature cited in the CRP report found that suicidal Asian Americans perceived less need for help and sought less services compared to Latinos, Asian and Pacific Islander youth had similar rates of emotional disturbance to the total population, Asian and Pacific Islander women over 65 years of age consistently had the highest suicide rates, and NHPI adults had the highest rate of depressive disorders and second highest rate of anxiety disorders among all racial groups. In San Diego, the 2012 County of San Diego ‘Progress towards Reducing Disparities: A Report for San Diego County Mental Health’ report found that the most common mental health disorders diagnosed among Asian American and NHPI adults were major depression disorders and schizophrenia/schizoaffective disorders. Aggregated data, stigma, language barriers, lack of access to care, complexity of healthcare systems, unfamiliarity with Western treatment models, and lack of culturally competent services may contribute to deceivingly low rates of mental illness and utilization of services. In particular, low demand for pre-crisis services and conversely, increased use of hospital-based crisis services could signify delayed help-seeking due to stigma, mistrust, or language barriers. Among strategies cited to decrease barriers to accessing mental health, the report suggested creating programs for a specific culture, issue, topic, or age group, using social/recreational activities, providing services in their primary language, increasing the availability and affordability of services, outreaching to counteract stigma, disaggregating data, including the family, and creating a culturally sensitive/competent staff. For a more detailed list of community-defined recommendations and strategies, please refer to the report found here: http://crdp.pacificclinics.org/files/resource/2013/04/Report.pdf

Diabetes

According to the 2011-2012 CHIS, approximately 7.1% of Asian Americans have diabetes compared to 8.4% in California overall.

Overweight/Obesity

According to 2011-2012 CHIS data, Asians reported the lowest proportion of obesity compared to other racial groups (9.7% vs 24.8% in CA overall). Diet and exercise play an important role in maintaining a healthy weight. Roughly 27.9% ate fruits and vegetables 3 or more times a day and 35.4% reported regular walking.

Cardiovascular Disease

Heart disease was the leading cause of death among NHPIs and the second among Asian Americans according to 2005-2010 data from the California Department of Public Health.

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Smoking and hypertension rates, both significant risk factors for cardiovascular disease, were lowest among Asians compared to other racial groups according to 2011-2012 CHIS data.

Additional Barriers to Care

Roughly 56% of Asian Americans were foreign-born in San Diego according to five-year 2006- 2010 ACS estimates. This was higher than all other racial groups. They were also second behind Latinos in the percentage of the population with limited English proficiency (36% or Latinos vs. 29% of Asian Americans). This rate increases to 58% among Asian American seniors according to a 2015 Union of Pan Asian Communities report. By contrast, only 9% NHPIs were foreign- born and 11% had limited English proficiency.

FOOTNOTE California Reducing Disparities Project (CRDP) Asian and Pacific Islander Population Report. (2013). ‘In Our Own Words.’ Retrieved from http://crdp.pacificclinics.org/files/resource/2013/04/Report.pdf Union of Pan Asian Communities. (2015). A Community of Contrasts: Asian Americans, Native Hawaiians and Pacific Islanders in San Diego County. Retrieved from http://www.upacsd.com/wp-content/uploads/2015/05/Community-of-Contrasts-Report-6-1- 15.pdf UCLA California Health Interview Survey. A Health Profile of California’s Diverse Population, 2011-2012 Race/Ethnicity Health Profiles.

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American Indians/Alaskan Natives

According to the 2010 U.S. Census, 1.7% (5.2 million) of the U.S. population reported being American Indian/Alaskan Native (AI/AN) alone or in combination and they were found to largely reside in urban settings. The San Diego American Indian Health Center (SDAIHC) identified 0.9% of their service area population as AI/AN alone and 1.7% (52,749) reported they were AI/AN alone or in combination with other races. This culturally diverse group experiences significant challenges due to misclassification, particularly into the categories of Latino, Asian Pacific Islander and Other. Although typically undercounted in sampling efforts, in 2011 an oversample was done of the AI/AN population for the CHIS providing a more accurate estimate of the health status of the population. In California, the AI/AN population was found to have the highest percentage of individuals’ age 65 and older (28.4%) compared to other racial and ethnic groups. Additionally, a higher percentage reported being in fair or poor health compared to the state (25.6% vs. 19.4%) and 29.0% of AI/AN individuals in California reported delaying getting prescriptions or medical services in the past year, a proportion higher than all other racial or ethnic groups. They were, however, more likely to report they had a usual source of care with only 9.7% of AI/ANs compared to 17.6% in the state citing they had no usual source of care. To better understand morbidity and mortality, Table 4. describes the leading causes of death among Native Americans in San Diego County, followed by a more detailed description of how the top four health needs affect the AI/AN population. While not mentioned below, asthma is also of particular concern in this population (23% vs. 7.7% in CA).

Table 4. Top Causes of Mortality, 2003-2007, SDAIHC Service Area AI/AN All Race Rank Rate per Rate per Cause of Death 100,000 Cause of Death 100,000 1 Heart Disease 124.5 Heart Disease 179.5 2 Cancer 116.4 Cancer 172.2 3 Diabetes 47.0 Stroke 46.1 4 Stroke 42.6 Chronic Lower Respiratory 38.9 Disease 5 Unintentional Injury 34.5 Alzheimer’s Disease 36.3 *Adapted from ‘San Diego American Indian Health Center: Community Health Profile, 2011’; Source: U.S. Center for Health Statistics

Behavioral Health According to the AI/AN focused CRDP Population Report focusing on behavioral health, there are a number of challenges, needs and opportunities to improving mental health wellness. Historical trauma, cultural and language differences, barriers to accessing services including tribal enrollment, data limitations, and mental health care billing contributed to mental health disparities in this population. The CRDP Population Report suggested that to improve Native American wellness, more collective, holistic approaches with integrated family and community support were need as opposed to the more Western individualist interventions. It emphasized

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healing though increased participation in traditional activities, improved cultural connectivity, use traditional healers and practices and integration of mental health and substance abuse prevention and treatment. Finally given the diversity of the AI/AN population, a number of successful programs were cited based on practice and community-based evidence. For more information the report can be viewed at http://www.nativehealth.org/content/publications.

Diabetes

According to the 2011-2012 CHIS, approximately 13.9% of AI/AN population reported having ever been diagnosed diabetes, which is significantly higher percentage than California overall (8.4%), and higher than any other racial or ethnic group. According to the 2011 SDAIHC Community Profile, diabetes-associated deaths were the third highest cause of mortality among AI/ANs in the San Diego service area and an estimated 16.0% of AI/ANs reported being told they have diabetes.

Overweight/Obesity

According to 2011-2012 CHIS data, AI/AN adults reported the highest proportion of obesity compared to other racial groups (36.2% vs 24.8% in CA overall). Estimates from the 2005-2010 BRFSS found that in the SDAIHC service area 41.1% of the AI/AN population were obese compared to just 23.6% of the general population. Diet and exercise play an important role in maintaining a healthy weight. Roughly 27.2% reported eating fruits and vegetables 3 or more times a day and 35.0% reported regular walking (2011-2012 CHIS).

Cardiovascular Disease

Heart disease and stroke were the first and fourth leading cause of death respectively among AI/ANs in the service area of the San Diego Indian Health according to 2003-2007 data from the U.S. Center for Health Statistics. Smoking and hypertension rates, both significant risk factors for cardiovascular disease, were highest among AI/ANs compared to other racial groups (2011- 2012 CHIS).

FOOTNOTE California Reducing Disparities Project (CRDP) Native American Strategic Planning Workgroup Report. ‘Native Vision: A Focus on Improving Behavioral Health Wellness for California Native Americans.’ UCLA California Health Interview Survey. A Health Profile of California’s Diverse Population, 2011-2012 Race/Ethnicity Health Profiles. San Diego American Indian Health Center. (2011). Community Health Profile. Retrieved from http://www.uihi.org/download/CHP_San-Diego_Final.pdf

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Latinos

According to the 2010 U.S. Census, Latinos constitute 16.3% (50.5 million) of the U.S. population. They are also the largest racial or ethnic group in California and estimates from the California Department of Finance suggest that Latino population comprises 52% of the state population by 2050. Furthermore, roughly 53% of California’s elementary school children are now of Latino origin (Department of Education, 2012). In particular, Grieco (2010) found that roughly 82% of Latinos in California were of Mexican descent. Estimates from the 2011 ACS showed that roughly 32.5% of the San Diego County population identified as Hispanic or Latino, ranking 10th among U.S. counties with the largest Hispanic population. Data from the 2011- 2012 CHIS found that Latinos had the highest proportion of adults (58.2%) living below 200% of the federal poverty level among all racial and ethnic groups. Latinos in California also had the highest percentage of adults (27.5%) who reported being in fair or poor health compared to other racial and ethnic groups. Finally, 25.5% of Latinos reported having no usual source of care when sick or in need of health advice; this proportion was the highest among all racial groups. The Hispanic Community Health Study/Study of Latinos, a longitudinal study of over 16,000 Latinos in four locations including San Diego, and the CRDP Population Report were used to gain further insight into how the top four health conditions impact the Latino population.

Behavioral Health According to the CRDP Population Report focusing on behavioral health in Latinos, the Hispanic population face many life stressors and experiences, including poor housing, abuse, trauma, stigma and discrimination, which contribute to mental health problems. In particular, depression is a major concern and a leading cause of disability, especially for Latino youth (McKenna, Michaud, Murray, and Marks, 2005). The Hispanic Community Health Study/Study of Latinos found that roughly 1 in 3 women compared to 1 in 5 men reported high depressive symptoms. These differences were less pronounced for anxiety, which ranged from 13.4% to 16.4% among breakouts by age and sex. The CRDP Population Report also cites literature emphasizing that utilization differs by nativity status. For example, Grant et al. (2011) found that approximately one quarter (24.2%) of U.S.-born Latinos received minimally adequate treatment for their mental health needs, similar to the California rate of 23.4%, but only 10% of Latinos born abroad received minimally adequate treatment. Higher social acculturation, including changes in lifestyle, cultural practices, increased stress, and adoption of new social norms were found to be associated with a decline in health status (Alegria, Chatterji, Wells, Cao, Chen, Takeuchi et al., 2008).

While the lack of health insurance coverage, immigration status, poverty, masculinity, inadequate transportation, and lack of information/awareness of existing mental health services are significant barriers to mental health care, stigma continues to be a main contributing factor. The report found that cultural beliefs may be used to explain mental illness as fate, and decrease help-seeking. Other barriers included a shortage of culturally and linguistically appropriate services, qualified mental health professionals and academic and school-based mental health programs, structural barriers to care (no touching protocols, hours,

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no privacy), and social exclusion. Strategies to improve these disparities included: (1) school- based and academic mental health programs; (2) community-based organizations and co- location of services; (3) community media; (4) culturally and linguistically appropriate treatment; (5) workforce development to sustain a culturally and linguistically competent mental health workforce; and (6) community outreach and engagement. Finally, three Latino cultural values were cited to have the greatest potential to influence the delivery of mental health services to Latinos: familismo, respeto and personalismo (incorporating a person- centered approach that emphasizes empathy, warmth, and attentiveness and that uses titles of respect and physical proximity) (Añez, Paris, Bedregal, Davidson, and Grilo, 2005; Garza and Watts, 2010).

Diabetes

According to the 2011-2012 CHIS, approximately 9.9% of the adult Latino population reported having ever been diagnosed diabetes. Results from The Hispanic Community Health Study/Study of Latinos found that the percentage of adults with pre-diabetes was lowest in the 18-44 age group and highest among middle age Latinos (45-64). Furthermore, one in three participants had pre-diabetes regardless of background, although Mexicans had a marginally higher at 37.7%. The percentage of Latinos with diabetes in the study increased substantially with age: roughly 6% among 18-44 year olds, 26% among 45-64 year olds, and 46% among 65- 74 year olds. The study also determined that about two-thirds of participants who had diabetes were aware of it but this increased with age, and similarly, only half of those with diabetes had their condition under control.

Overweight/Obesity

According to 2011-2012 CHIS data, 32.6% of Latino adults were estimated to be obese compared to 24.8% in CA overall. Diet and exercise play an important role in maintaining a healthy weight. Roughly 21.4% reported eating fruits and vegetables 3 or more times a day and 34.8% reported regular walking in the past week (2011-2012 CHIS). Also of interest, Latino adults had a higher proportion of food insecurity (26.8%) than other racial and ethnic groups, and this was significantly higher than the state (14.9%). The Hispanic Community Health Study/Study of Latinos found that the percentage of obese Latinos (ranging from 30.3-46.8%) was roughly the same across age groups and backgrounds.

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Cardiovascular Disease (CVD)

Results from The Hispanic Community Health Study/Study of Latinos found that more men than women reported having coronary heart disease and the percentage increased with age, peaking at 13.6% of men aged 65-74. This trend was similar for participants’ self-reported history of stroke. Major risk factors for CVD including hypertension, high cholesterol, obesity, diabetes, and smoking. The Hispanic Community Health Study/Study of Latinos also found that the number of CVD risk factors experienced by Latinos increased by age for both men and women. In particular, the percentage of Latinos with hypertension in the study increased substantially with age: roughly 7-9% among 18-44 year olds, 40-41% among 45-64 year olds, and 72-77% among 65-74 year olds.

______FOOTNOTE U.S. Census Bureau. (2011). Overview of Race and Hispanic Origin: 2010. Retrieved from https://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf Pew Research Center. (2013). Mapping the Latino Population, By State, County and City. Retrieved from http://www.pewhispanic.org/files/2013/08/latino_populations_in_the_states_counties_and_cities_FINAL.pdf California Reducing Disparities Project (CRDP) Latino Strategic Planning Workgroup Report. (2012) ‘Community-Defined Solutions for Latino Mental Health Care Disparities.’ National Institutes of Health. (2013). Hispanic Community Health Study/Study of Latinos Data Book: A Report to the Communities. UCLA California Health Interview Survey. A Health Profile of California’s Diverse Population, 2011-2012 Race/Ethnicity Health Profiles.

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African Americans

According to the 2010 Census, approximately 12.6% (38.9 million) of the U.S. population identified as “black or African American.” In California, they made up 6.2% of the total state population (2010 Census). Compared to the percentage of the U.S. and California populations that identify as African American, there are a number of risk factors that disproportionately affect this group and may contribute to poorer health outcomes (Table 5). Additionally, 2011- 2012 CHIS data shows that roughly 23.3% reported being in fair or poor health compared to 19.4% in the state.

Table 5. Percentage of African Americans with At-Risk Factors for Health Disparities* Risk Factor U.S. Population California Population Homeless 40% 45% (est.) Juveniles in Legal Custody 40% 28% Incarceration (All Prisoners) 50% 35% Foster Care 31% 45% Below Poverty Level 25% 20% *Adapted from the CRDP African American Strategic Planning Workgroup Report; Source: Source: U.S. Census Bureau, 2009; Poverty data: U.S. Census Bureau, American Community Survey, 2005-2009 U.S. Data; Homeless data: Interagency Council on the Homeless Report, 2011; Homeless data: HUD Annual Homeless Assessment Report (AHAR), 2009; Juvenile data: Office of Juvenile Justice & Delinquency Prevention, 2011; Incarceration data: California Department of Corrections and U.S. Department of Justice

Behavioral Health According to the CRDP Population Report focusing on behavioral health, in 2007-2008, African Americans represented 5.8% of California’s population but accounted for 16.59% of clients served in the California Department of Mental Health system. During the same year, the top three mental health diagnoses among this population were depressive disorders (12.6%), schizophrenia (8.4%), and bipolar disorder (6.2%). In a survey done for the CRDP Population Report, the top four mental health conditions that received the highest responses were bipolar, schizophrenia, drug addiction and depression. However, the report finds that in relationship to the black population, the mental health system has offered “inaccurate diagnoses, disproportionate findings of severe illness, greater usage of involuntary commitments, and inadequacy of service integration. “ In particular, African Americans tended to be over diagnosed for poorer treatment outcomes, such as schizophrenia, while anxiety and mood disorders often go untreated, and were more likely to have their first contact of mental health in an emergency room as opposed to in an outpatient care setting. Similarly, the report also states that black youth tend to be over diagnosed with conduct disorder and under diagnosed for depression. This has contributed to increased stigma in the black community that defines mental illness as “crazy,” personally caused, and difficult to resolve.

The CRD report found that current barriers to care include stress, perceived discrimination and racism, personal crises, insurance coverage, financial resources, communication, stigma and lack of African American providers. African Americans may over-rely on more informal

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approaches to help with behavioral disorders and thus underutilize behavioral health services. In particular, the help seeking behavior of African Americans tends to be delayed and rely on the black church. Delayed help seeking for behavioral health problems among blacks has been found to last for years or even decades and is likely contribute to increased emergency room use. A number of suggestions for prevention and early intervention were found as a result of community input and quantitative data collection including working with the faith-based community, working with the criminal justice system, training first responders to work in partnership with African Americans, working with hospital staff in emergency rooms, targeting the whole person, creating more opportunities for feedback on care received and providing more jobs for survivors of mental issues. Furthermore, the report states that there is a missed prevention and early intervention opportunity in our public school system including health screening and low academic scores as possible indicators of mental illness, learning disability, developmentally delayed or medical problems. For a more complete list of suggestions and statistics, please refer to the CRDP Population Report: https://www.cdph.ca.gov/programs/Documents/African_Am_CRDP_Pop_Rept_FINAL2012.pdf

Diabetes According to the 2011-2012 CHIS, approximately 11.4% of the black adult population reported having ever been diagnosed diabetes, which is significantly higher percentage than California overall (8.4%)

Overweight/Obesity

According to 2011-2012 CHIS data, African American adults had the second the highest proportion of obesity, behind AI/ANs, compared to other racial groups in California (36.1% vs 24.8% in CA overall). Diet and exercise play an important role in maintaining a healthy weight. Black adults had the lowest proportion of engagement in regular walking in the past week and consumption of fruits and vegetables 3 or more times a day compared to other racial and ethnic groups (2011-2012 CHIS).

Cardiovascular Disease

According to 2013 U.S. Census data, diseases of the heart were the leading cause of death for African Americans at 23.8%. Behind Native Americans, blacks also had the highest percentage of individuals with high blood pressure when compared to other racial and ethnic groups (2011- 2012 CHIS).

FOOTNOTE CDC/National Center for Health Statistics, National Vital Statistics System. Mortality, 2013. Retrieved from http://www.cdc.gov/nchs/data/dvs/LCWK1_2013.pdf California Reducing Disparities Project (CRDP) African American Strategic Planning Workgroup Report. (2012) ‘WE AIN’T CRAZY! Just Coping With a Crazy System:’ Pathways into the Black Population for Eliminating Mental Health Disparities.’ Retrieved from http://www.cdph.ca.gov/programs/Documents/African_Am_CRDP_Pop_Rept_FINAL2012.pdf UCLA California Health Interview Survey. A Health Profile of California’s Diverse Population, 2011-2012 Race/Ethnicity Health Profiles.

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Homeless

The Regional Taskforce for the Homeless conducted a count of San Diego homeless on January 23rd, 2015. The data collected from this 2015 Point-in-Time count provides an important snapshot of the demographic and vital statistics of the San Diego homeless population. According to the WeALLCount report, there is estimated to be 8,742 homeless individuals in San Diego County, roughly half of which were unsheltered at the time of the survey. Compared to 2014 there was a 4.3% increase in the number of unsheltered homeless and a 1.4% increase in the number of homeless persons staying in the shelter system. A sample of unsheltered homeless individuals was interviewed to estimate the characteristics of this population.

The majority of unsheltered homeless were male (70%) and between the ages of 25 and 54 (58%). The majority of those surveyed were white (64%), followed by black or African American (22%), multiple races (7%), AI/AN (4%), Native Hawaiian or Other Pacific Islander (2%) and Asian (1%). Roughly 35% reported having a physical disability, 63% have spent time in jail, prison, or both, and 70% have been homeless for a year or longer. Loss of a job was the most common cause of homelessness (27%), followed by disability (9%), loss of a spouse (5%), and abuse (5%). In terms of accessing healthcare, unsheltered homeless cited clinic/urgent care (42%) and the emergency room, no appointment (35%) as their leading place of health care service. The majority of unsheltered homeless had health insurance (63%) with 75% insured through Medicaid and 15% covered by Medicare. Approximately a third (39%) reported not seeing a doctor despite needing to largely because of cost (39%), distance (31%), and fear (20%).

Additionally 16% were veterans, almost half of which entered into service between 1976-1990. While there has been a decline in the number of homeless over the last five years, there was a 22% increased in the number of unsheltered veterans from 2014 to 2015. The full report can be found at http://www.rtfhsd.org/publications/

Behavioral Health Of the unsheltered homeless, 17% self-reported problems with substance/alcohol abuse and 19% self-reported having severe mental illness, defined as a mental illness that is severe, long term, and inhibits their ability to live independently. Diabetes Approximately 9.1% of unsheltered homeless in San Diego had diabetes, a similar rate to the general population but it is estimated that only 19% of unsheltered diabetics use insulin.

Cardiovascular Disease According to the 2015 WeALLCount report, approximately 28.9% were estimated to have a heart condition. Additionally, a large majority (71%) reported smoking at least 100 cigarettes in their lifetime. ______FOOTNOTE Regional Taskforce on the Homeless. (2015). 2015 WeALLCount Results. Retrieved from http://www.rtfhsd.org/wp/wp- content/uploads/2011/08/2015-WeAllCount-Results-Final.pdf

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LGBTQ

According to the 2013 National Health Interview Survey (NHIS), roughly 97.7% of the U.S. population over the age of 18 identified as straight, 1.6% identified as gay or lesbian, and 0.7% identified as bisexual. Overall health status was largely the same among all groups, although among women age 18-64, a higher proportion of those who identified as straight (63.3%) were in excellent or very good health compared to those who identified as gay or lesbian (54.0%). When evaluating access to health care by sexual orientation, the report found that among women, a higher percentage of those age 18-64 who identified as straight (85.5%) had a usual place to go for medical care compared to those who identified as gay or lesbian (75.6%) or bisexual (71.6%). Roughly 15.2% of gay or lesbian women age 18-64 also failed to obtain needed medical care in the past year due to cost compared to 9.6% of straight women. While this provides baseline data regarding the health of this group, it is important to note that there are significant limitations to data on sexual orientation, including the lack of data on gender identity and potentially biased estimates due to increased risk and stigma or lack of identification as LGBTQ. The LGBTQ group is a very heterogeneous entity, found within all races, religions and socioeconomic backgrounds.

Behavioral Health According to the CRDP Population Report focusing on behavioral health in the LGBTQ population, lack of cultural competency in the health care system, reduced access to employer- provided health insurance and/or lack of domestic partner benefits, and social stigma against LGBTQ persons were cited as major contributing factors to negative health outcomes in the LGBTQ community and these factors were amplified among LGBTQ persons of color. The report’s community survey found that over 75% of respondents somewhat or strongly agreed they had experienced emotional difficulties which were directly related to their sexual identity or gender identity/expression. This was highest percentages were found among the Trans Spectrum group, queer-identified individuals, Native Americans and youth. Of those services the population wanted but did not receive were individual counseling/therapy, couples or family counseling, peer support groups and non-Western medical intervention. In particular, those on Medi-Cal had more difficulty accessing services than those who reported having private insurance. Among the recommendations to improve mental and behavioral health for the LGBTQ community, the CRDP Population Report emphasizes the need for demographic information to be collected, workforce training on cultural competency and the distinctness of each sector of the LGBTQ community, development of effective anti-bullying and anti-harassment campaigns, and the creation of a safe and welcoming space for LGBTQ individuals seeking services and LGBTQ employees.

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Overweight/Obesity

According to the 2013 NHIS, a higher percentage of straight men aged 20–64 (30.7%) were obese compared to men who identified as gay (23.2%) and similarly, among women aged 20– 64, a higher percentage of those who identified as bisexual (40.4%) were obese compared to women who identified as straight (28.8%). No differences were found among levels of aerobic exercise among the groups.

FOOTNOTE National Health Statistics Reports. (2014). Sexual Orientation and Health Among U.S. Adults: National Health Interview Survey, 2013. Retrieved from http://www.cdc.gov/nchs/data/nhsr/nhsr077.pdf California Reducing Disparities Project (CRDP) LGBTQ Strategic Planning Workgroup Report. ‘First, Do No Harm: Reducing Disparities for Lesbian, Gay, Bisexual, Transgender, Queer and Questioning Populations in California.’ Retrieved from https://www.cdph.ca.gov/programs/Documents/LGBTQ_Population_Report.pdf

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Refugee Population

According to a 2014 report by the United Nations High Commissioner for Refugees, there was marked growth in forced displacement globally with a total of 59.5 million individuals who have been forcibly displaced as a result of persecution, conflict, generalized violence, or human rights violations. In 2014, 13.9 million individuals were newly displaced, including 11.0 million internally displaced individuals and 2.9 million new refugees. Of 1.7 million submitted applications for asylum and refugee status, 121,200 were to the United States and 73,000 were admitted in 2014. During the 2010-2014 federal fiscal year, 31,221 refugees arrived in California. Of those, 13,801 refugees arrived in San Diego County, ranking highest among all California counties in every year in the number of refugee admissions. The largest group arriving to California was from Iraq (15,736), followed by Iran (7,361), Southeast Asia (2,785). A slightly different trend was seen in San Diego with 10,363 refugees arriving from Iraq, 1,281 from Africa, and 1,118 from Southeast Asia over the course of four years. According to the County of San Diego ‘2011 Refugee Fact Sheet,’ the top cities/communities in which refugees resettled were San Diego (820), El Cajon (677) and Spring Valley (62) in 2011.

Figure 1. Refugee Arrivals into California and San Diego, 2010-2014 14000 8563 12000

10000 6119 5183 8000 6382

6000 4974 3663 4000 2622 2661 2000 2745 2110 0 2010 2011 2012 2013 2014 California San Diego County

Source: California Department of Social Services-Refugee Programs Bureau, Refugee Arrivals Into California Counties, Federal Fiscal Years 2010 – 2014 (October 1, 2009 through September 30, 2014)

A 2007 Assessment of Community Member Attitudes Towards the Health Needs of Refugees in San Diego found the following to be major perceived health concerns (Table 6.). Rankings should be taken with caution due to the qualitative nature of the data.

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Table 6. Major Perceived Refugee Health Concerns by Demographic Group Rank Children Women Elderly 1 Nutritional Issues: Reproductive Health Hypertension Obesity/Malnourishment Issues 2 Mental Health Domestic Violence Diabetes 3 -- Mental Health Mental Health Other Important Alcohol/Drugs, Asthma, Nutritional Issues, Arthritis, Cardiovascular Health Conditions Sexually Transmitted Obesity, Sexually Conditions, Hearing, Infections, Transmitted Infections Vision Immunizations Source: University of California, San Diego Assessment of Community Member Attitudes towards the Health Needs of Refugees in San Diego, 2007

Behavioral Health The 2007 assessment found that mental health was among the most commonly mentioned health concerns for the San Diego refugee community. In particular, depression and posttraumatic stress disorder or “traumatized living” were cited as problems. Factors contributing to depression were feelings of loneliness, lack of control over their environment, and hopelessness. Stigma, cultural issues, fear of appearing ‘crazy,’ and a lack of knowledge of symptoms were obstacles to acknowledging mental illness and accessing treatment. The report found that mental health issues were found to play a role in physical health problems of refugees. Those who did seek treatment struggled to find culturally appropriate services specific to their unique stressors and language needs. This is particularly true for the elderly who have greater barriers to care, such as transportation, and may experience increased isolation.

Diabetes Diabetes and management of the disease was identified as an emerging health issue for refugees. The prevalence of diabetes and its causes were thought to vary depending on the country of origin and acculturation levels according to San Diego interviewees.

Obesity According to the 2007 assessment regarding the health of refugees, those interviewed had concerns over the changing eating habits of their children, including the lack of nutritious foods and potential weight gain. Reasons for this were higher cost of nutritious food, desire for children to ‘fit in,’ and increased sedentary lifestyle. In general, obesity was found to be more prevalent among those who had lived in the U.S. longer thanks to poor diet choices, lack of knowledge of healthy practices, acculturation problems shopping and preparing food with new ingredients, and overall lifestyle changes.

Cardiovascular Disease While cardiovascular disease specifically was not a major concern mentioned by San Diego refugees and providers in the 2007 assessment, several contributing risk factors were

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frequently mentioned. Hypertension was cited as a perceived health concern by more subjects in the assessment than any other health concern, with the exception of mental health, and was found to increase with age. Research into potential causes identified stress, psychosocial issues, and diet as potentially exacerbating forces. High cholesterol was also mentioned by providers for refugees as a condition that emerged upon resettlement, due to changes in diet and lifestyle.

Barriers to Care The report also found the top five perceived barriers to accessing healthcare were lack of transportation, language barriers, gaps in insurance and unfamiliarity with the health system. Language barriers including interpretation and translated health information were found to be barriers to accessing preventative services. Cultural barriers were also cited including the role of the physician, stigma, and the gender of the physician.

FOOTNOTE United Nations High Commissioner for Refugees. (2014). “UNHCR Global Trends 2014,” Retrieved from http://unhcr.org/556725e69.html County of San Diego. (2011). “2011 Refugee Fact Sheet,” Retrieved from http://www.sandiegocounty.gov/hhsa/programs/phs/documents/Refugee_FactSheet2011.pdf University of California- San Diego. (2007). Assessment of Community Member Attitudes Towards the Health Needs of Refugees in San Diego. California Department of Social Services - Refugee Programs Bureau. Refugee Arrivals into California Counties, FY 2010 – 2014.

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Appendix Description of Community Needs E Index

Dignity Health and Truven Health jointly developed the nation’s first standardized CNI.68 The CNI identifies the severity of health vulnerability for every ZIP code in the U.S. based on specific barriers to health care access.

The CNI provides a score for every populated ZIP code in the U.S. on a scale of 1.0 to 5.0. A score of 1.0 indicates a ZIP code with the least need, while a score of 5.0 represents a ZIP code with the most need. For a detailed description of the CNI please visit the interactive website at: http://cni.chw-interactive.org/. The five barriers are listed below along with the individual 2013 statistics that were analyzed for each barrier.

1. Income Barrier  Percentage of households below poverty line, with head of household age 65 or more  Percentage of families with children under 18 below poverty line  Percentage of single female-headed families with children under 18 below poverty line

2. Cultural Barrier  Percentage of the population that is minority (including Hispanic ethnicity)  Percentage of the population over age 5 that speaks English poorly or not at all

3. Educational Barrier  Percentage of the population over 25 without a high school diploma

4. Insurance Barrier  Percentage of the population in the labor force, aged 16 or more, without employment  Percentage of the population without health insurance

5. Housing Barrier  Percentage of the population renting their home

Based on these 5 categories and 9 total criteria, every ZIP code in the U.S. was assigned an index number:  Scale of 1 – 5  5 represents the most vulnerable communities; 1 the least vulnerable

68 Source: Dignity Health, Community Need Index. http://cni.chw- interactive.org/Truven%20Health_2015%20Source%20Notes_Community%20Need%20Index.pdf

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Appendix Community Needs Index Map of San F Diego County

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Appendix Health Access and Navigation G Survey

English

Spanish

Oncology

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English

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Spanish

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Oncology

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Appendix H Key Informant Interview Questions

Welcome/Introduction: Seven hospitals and health care systems – including Sharp HealthCare – have come together under the auspices of the Hospital Association of San Diego and Imperial Counties (HASD&IC) and the Institute for Public Health (IPH) to conduct a triennial Community Health Needs Assessment (CHNA) that identifies and prioritizes the most critical health-related needs of San Diego County residents. A longitudinal review of CHNAs conducted over the past 15 years reveals that overarching health needs in the region have remained relatively stable over time. Based on 2013 CHNA findings and the consistency of these findings over time, it is likely that going forward, cardiovascular disease, Type 2 diabetes, behavioral health and obesity will continue to be top community health concerns in our region, particularly in high need communities.

Sharp HealthCare based its individual hospital CHNAs on this model, and through further outreach and analyses, identified additional health needs for its hospitals, including: cancer, high-risk pregnancy, and senior health.

In recognition of the challenges that health providers, community organizations and residents face in their efforts to prevent, diagnose and manage these chronic conditions, the 2016 CHNA process will focus on gaining deeper insight into the top health needs identified in the Sharp HealthCare 2013 CHNAs. Accordingly, participating hospitals are seeking input from local case managers, health navigators and community organizations in order to better understand the challenges and opportunities that arise from the top four community health needs.

Top community health needs identified across Sharp HealthCare (listed alphabetically, not ranked):

1. Behavioral health 5. High-risk pregnancy 2. Cancer 6. Obesity 3. Cardiovascular disease 7. Senior Health 4. Diabetes, Type 2

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Key Informant Questions

1. Most important health issues or needs:

a. For disease specific expertise: With in your expertise area what are the most important issues found in your population insert expertise area (e.g. Cardiovascular Disease)? (e.g. hypertension could be a major health issue that affects cardiovascular health or a frequent behavioral health issue could be depression.)

b. For population specific expertise: What do you think are the most important health issues for insert population expertise (e.g. Latino’s) related to behavioral health, cardiovascular disease, diabetes and obesity? (Please explore within the health needs that you feel are most important; for example hypertension could be a major health issue that affects cardiovascular health, or a frequent behavioral health issue could be depression.)

2. What do you think are the most important risk factors related to the health issues you just mentioned?

3. What strategies do you think would be most effective for patients, physicians, case managers etc. in addressing the health needs or risk factors above?

4. What resources need to be developed or increased in order to address the health needs or risk factors above?

5. Are there systems, policy, or environmental changes that, if implemented, could help the hospitals address these health needs or risk factors?

6. Can you recommend any partnerships or collaborations between hospitals and specific organizations that would help to address the health needs or risk factors above?

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Appendix Case Manager/Health Navigator I Discussion Tool

CASE MANAGER/HEALTH NAVIGATOR DISCUSSION TEMPLATE – Sharp HealthCare

In recognition of the challenges that health providers, community organizations and residents face in their efforts to prevent, diagnose and manage these chronic conditions, the 2016 CHNA process will focus on gaining deeper insight into the top health needs identified in the Sharp HealthCare 2013 CHNAs. Accordingly, participating hospitals are seeking input from local case managers, health navigators and community organizations in order to better understand the challenges and opportunities that arise from the top four community health needs.

Top community health needs identified across Sharp HealthCare (listed alphabetically, not ranked):

1. Behavioral health 2. Cancer 3. Cardiovascular disease 4. Diabetes, Type 2 5. High-risk pregnancy 6. Obesity 7. Senior health

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GENERAL DISCUSSION TEMPLATE- Sharp HealthCare Questions to aid in discussion. Keep in mind the top health needs.

The Ice-Breaker - round robin - each person asked to make an individual statement, the facilitator starts and provides an example (if names have already been given at beginning of meeting skip to D)

a. Name b. Position/role c. How long at Sharp HealthCare d. Favorite healthy activity or healthy food

1. What are the most common health issues or needs of your clients? (Please explore within the health needs that you feel are most important; for example hypertension could be a major health issue that affects cardiovascular health, or a frequent behavioral health issue with your clients could be depression.) 2. For the health issues and needs identified above, what are the challenges your clients face to improving their health? This could refer to any aspect of health (i.e. behavior change, access, etc.) 3. When your patients are unable to adopt healthy behaviors, what are their reasons for not adopting changes? Follow up Questions if needed: a. What barriers or lack of resources contribute to this challenge? b. What knowledge/education would be beneficial to help your patient adopt behavior change? 4. What are the top challenges that you, as case managers/Health Educators, face to successfully helping your clients meet their health needs? 5. What have you have found works best with your clients to help them meet their health needs? (For example health navigators, mobile devices and apps, translators, etc.) 6. How could your facility collaborate with community based organizations to help you meet the needs of your clients?

7. Is there anything else you would like us to know about the clients you serve and how to better understand their health needs?

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Appendix Map of Community and Region J Boundaries in San Diego County

Map created by Sharp Strategic Planning Department, January 2010.

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Appendix SGH Behavioral Health Hospital K Data

Table 1: SGH Behavioral Health Inpatient Top 10 ICD-9 Codes, CY2013

ICD-9 Male % Female % Top 10 ICD-9 Diagnosis Codes Code Frequency Percentage Freq.* Male Freq.* Female Depressive Disorder not 311.00 2,483 14.50% 840 4.90% 1,643 9.59% Elsewhere Classified Anxiety State Unspecified 300.00 2,077 12.13% 653 3.81% 1,424 8.31% Nondependent Cannabis 305.20 701 4.09% 395 2.31% 306 1.79% Abuse Unspecified Use Nondependent Amphetamine or Related Acting 305.70 673 3.93% 385 2.25% 288 1.68% Sympathomimetic Abuse Unspecified Use Bipolar Disorder Unspecified 296.80 542 3.16% 195 1.14% 347 2.03% Other and Unspecified Alcohol Dependence 303.90 539 3.15% 355 2.07% 184 1.07% Unspecified Drinking Behavior Alzheimer’s Disease 331.00 488 2.85% 196 1.14% 292 1.71% Other and Unspecified Alcohol Dependence 303.91 487 2.84% 327 1.91% 160 0.93% Continuous Drinking Behavior Nondependent Alcohol Abuse 305.00 472 2.76% 312 1.82% 160 0.93% Unspecified Drinking Behavior Schizoaffective Disorder Chronic State With Acute 295.74 342 2.00% 175 1.02% 167 0.98% Exacerbation Other Diagnoses In This -- 8,322 48.59% 4,340 25.34% 3,982 23.25% Identified Health Area Total ICD-9 Code Count 17,126 -- 8,173 47.7% 8,953 52.3% Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 2: SGH Behavioral Health Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 18 0.26% 18 - 34 Years 1,020 14.77% 35 - 64 Years 3,508 50.79% 65 Years or 2,361 34.18% Greater Total Encounters 6,907 -- Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data

Table 3: SGH Behavioral Health Ambulatory Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Depressive Disorder not 311.00 88 30.45% 32 11.07% 56 19.38% Elsewhere Classified Anxiety State Unspecified 300.00 75 25.95% 29 10.03% 46 15.92% Bipolar Disorder 296.80 13 4.50% 6 2.08% 7 2.42% Unspecified Nondependent Alcohol 305.03 10 3.46% 7 2.42% 3 1.04% Abuse in Remission Other and Unspecified Alcohol Dependence 303.90 9 3.11% 8 2.77% 1 0.35% Unspecified Drinking Behavior

Alzheimer’s Disease 331.00 8 2.77% 4 1.38% 4 1.38%

Nondependent Other Mixed or Unspecified Drug 305.93 7 2.42% 4 1.38% 3 1.04% Abuse in Remission Nondependent Cannabis 305.21 7 2.42% 4 1.38% 3 1.04% Abuse Continuous Use Unspecified Intellectual 319.00 6 2.08% 4 1.38% 2 0.69% Disabilities Other Specified Delays in 315.80 4 1.38% 2 0.69% 2 0.69% Development Other Diagnoses In This -- 62 21.45% 30 10.38% 32 11.07% Identified Health Area Total ICD-9 Code Count 289 -- 130 44.98% 159 55.02% Data Source: SpeedTrack CUPID; OSHPD Ambulatory Surgery Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 4: SGH Behavioral Health Ambulatory Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 2 1.03% 18 - 34 Years 15 7.73% 35 - 64 Years 116 59.79% 65 Years or 61 31.44% Greater Total Encounters 194 -- Data Source: SpeedTrack CUPID; OSHPD Ambulatory Surgery Hospital Discharge Data

Table 5: SGH Behavioral Health Emergency Department Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Anxiety State Unspecified 300.00 6,168 21.83% 1,996 7.06% 4,172 14.77% Depressive Disorder not 311.00 4,705 16.65% 1,463 5.18% 3,242 11.48% Elsewhere Classified Bipolar Disorder 296.80 2,207 7.81% 898 3.18% 1,309 4.63% Unspecified Unspecified Type Schizophrenia Unspecified 295.90 1,402 4.96% 779 2.76% 623 2.21% State Nondependent Alcohol Abuse Unspecified Drinking 305.00 1,309 4.63% 784 2.78% 525 1.86% Behavior Nondependent Cannabis 305.20 1,163 4.12% 700 2.48% 463 1.64% Abuse Unspecified Use Nondependent Amphetamine or Related 305.70 1,096 3.88% 621 2.20% 475 1.68% Acting Sympathomimetic Abuse Unspecified Use Other Mixed or Unspecified Drug Abuse Unspecified 305.90 583 2.06% 297 1.05% 286 1.01% Use Schizoaffective Disorder 295.70 541 1.91% 311 1.10% 230 0.81% Unspecified State Posttraumatic Stress 309.81 507 1.79% 195 0.69% 312 1.10% Disorder Other Diagnoses In This -- 8,571 30.34% 4,582 16.22% 3,989 14.12% Identified Health Area Total ICD-9 Code Count 28,252 -- 12,626 44.69% 15,626 55.31% Data Source: SpeedTrack CUPID; OSHPD Emergency Department Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 6: SGH Behavioral Health Emergency Department Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 459 3.24% 18 - 34 Years 4,740 33.47% 35 - 64 Years 7,429 52.45% 65 Years or 1,535 10.84% Greater Total Encounters 14,163 -- Data Source: SpeedTrack CUPID; OSHPD Emergency Department Hospital Discharge Data

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Appendix SGH Cardiovascular Health Hospital L Data

Table 1: SGH Cardiovascular Inpatient Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis Male Female % Codes ICD-9 Code Frequency Percentage Freq.* % Male Freq.* Female Unspecified Essential 401.90 9,139 24.77% 4,137 11.21% 5,002 13.56% Hypertension Congestive Heart Failure 428.00 4,069 11.03% 2,135 5.79% 1,934 5.24% Unspecified Atrial Fibrillation 427.31 3,467 9.40% 1,799 4.88% 1,668 4.52% Coronary Atherosclerosis of 414.01 3,279 8.89% 1,799 4.88% 1,480 4.01% Native Coronary Artery Hypertensive Chronic Kidney Disease Unspecified With Chronic Kidney 403.90 1,736 4.71% 1,031 2.79% 705 1.91% Disease Stage I Through Stage IV or Unspecified Coronary Atherosclerosis of Unspecified Type of Vessel 414.00 1,288 3.49% 881 2.39% 407 1.10% Native or Graft Malignant Essential 401.00 1,265 3.43% 535 1.45% 730 1.98% Hypertension

Old Myocardial Infarction 412.00 1,213 3.29% 719 1.95% 494 1.34%

Chronic Diastolic Heart 428.32 789 2.14% 345 0.94% 444 1.20% Failure Other Specified Forms of Chronic Ischemic Heart 414.80 716 1.94% 473 1.28% 243 0.66% Disease Other Diagnoses In This -- 9,931 26.92% 5,153 13.97% 4,778 12.95% Identified Health Area Total ICD-9 Code Count 36,892 -- 19,007 51.5% 17,885 48.5% Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 2: SGH Cardiovascular Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 5 0.03% 1 - 17 Years 2 0.01% 18 - 34 Years 305 2.03% 35 - 64 Years 5,823 38.84% 65 Years or 8,857 59.08% Greater Total Encounters 14,992 -- Data Source: SpeedTrack CUPID; Inpatient Hospital Discharge Data

Table 3: SGH Cardiovascular Ambulatory Surgery Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Unspecified Essential 401.90 1,983 55.87% 26.60% 29.28% Hypertension 944 1,039 Coronary Atherosclerosis of 414.01 476 13.41% 9.13% 4.28% Native Coronary Artery 324 152 Atrial Fibrillation 427.31 197 5.55% 134 3.78% 63 1.78%

Old Myocardial Infarction 412.00 108 3.04% 2.37% 0.68% 84 24 Congestive Heart Failure 428.00 97 2.73% 1.94% 0.79% Unspecified 69 28 Other Specified Forms of Chronic Ischemic Heart 414.80 74 2.09% 1.78% 0.31% Disease 63 11 Hypertensive Chronic Kidney Disease Unspecified With Chronic Kidney 403.90 61 1.72% 38 1.07% 23 0.65% Disease Stage I Through Stage IV or Unspecified Coronary Atherosclerosis of Unspecified Type of Vessel 414.00 54 1.52% 1.35% 0.17% Native or Graft 48 6 Other and Unspecified 413.90 44 1.24% 0.82% 0.42% Angina Pectoris 29 15 Intermediate Coronary 411.10 38 1.07% 0.73% 0.34% Syndrome 26 12 Other Diagnoses In This -- 417 11.75% 7.27% 4.48% Identified Health Area 258 159 Total ICD-9 Code Count 3,549 -- 2,017 56.83% 1,532 43.17% Data Source: SpeedTrack CUPID; OSHPD Ambulatory Surgery Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 4: SGH Cardiovascular Ambulatory Surgery Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 0 0.00% 18 - 34 Years 23 0.98% 35 - 64 Years 918 39.01% 65 Years or 1,412 60.01% Greater Total Encounters 2,353 -- Data Source: SpeedTrack CUPID; Ambulatory Surgery Hospital Discharge Data

Table 5: SGH Cardiovascular Emergency Department Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female Codes Code Frequency Percentage Freq.* % Male Freq.* % Female Unspecified Essential 401.90 16,526 59.00% 6,855 24.47% 9,671 34.53% Hypertension Atrial Fibrillation 427.31 1,887 6.74% 878 3.13% 1,009 3.60% Congestive Heart Failure 428.00 1,846 6.59% 903 3.22% 943 3.37% Unspecified Coronary Atherosclerosis of 414.01 1,499 5.35% 787 2.81% 712 2.54% Native Coronary Artery Old Myocardial Infarction 412.00 1,426 5.09% 757 2.70% 669 2.39% Coronary Atherosclerosis of Unspecified Type of Vessel 414.00 1,050 3.75% 646 2.31% 404 1.44% Native or Graft Hypertensive Chronic Kidney Disease Unspecified With Chronic Kidney 403.90 803 2.87% 414 1.48% 389 1.39% Disease Stage I Through Stage IV or Unspecified Malignant Essential 401.00 759 2.71% 270 0.96% 489 1.75% Hypertension Hypertensive Chronic Kidney Disease Unspecified With Chronic Kidney 403.91 304 1.09% 169 0.60% 135 0.48% Disease Stage V or End Stage Renal Disease Hemiplegia Affecting 438.20 156 0.56% 69 0.25% 87 0.31% Unspecified Side Other Diagnoses In This -- 1,753 6.26% 844 3.01% 909 3.25% Identified Health Area Total ICD-9 Code Count 28,009 -- 12,592 44.96% 15,417 55.04% Data Source: SpeedTrack CUPID; OSHPD Emergency Department Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 6: SGH Cardiovascular Emergency Department Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 18 0.09% 18 - 34 Years 1,185 5.96% 35 - 64 Years 10,846 54.57% 65 Years or 7,825 39.37% Greater Total Encounters 19,874 -- Data Source: SpeedTrack CUPID; Emergency Department Hospital Discharge Data

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Appendix M SGH Diabetes Hospital Data

Table 1: SGH Diabetes Inpatient Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 ICD-9 Male Female Diagnosis Codes Code Frequency Percentage Freq.* % Male Freq.* % Female Diabetes Mellitus Without Mention of Complication Type II 250.00 3,906 45.61% 1,879 21.94% 2,027 23.67% or Unspecified Type not Stated as Uncontrolled Diabetes With Renal Manifestations Type II or Unspecified Type 250.40 718 8.38% 397 4.64% 321 3.75% not Stated as Uncontrolled Diabetes Mellitus Without Mention of Complication Type II 250.02 700 8.17% 357 4.17% 343 4.01% or Unspecified Type Uncontrolled Diabetes With Neurological Manifestations Type II 250.60 662 7.73% 363 4.24% 299 3.49% or Unspecified Type not Stated as Uncontrolled Abnormal Glucose Tolerance of Mother 648.81 339 3.96% 0 0.00% 339 3.96% With Delivery Diabetes With Neurological Manifestations Type II 250.62 300 3.50% 165 1.93% 135 1.58% or Unspecified Type Uncontrolled Diabetes With Other Specified 250.80 297 3.47% 166 1.94% 131 1.53% Manifestations Type II

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or Unspecified Type not Stated as Uncontrolled Diabetes With Renal Manifestations Type II 250.42 241 2.81% 135 1.58% 106 1.24% or Unspecified Type Uncontrolled Diabetes With Ophthalmic Manifestations Type II or Unspecified Type 250.50 176 2.06% 87 1.02% 89 1.04% not Stated as Uncontrolled

Diabetes With Peripheral Circulatory Disorders Type II or 250.70 152 1.77% 88 1.03% 64 0.75% Unspecified Type not Stated as Uncontrolled Other Diagnoses In This Identified Health -- 1,073 12.53% 498 5.82% 575 6.71% Area Total ICD-9 Code 8,564 -- 4,135 48.3% 4,429 51.7% Count Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

Table 2: SGH Diabetes Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 2 0.03% 18 - 34 Years 387 5.73% 35 - 64 Years 2,912 43.12% 65 Years or 3,453 51.13% Greater Total Encounters 6,754 -- Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data

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Table 3: SGH Diabetes Ambulatory Surgery Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis Male Female % Codes ICD-9 Code Frequency Percentage Freq.* % Male Freq.* Female Diabetes Mellitus Without Mention of Complication Type II or 250.00 665 87.39% 365 47.96% 300 39.42% Unspecified Type not Stated as Uncontrolled Diabetes With Neurological Manifestations Type II or 250.60 24 3.15% 13 1.71% 11 1.45% Unspecified Type not Stated as Uncontrolled Diabetes With Renal Manifestations Type II or 250.40 13 1.71% 8 1.05% 5 0.66% Unspecified Type not Stated as Uncontrolled Diabetes With Other Specified Manifestations Type II or Unspecified 250.80 11 1.45% 8 1.05% 3 0.39% Type not Stated as Uncontrolled Diabetes Mellitus Without Mention of Complication Type II or 250.02 9 1.18% 7 0.92% 2 0.26% Unspecified Type Uncontrolled Diabetes With Peripheral Circulatory Disorders Type II or Unspecified 250.70 8 1.05% 5 0.66% 3 0.39% Type not Stated as Uncontrolled Diabetes With Ophthalmic Manifestations Type II or 250.50 8 1.05% 5 0.66% 3 0.39% Unspecified Type not Stated as Uncontrolled Diabetes With Neurological Manifestations Type I 250.61 5 0.66% 3 0.39% 2 0.26% [Juvenile Type] not Stated as Uncontrolled Abnormal Glucose Tolerance of Mother 648.83 3 0.39% 0 0.00% 3 0.39% Antepartum Diabetes With 250.62 3 0.39% 3 0.39% 0 0.00%

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Neurological Manifestations Type II or Unspecified Type Uncontrolled Other Diagnoses In This -- 12 1.58% 0.79% 0.79% Identified Health Area 6 6 Total ICD-9 Code Count 761 -- 423 55.58% 338 44.42%

Data Source: SpeedTrack CUPID; OSHPD Ambulatory Surgery Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

Table 4: SGH Diabetes Ambulatory Surgery Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 0 0.00% 18 - 34 Years 8 1.08% 35 - 64 Years 306 41.30% 65 Years or 427 57.62% Greater Total Encounters 741 -- Data Source: SpeedTrack CUPID; OSHPD Ambulatory Surgery Hospital Discharge Data

Table 5: SGH Diabetes Emergency Department Top 10 ICD-9 Codes, CY2013 Top 10 ICD-9 ICD-9 Male Female Diagnosis Codes Code Frequency Percentage Freq.* % Male Freq.* % Female Diabetes Mellitus Without Mention of Complication Type II 250.00 7,192 83.64% 3,088 35.91% 4,104 47.73% or Unspecified Type not Stated as Uncontrolled Diabetes With Neurological Manifestations Type II 250.60 355 4.13% 177 2.06% 178 2.07% or Unspecified Type not Stated as Uncontrolled Diabetes Mellitus Without Mention of Complication Type II 250.02 236 2.74% 113 1.31% 123 1.43% or Unspecified Type Uncontrolled Diabetes With Other 250.80 186 2.16% 108 1.26% 78 0.91% Specified

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Manifestations Type II or Unspecified Type not Stated as Uncontrolled Diabetes With Renal Manifestations Type II or Unspecified Type 250.40 180 2.09% 92 1.07% 88 1.02% not Stated as Uncontrolled Diabetes Mellitus Without Mention of Complication Type I 250.01 77 0.90% 37 0.43% 40 0.47% [Juvenile Type] not Stated as Uncontrolled Diabetes With Ophthalmic Manifestations Type II 250.50 56 0.65% 22 0.26% 34 0.40% or Unspecified Type not Stated as Uncontrolled Antepartum Diabetes 648.03 41 0.48% 0 0.00% 41 0.48% Mellitus Diabetes With Neurological Manifestations Type II 250.62 36 0.42% 20 0.23% 16 0.19% or Unspecified Type Uncontrolled Diabetes With Unspecified Complication Type II 250.92 26 0.30% 10 0.12% 16 0.19% or Unspecified Type Uncontrolled Other Diagnoses In This Identified Health -- 214 2.49% 117 1.36% 97 1.13% Area Total ICD-9 Code 8,599 -- 3,784 44.01% 4,815 56.0% Count

Data Source: SpeedTrack CUPID; OSHPD Emergency Department Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 6: SGH Diabetes Emergency Department Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 27 0.33% 18 - 34 Years 670 8.12% 35 - 64 Years 4,734 57.37% 65 Years or 2,821 34.19% Greater Total Encounters 8,252 -- Data Source: SpeedTrack CUPID; OSHPD Emergency Department Hospital Discharge Data

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Appendix N SGH Obesity Hospital Data

Table 1: SGH Obesity Inpatient Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Obesity Unspecified 278.00 2,876 31.68% 1,008 11.10% 1,868 20.58% Morbid Obesity 278.01 2,029 22.35% 734 8.09% 1,295 14.27% Body Mass Index 40.0-44.9 Adult V85.41 781 8.60% 226 2.49% 555 6.11% Body Mass Index 45.0-49.9 Adult V85.42 375 4.13% 117 1.29% 258 2.84% Body Mass Index 50.0-59.9 Adult V85.43 286 3.15% 89 0.98% 197 2.17% Body Mass Index Between 34.0-34.9 Adult V85.34 245 2.70% 101 1.11% 144 1.59% Body Mass Index Between 35.0-35.9 Adult V85.35 242 2.67% 88 0.97% 154 1.70% Body Mass Index Between 36.0-36.9 Adult V85.36 215 2.37% 76 0.84% 139 1.53% Body Mass Index Between 32.0-32.9 Adult V85.32 205 2.26% 72 0.79% 133 1.47% Body Mass Index Between 30.0-30.9 Adult V85.30 204 2.25% 81 0.89% 123 1.35% Other Diagnoses In This -- 1,620 17.85% 592 6.52% 1,028 11.32% Identified Health Area Total ICD-9 Code Count 9,078 -- 3,184 35.07% 5,894 64.93% Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

Table 2: SGH Obesity Inpatient Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 7 0.14% 18 - 34 Years 959 19.27% 35 - 64 Years 2,671 53.67% 65 Years or 1,340 26.92% Greater Total Encounters 4,977 -- Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data

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Table 3: SGH Obesity Ambulatory Surgery Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Obesity Unspecified 278.00 184 52.27% 86 24.43% 98 27.84% Morbid Obesity 278.01 97 27.56% 46 13.07% 51 14.49% Overweight 278.02 22 6.25% 14 3.98% 8 2.27% Body Mass Index 40.0-44.9 V85.41 10 2.84% 1.14% 1.70% Adult 4 6 Body Mass Index 50.0-59.9 V85.43 5 1.42% 0.28% 1.14% Adult 1 4 Body Mass Index Between V85.35 4 1.14% 0.85% 0.28% 35.0-35.9 Adult 3 1 Body Mass Index Between V85.38 3 0.85% 0.85% 0.00% 38.0-38.9 Adult 3 0 Body Mass Index Between V85.37 3 0.85% 0.57% 0.28% 37.0-37.9 Adult 2 1 Body Mass Index Between V85.33 3 0.85% 0.57% 0.28% 33.0-33.9 Adult 2 1 Body Mass Index Between V85.31 3 0.85% 0.57% 0.28% 31.0-31.9 Adult 2 1 Other Diagnoses In This -- 18 5.11% 3.41% 1.70% Identified Health Area 12 6 Total ICD-9 Code Count 352 -- 175 49.72% 177 50.28% Data Source: SpeedTrack CUPID; OSHPD Ambulatory Surgery Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

Table 4: SGH Obesity Ambulatory Surgery Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 0 0.00% 18 - 34 Years 20 6.51% 35 - 64 Years 178 57.98% 65 Years or 109 35.50% Greater Total Encounters 307 -- Data Source: SpeedTrack CUPID; OSHPD Ambulatory Surgery Hospital Discharge Data

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Table 5: SGH Obesity Emergency Department Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Obesity Unspecified 278.00 1,967 46.26% 606 14.25% 1,361 32.01% Morbid Obesity 278.01 1,075 25.28% 353 8.30% 722 16.98% Body Mass Index 40.0-44.9 V85.41 236 5.55% 1.62% 3.93% Adult 69 167 Body Mass Index 45.0-49.9 V85.42 121 2.85% 0.89% 1.95% Adult 38 83 Body Mass Index 50.0-59.9 V85.43 94 2.21% 0.68% 1.53% Adult 29 65 Body Mass Index Between V85.36 73 1.72% 0.66% 1.06% 36.0-36.9 Adult 28 45 Body Mass Index Between V85.32 71 1.67% 0.63% 1.03% 32.0-32.9 Adult 27 44 Body Mass Index Between V85.37 66 1.55% 0.54% 1.01% 37.0-37.9 Adult 23 43 Body Mass Index Between V85.35 64 1.51% 0.54% 0.96% 35.0-35.9 Adult 23 41 Body Mass Index Between V85.34 64 1.51% 0.45% 1.06% 34.0-34.9 Adult 19 45 Other Diagnoses In This -- 421 9.90% 3.53% 6.37% Identified Health Area 150 271 Total ICD-9 Code Count 4,252 -- 1,365 32.10% 2,887 67.90% Data Source: SpeedTrack CUPID; OSHPD Emergency Department Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

Table 6: SGH Obesity Emergency Department Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 1 0.03% 1 - 17 Years 37 1.22% 18 - 34 Years 706 23.26% 35 - 64 Years 1,807 59.54% 65 Years or 484 15.95% Greater Total Encounters 3,035 -- Data Source: SpeedTrack CUPID; OSHPD Emergency Department Hospital Discharge Data

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Appendix 69 O SGH Senior Health Hospital Data

Table 1: SGH Senior Health - Top 10 Behavioral Health Inpatient 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Depressive Disorder not 311.00 1,089 23.93% 348 7.65% 741 16.29% Elsewhere Classified Anxiety State Unspecified 300.00 771 16.95% 192 4.22% 579 12.73% Alzheimer’s Disease 331.00 468 10.29% 184 4.04% 284 6.24% Bipolar Disorder 296.80 112 2.46% 41 0.90% 71 1.56% Unspecified Other and Unspecified Alcohol Dependence 303.90 106 2.33% 72 1.58% 34 0.75% Unspecified Drinking Behavior Unspecified Psychosis 298.90 101 2.22% 41 0.90% 60 1.32% Dysthymic Disorder 300.40 89 1.96% 19 0.42% 70 1.54% Major Depressive Affective Disorder Single Episode 296.20 87 1.91% 30 0.66% 57 1.25% Unspecified Degree Other and Unspecified Alcohol Dependence 303.91 86 1.89% 70 1.54% 16 0.35% Continuous Drinking Behavior Nondependent Alcohol Abuse Unspecified Drinking 305.00 79 1.74% 52 1.14% 27 0.59% Behavior Other Diagnoses In This -- 1,562 34.33% 773 16.99% 789 17.34% Identified Health Area Total ICD-9 Code Count 4,550 -- 1,822 40.0% 2,728 60.0% Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

69 Note: All Senior Health tables present data for SMH patients ages 65 years and older.

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Table 2: SGH Senior Health - Top 10 Behavioral Health Emergency Department ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Anxiety State Unspecified 300.00 804 28.30% 167 5.88% 637 22.42% Depressive Disorder not 311.00 668 23.51% 159 5.60% 509 17.92% Elsewhere Classified Alzheimer’s Disease 331.00 273 9.61% 101 3.56% 172 6.05% Bipolar Disorder 296.80 173 6.09% 60 2.11% 113 3.98% Unspecified Unspecified Psychosis 298.90 104 3.66% 33 1.16% 71 2.50% Unspecified Type Schizophrenia Unspecified 295.90 102 3.59% 38 1.34% 64 2.25% State Other and Unspecified Special Symptoms or 307.90 59 2.08% 23 0.81% 36 1.27% Syndromes not Elsewhere Classified Nondependent Alcohol Abuse Unspecified Drinking 305.00 56 1.97% 34 1.20% 22 0.77% Behavior Dementia With Lewy 331.82 39 1.37% 28 0.99% 11 0.39% Bodies Schizoaffective Disorder 295.70 39 1.37% 19 0.67% 20 0.70% Unspecified State Other Diagnoses In This -- 524 18.44% 228 8.03% 296 10.42% Identified Health Area Total ICD-9 Code Count 2,841 -- 890 31.3% 1,951 68.7% Data Source: SpeedTrack CUPID; OSHPD Emergency Department Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 3: SGH Senior Health - Top 10 Cardiovascular Inpatient 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Unspecified Essential 401.90 5,085 21.17% 2,000 8.33% 3,085 12.85% Hypertension Atrial Fibrillation 427.31 2,811 11.70% 1,327 5.53% 1,484 6.18% Congestive Heart Failure 428.00 2,772 11.54% 1,283 5.34% 1,489 6.20% Unspecified Coronary Atherosclerosis 414.01 2,163 9.01% 1,064 4.43% 1,099 4.58% of Native Coronary Artery Hypertensive Chronic Kidney Disease Unspecified With Chronic Kidney 403.90 1,316 5.48% 754 3.14% 562 2.34% Disease Stage I Through Stage IV or Unspecified Coronary Atherosclerosis of Unspecified Type of 414.00 1,006 4.19% 673 2.80% 333 1.39% Vessel Native or Graft Old Myocardial Infarction 412.00 721 3.00% 383 1.59% 338 1.41% Malignant Essential 401.00 661 2.75% 212 0.88% 449 1.87% Hypertension Chronic Diastolic Heart 428.32 556 2.32% 211 0.88% 345 1.44% Failure Acute on Chronic Diastolic 428.33 535 2.23% 208 0.87% 327 1.36% Heart Failure Other Diagnoses In This -- 6,390 26.61% 3,137 13.06% 3,253 13.55% Identified Health Area Total ICD-9 Code Count 24,016 -- 11,252 46.9% 12,764 53.1% Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 4: SGH Senior Health - Top 10 Cardiovascular Health Emergency Department ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Unspecified Essential 401.90 6,101 47.63% 2,086 16.29% 4,015 31.35% Hypertension Atrial Fibrillation 427.31 1,447 11.30% 609 4.75% 838 6.54% Congestive Heart Failure 428.00 1,007 7.86% 376 2.94% 631 4.93% Unspecified Coronary Atherosclerosis of 414.01 865 6.75% 378 2.95% 487 3.80% Native Coronary Artery Old Myocardial Infarction 412.00 683 5.33% 324 2.53% 359 2.80% Coronary Atherosclerosis of Unspecified Type of Vessel 414.00 664 5.18% 391 3.05% 273 2.13% Native or Graft Hypertensive Chronic Kidney Disease Unspecified With Chronic Kidney 403.90 542 4.23% 263 2.05% 279 2.18% Disease Stage I Through Stage IV or Unspecified Malignant Essential 401.00 311 2.43% 86 0.67% 225 1.76% Hypertension Hypertensive Chronic Kidney Disease Unspecified With Chronic Kidney 403.91 102 0.80% 54 0.42% 48 0.37% Disease Stage V or End Stage Renal Disease Chronic Diastolic Heart 428.32 96 0.75% 29 0.23% 67 0.52% Failure Other Diagnoses In This -- 990 7.73% 403 3.15% 587 4.58% Identified Health Area Total ICD-9 Code Count 12,808 -- 4,999 39.0% 7,809 61.0% Data Source: SpeedTrack CUPID; OSHPD Emergency Department Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 5: SGH Senior Health - Top 10 Diabetes Inpatient 10 ICD-9 Codes, CY2013

Top 10 ICD-9 ICD-9 Male % Female Diagnosis Codes Code Frequency Percentage Freq.* Male Freq.* % Female Depressive Disorder not 311.00 1,089 23.93% 348 7.65% 741 16.29% Elsewhere Classified Anxiety State 300.00 771 16.95% 192 4.22% 579 12.73% Unspecified Alzheimer’s 331.00 468 10.29% 184 4.04% 284 6.24% Disease Bipolar Disorder 296.80 112 2.46% 41 0.90% 71 1.56% Unspecified Other and Unspecified Alcohol 303.90 106 2.33% 72 1.58% 34 0.75% Dependence Unspecified Drinking Behavior Unspecified 298.90 101 2.22% 41 0.90% 60 1.32% Psychosis Dysthymic 300.40 89 1.96% 19 0.42% 70 1.54% Disorder Major Depressive Affective Disorder Single Episode 296.20 87 1.91% 30 0.66% 57 1.25% Unspecified Degree Other and Unspecified Alcohol 303.91 86 1.89% 70 1.54% 16 0.35% Dependence Continuous Drinking Behavior Nondependent Alcohol Abuse 305.00 79 1.74% 52 1.14% 27 0.59% Unspecified Drinking Behavior Other Diagnoses In This Identified -- 1,562 34.33% 773 16.99% 789 17.34% Health Area Total ICD-9 Code 4,550 -- 1,822 40.0% 2,728 60.0% Count

Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 6: SGH Senior Health - Top 10 Diabetes Emergency Department ICD-9 Codes, CY2013

ICD-9 Male Female % Top 10 ICD-9 Diagnosis Codes Code Frequency Percentage Freq.* % Male Freq.* Female Diabetes Mellitus Without Mention of Complication Type 250.00 2,502 86.63% 985 34.11% 1,517 52.53% II or Unspecified Type not Stated as Uncontrolled Diabetes With Neurological Manifestations Type II or 250.60 101 3.50% 44 1.52% 57 1.97% Unspecified Type not Stated as Uncontrolled Diabetes With Renal Manifestations Type II or 250.40 88 3.05% 43 1.49% 45 1.56% Unspecified Type not Stated as Uncontrolled Diabetes With Other Specified Manifestations Type II or 250.80 66 2.29% 36 1.25% 30 1.04% Unspecified Type not Stated as Uncontrolled Diabetes Mellitus Without Mention of Complication Type 250.02 59 2.04% 25 0.87% 34 1.18% II or Unspecified Type Uncontrolled Diabetes With Ophthalmic Manifestations Type II or 250.50 17 0.59% 6 0.21% 11 0.38% Unspecified Type not Stated as Uncontrolled Diabetes With Peripheral Circulatory Disorders Type II 250.70 10 0.35% 7 0.24% 3 0.10% or Unspecified Type not Stated as Uncontrolled Diabetes With Renal Manifestations Type II or 250.42 9 0.31% 7 0.24% 2 0.07% Unspecified Type Uncontrolled Diabetes Mellitus Without Mention of Complication Type 250.01 8 0.28% 3 0.10% 5 0.17% I [Juvenile Type] not Stated as Uncontrolled Diabetes With Unspecified Complication Type II or 250.92 5 0.17% 1 0.03% 4 0.14% Unspecified Type Uncontrolled Other Diagnoses In This -- 23 0.80% 13 0.45% 10 0.35% Identified Health Area

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Total ICD-9 Code Count 2,888 -- 1,170 40.5% 1,718 59.5% Data Source: SpeedTrack CUPID; OSHPD Emergency Department Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

Table 7: SGH Senior Health - Top 10 Obesity Inpatient ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Obesity Unspecified 278.00 817 33.65% 333 13.71% 484 19.93% Morbid Obesity 278.01 499 20.55% 193 7.95% 306 12.60% Body Mass Index 40.0-44.9 V85.41 179 7.37% 48 1.98% 131 5.40% Adult Body Mass Index Between V85.32 72 2.97% 37 1.52% 35 1.44% 32.0-32.9 Adult Body Mass Index 45.0-49.9 V85.42 71 2.92% 23 0.95% 48 1.98% Adult Body Mass Index Between V85.36 67 2.76% 26 1.07% 41 1.69% 36.0-36.9 Adult Body Mass Index Between V85.34 67 2.76% 29 1.19% 38 1.57% 34.0-34.9 Adult Body Mass Index Between V85.30 67 2.76% 31 1.28% 36 1.48% 30.0-30.9 Adult Body Mass Index Between V85.33 65 2.68% 28 1.15% 37 1.52% 33.0-33.9 Adult Body Mass Index Between V85.31 61 2.51% 24 0.99% 37 1.52% 31.0-31.9 Adult Other Diagnoses In This -- 463 19.07% 191 7.87% 272 11.20% Identified Health Area Total ICD-9 Code Count 2,428 -- 963 39.7% 1,465 60.3% Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 8: SGH Senior Health - Top 10 Obesity Emergency Department ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Obesity Unspecified 278.00 319 46.84% 103 15.12% 216 31.72% Morbid Obesity 278.01 170 24.96% 49 7.20% 121 17.77% Body Mass Index 40.0-44.9 V85.41 30 4.41% 6 0.88% 24 3.52% Adult Body Mass Index Between V85.35 16 2.35% 5 0.73% 11 1.62% 35.0-35.9 Adult Body Mass Index 45.0-49.9 V85.42 14 2.06% 3 0.44% 11 1.62% Adult Body Mass Index Between V85.34 14 2.06% 3 0.44% 11 1.62% 34.0-34.9 Adult Body Mass Index Between V85.32 14 2.06% 4 0.59% 10 1.47% 32.0-32.9 Adult Body Mass Index Between V85.30 14 2.06% 4 0.59% 10 1.47% 30.0-30.9 Adult Body Mass Index Between V85.37 12 1.76% 6 0.88% 6 0.88% 37.0-37.9 Adult Body Mass Index Between V85.33 11 1.62% 4 0.59% 7 1.03% 33.0-33.9 Adult Other Diagnoses In This -- 67 9.84% 18 2.64% 49 7.20% Identified Health Area Total ICD-9 Code Count 681 -- 205 30.1% 476 69.9% Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Appendix P SGH Oncology Hospital Data

Table 1: SGH Oncology Inpatient Top 10 ICD-9 Codes, CY2013

ICD-9 Male Female % Top 10 ICD-9 Diagnosis Codes Code Frequency Percentage Freq.* % Male Freq.* Female Secondary Malignant Neoplasm of Bone and Bone 198.50 182 4.83% 116 3.08% 66 1.75% Marrow Malignant Neoplasm of Liver 197.70 175 4.65% 83 2.20% 92 2.44% Secondary Benign Neoplasm of Colon 211.30 171 4.54% 93 2.47% 78 2.07% Leiomyoma of Uterus 218.90 137 3.64% 0 0.00% 137 3.64% Unspecified Secondary Malignant 197.00 130 3.45% 53 1.41% 77 2.05% Neoplasm of Lung

Essential Thrombocythemia 238.71 126 3.35% 54 1.43% 72 1.91%

Malignant Neoplasm of 185.00 119 3.16% 119 3.16% 0 0.00% Prostate Malignant Neoplasm of 162.90 111 2.95% 61 1.62% 50 1.33% Bronchus and Lung Unspecified Secondary Malignant Neoplasm of Brain and Spinal 198.30 91 2.42% 32 0.85% 59 1.57% Cord Malignant Neoplasm of Upper 162.30 86 2.28% 49 1.30% 37 0.98% Lobe Bronchus or Lung Other Diagnoses In This -- 2,437 64.73% 1,098 29.16% 1,339 35.56% Identified Health Area Total ICD-9 Code Count 3,765 -- 1,758 46.7% 2,007 53.3% Data Source: SpeedTrack CUPID; OSHPD Inpatient Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 2: SGH Oncology Inpatient Encounters by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 0 0.00% 18 - 34 Years 55 5.16% 35 - 64 Years 478 44.88% 65 Years or 532 49.95% Greater Total Encounters 1,065 -- Data Source: SpeedTrack CUPID; Inpatient Hospital Discharge Data

Table 3: SGH Oncology Ambulatory Surgery Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Benign Neoplasm of Colon 211.30 865 41.33% 426 20.35% 439 20.97% Benign Neoplasm of 211.40 280 13.38% 153 7.31% 127 6.07% Rectum and Anal Canal Benign Neoplasm of 211.10 105 5.02% 35 1.67% 70 3.34% Stomach Lipoma of Other Specified 214.80 62 2.96% 33 1.58% 29 1.39% Sites Lipoma of Spermatic Cord 214.40 44 2.10% 44 2.10% 0 0.00% Leiomyoma of Uterus 218.90 38 1.82% 0 0.00% 38 1.82% Unspecified Malignant Neoplasm of Breast (Female) 174.90 33 1.58% 0 0.00% 33 1.58% Unspecified Site Neoplasm of Uncertain Behavior of Stomach 235.20 28 1.34% 13 0.62% 15 0.72% Intestines and Rectum Malignant Neoplasm of Other Specified Sites of 174.80 25 1.19% 0 0.00% 25 1.19% Female Breast Malignant Neoplasm of 188.90 23 1.10% 19 0.91% 4 0.19% Bladder Part Unspecified Other Diagnoses In This -- 590 28.19% 256 12.23% 334 15.96% Identified Health Area Total ICD-9 Code Count 2,093 -- 979 46.8% 1,114 53.2% Data Source: SpeedTrack CUPID; OSHPD Ambulatory Surgery Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 4: SGH Oncology Ambulatory Surgery by Age, CY 2013

Age Range Frequency % Under 1 Year 0 0.00% 1 - 17 Years 0 0.00% 18 - 34 Years 19 1.44% 35 - 64 Years 734 55.56% 65 Years or 568 43.00% Greater Total Encounters 1,321 -- Data Source: SpeedTrack CUPID; Ambulatory Surgery Discharge Data

Table 5: SGH Oncology Emergency Department Top 10 ICD-9 Codes, CY2013

Top 10 ICD-9 Diagnosis ICD-9 Male Female % Codes Code Frequency Percentage Freq.* % Male Freq.* Female Leiomyoma of Uterus 218.90 233 13.77% 0 0.00% 233 13.77% Unspecified Malignant Neoplasm of Breast (Female) 174.90 125 7.39% 0 0.00% 125 7.39% Unspecified Site Malignant Neoplasm of 185.00 100 5.91% 100 5.91% 0 0.00% Prostate Malignant Neoplasm of Bronchus and Lung 162.90 80 4.73% 44 2.60% 36 2.13% Unspecified Essential Thrombocythemia 238.71 74 4.37% 19 1.12% 55 3.25% Other Malignant Lymphomas Unspecified 202.80 58 3.43% 30 1.77% 28 1.65% Site Malignant Neoplasm of 153.90 44 2.60% 22 1.30% 22 1.30% Colon Unspecified Site Secondary Malignant Neoplasm of Bone and 198.50 43 2.54% 21 1.24% 22 1.30% Bone Marrow Other Malignant Neoplasm 199.10 38 2.25% 20 1.18% 18 1.06% of Unspecified Site Benign Neoplasm of Colon 211.30 35 2.07% 14 0.83% 21 1.24% Other Diagnoses In This -- 862 50.95% 361 21.34% 501 29.61% Identified Health Area Total ICD-9 Code Count 1,692 -- 631 37.3% 1,061 62.7% Data Source: SpeedTrack CUPID; OSHPD Emergency Department Hospital Discharge Data *Male Frequency and Female Frequency are out of the combined Frequency total.

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Table 6: SGH Oncology Emergency Department by Age, CY 2013

Age Range Frequency % Under 1 Year 1 0.13% 1 - 17 Years 2 0.26% 18 - 34 Years 70 9.10% 35 - 64 Years 423 55.01% 65 Years or 273 35.50% Greater Total Encounters 769 -- Data Source: SpeedTrack CUPID; Emergency Department Discharge Data

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Appendix Demographic Information – Health Q Access and Navigation Survey, HASD&IC 2016 CHNA

DEMOGRAPHIC INFORMATION, HEALTH ACCESS AND NAVIGATION SURVEY, HASD&IC 2016 CHNA

Demographic n %

Community Member/Resident 195 85.2% RLA Leader 17 7.4% SD County Representative 17 7.4% Total Individuals 229 100.0% Race/Ethnicity

Asian/Pacific Islander 8 3.7% Black 5 2.3% Hispanic 150 68.5% White 59 26.9% Other (Multi Race/Native American) 2 0.9% Total Individuals* 219 100.0% Populations Survey Participant has Knowledge of Low Income 135 78.0% Medically Underserved 64 37.0% Populations with Chronic Conditions 51 29.5% Minority Population 44 25.4% Other 22 12.7% Total Individuals* 173 100.0% Region Community Resident Lives in or Works in** Central 23 10.0% East 14 6.1% North Central 34 14.7% North Coastal 34 14.7% North Inland 34 14.7% South 107 46.3% Total Individuals* 231 100.0% Who have you helped navigate thru the health system? (check all that apply) Yourself (18+) 124 57.1%

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Child 73 33.6% Another Adult 95 43.8% Older Adult (65+ yrs.) 37 17.1% Total Individuals* 217 100.0% *Note: Total individuals who answered question. Persons could choose more than one category therefore the individual categories do not add up to the total individuals. ** Created regions based on ZIP code, when no ZIP code was reported used the region the survey participant chose.

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Appendix

Demographic Information – Health R Access and Navigation Survey, SGH 2016 CHNA

TABLE 1: BEHAVIORAL HEALTH – HEALTH ACCESS AND NAVIGATION SURVEY PARTICIPANT DEMOGRAPHICS, SHARP 2016 CHNA

Total Respondents (N=46)

n % Race/Ethnicity Asian/Pacific Islander 0 0.0% Black 1 2.4% Hispanic 2 5% White 39 92.9% Other (multi race/Native American) 0 0.0% Total 42 Region Community Resident Lives in* Central 3 6.7% East 7 15.6% North Central 21 46.7% North Coastal 8 17.8% North Inland 4 8.9% South 2 4.4% Total 45 Who have you helped navigate thru the health system? (check all that apply) Yourself (18+) 36 83.7% Child 4 9.3% Another Adult 12 27.9% Older Adult (65+ yrs) 4 9.3% Total # of Individuals who responded** 43 *created based on zip code and when no zip, used region, if neither then left blank. **Total may differ due to the ability of participants to check more than one option

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TABLE 2: ONCOLOGY – HEALTH ACCESS AND NAVIGATION SURVEY PARTICIPANT DEMOGRAPHICS, SHARP 2016 CHNA

Total Respondents (N=31)

n % Race/Ethnicity Asian/Pacific Islander 3 9.7% Black 2 6.5% Hispanic 7 23% White 19 61.3% Other (multi race/Native American) 0 0.0% Total 31 Region Community Resident Lives in* Central 4 12.9% East 3 9.7% North Central 8 25.8% North Coastal 0 0.0% North Inland 3 9.7% South 13 41.9% Total 31 Who have you helped navigate thru the health system? (check all that apply) Yourself (18+) 23 76.7% Child 2 6.7% Another Adult 6 20.0% Older Adult (65+ yrs) 5 16.7% Total # of Individuals who responded** 30 *created based on zip code and when no zip, used region, if neither then left blank. **Total may differ due to the ability of participants to check more than one option

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TABLE 3. SENIOR HEALTH – HEALTH ACCESS AND NAVIGATION SURVEY PARTICIPANT DEMOGRAPHICS, SHARP 2016 CHNA

Total Respondents (N=27)

n % Race/Ethnicity Asian/Pacific Islander 2 8.0% Black 1 4.0% Hispanic 4 16% White 18 72.0% Other (multi race/Native American) 1 4.0% Total 25 Region Community Resident Lives in* Central 13 48.1% East 7 25.9% North Central 5 18.5% North Coastal 0 0.0% North Inland 0 0.0% South 2 7.4% Total 27 Who have you helped navigate thru the health system? (check all that apply) Yourself (18+) 19 70.4% Child 4 14.8% Another Adult 8 29.6% Older Adult (65+ yrs) 11 40.7% Total # of Individuals who responded** 27 *created based on zip code and when no zip, used region, if neither then left blank. **Total may differ due to the ability of participants to check more than one option

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Appendix 2-1-1 San Diego Directory of S Services

2-1-1 Taxonomy of Services Available in San Diego Related to the Top 4 Health Needs

Mental Health and Substance Abuse Services # Services

Behavioral Learning Therapy 4 Behavior Modification 38 Cognitive Behavioral Therapy 8 Dialectical Behavior Therapy 1 Psychosocial Therapy 3 Multimodal Therapy 1 Pastoral Counseling 3 Psychodynamic Therapy 1 Psychotherapy/Psychoanalysis 6 Conjoint Counseling 5 Family Counseling 43 Group Counseling 27 Individual Counseling 38 Internet Counseling 3 Peer Counseling 14 Talklines/Warmlines 7 Counseling Services 10 General Counseling Services 64 Specialized Counseling Services 13 Abuse Counseling 20 Child Abuse Counseling 10 Counseling for Children Affected by Domestic 2 Violence Elder Abuse Counseling 2 Parent Abuse Counseling 2 Spouse/Intimate Partner Abuse Counseling 8 Adolescent/Youth Counseling 43 Anger Management 39 Bereavement Counseling 8 Caregiver Counseling 3 Child Guidance 3 Crime Victim/Witness Counseling 6 Cultural Transition Counseling 1

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Divorce Counseling 1 Employment Transition Counseling 6 Ex-Offender Counseling 2 Gambling Counseling/Treatment 2 Gender Identity Counseling 1 Geriatric Counseling 3 Health/Disability Related Counseling 34 Juvenile Delinquency Diversion Counseling 18 Marriage Counseling 5 Parent Child Interactive Therapy 1 Parent Counseling 4 Perinatal/Postpartum Depression Counseling 5 Post abortion Counseling 6 Psychiatric Disorder Counseling 3 Sex Offender Counseling 2 Sexual Assault Counseling 17 Sexual Orientation Counseling 2 Terminal Illness Counseling 2 Veteran Reintegration Counseling 9 Crisis Intervention 22 Crisis Intervention Hotlines/Helplines 24 Child Abuse Hotlines 11 Domestic Violence Hotlines 8 General Crisis Intervention Hotlines 5 Human Trafficking Hotlines 3 Mental Health Hotlines 4 Runaway/Homeless Youth Helplines 4 Sexual Assault Hotlines 8 Suicide Prevention Hotlines 5 Suicide Prevention Hotlines For Veterans 1 Crisis Residential Treatment 6 In Person Crisis Intervention 40 Internet Based Crisis Intervention 1 Involuntary Psychiatric Intervention 1 Psychiatric Mobile Response Teams 1 Psychiatric Emergency Room Care 1 Mental Health Evaluation 54 Central Intake/Assessment for Mental Health Services 8 Clinical Psychiatric Evaluation 7 Mental Health Screening 13 Anxiety Disorders Screening 6

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Depression Screening 3 Psychological Assessment 13 Psychological Testing 3 Psychosocial Evaluation 19 Psychiatric Services 5 Adult Psychiatry 2 Eating Disorders Treatment 4 Geriatric Psychiatry 1 Special Psychiatric Programs 5 Assertive Community Treatment 4 Home Based Mental Health Services 2 Integrated Dual Diagnosis Treatment 1 Psychiatric Case Management 26 Psychiatric Day Treatment 21 Psychiatric Medication Services 17 Psychiatric Medication Monitoring 9 Psychiatric Rehabilitation 23 Clubhouse Model Psychiatric Rehabilitation 13 Supportive Therapies 1 Art Therapy 5 Equestrian Therapy 2 Music Therapy 2 Pet Assisted Therapy 3 Play Therapy 5 Recreational Therapy 10 Inpatient Mental Health Facilities 1 Psychiatric Hospitals 1 Adult Psychiatric Hospitals 14 Children's/Adolescent Psychiatric Hospitals 2 Psychiatric Inpatient Units 1 Adolescent Psychiatric Inpatient Units 2 Adult Psychiatric Inpatient Units 10 Children's Psychiatric Inpatient Units 6 Outpatient Mental Health Facilities 11 Community Mental Health Agencies 57 Family Counseling Agencies 8 Mental Health Drop In Centers 6 Private Therapy Practices 1 Residential Treatment Facilities 1 Adult Residential Treatment Facilities 6 Children's/Adolescent Residential Treatment Facilities 5

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Early Intervention for Mental Illness 6 Mental Health Information/Education 3 Family Psychoeducation 1 General Mental Health Information/Education 37 Mental Health Related Prevention Programs 6 Body Image Education 1 Gambling Addiction Prevention Programs 1 Runaway Prevention Programs 1 Suicide Prevention Programs 3 Licensed Clinical Social Worker Referrals 1 Psychiatrist Referrals 1 Psychologist Referrals 3 Mental Health Halfway Houses 3 Psychiatric Aftercare Services 5 Psychiatric Resocialization 2 Central Intake/Assessment for Alcohol Abuse 7 Central Intake/Assessment for Drug Abuse 7 Drug/Alcohol Testing 22 General Assessment for Substance Abuse 8 Substance Abuse Screening 6 Substance Abuse Treatment Orders 1 Detoxification 1 Alcohol Detoxification 2 Inpatient Medically Assisted Alcohol Detoxification 4 Non-Medically Assisted Alcohol Detoxification 6 Outpatient Medically Assisted Alcohol Detoxification 2 Drug Detoxification 3 Inpatient Drug Detoxification 7 Opioid Detoxification 5 Outpatient Drug Detoxification 6 Social Model Drug Detoxification 6 DUI Offender Programs 2 First Offender DUI Programs 2 Multiple Offender DUI Programs 2 Alcohol Abuse Education/Prevention 17 Alcohol/Drug Impaired Driving Prevention 4 Drug Abuse Education/Prevention 19 Smoking Education/Prevention 8 Substance Abuse Treatment Programs 6 Comprehensive Outpatient Substance Abuse Treatment 13 Comprehensive Outpatient Alcoholism Treatment 24

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Comprehensive Outpatient Drug Abuse Treatment 25 Inpatient Substance Abuse Treatment Facilities 1 Inpatient Alcoholism Treatment Facilities 6 Inpatient Drug Abuse Treatment Facilities 6 Medication Assisted Maintenance Treatment for Opioid 7 Addiction Perinatal Substance Abuse Treatment 1 Perinatal Alcoholism Treatment 7 Perinatal Drug Abuse Treatment 4 Residential Alcoholism Treatment Facilities 36 Residential Drug Abuse Treatment Facilities 37 Smoking Cessation 7 Substance Abuse Counseling 7 Alcoholism Counseling 15 Drug Abuse Counseling 17 Substance Abuse Day Treatment 1 Alcoholism Day Treatment 8 Drug Day Treatment 8 Supportive Substance Abuse Services 2 Relapse Prevention Programs 3 Smoking Cessation Support 9 Alcohol Related Crisis Intervention 12 Drug Related Crisis Intervention 13 Alcoholism Drop In Services 6 Drug Drop In Services 6 Alcoholism Hotlines 3 Drug Abuse Hotlines 5 Substance Abuse Intervention Programs 1 Substance Abuse Referrals 4 Transitional Residential Substance Abuse Services 4 Recovery Homes/Halfway Houses 1 Alcoholism Related Recovery Homes/Halfway Houses 3 Drug Related Recovery Homes/Halfway Houses 1 Sober Living Homes 7 Sober Living Homes for Recovering Alcoholics 6 Sober Living Homes for Recovering Drug Abusers 4 Number of Services Available for Mental Health and Substance 190 Abuse Services *Pathway: 2-1-1 Resources and Services Tab > Directory of Services > Outline of Categories > Mental Health and Substance Abuse Services > Removed those with '0' programs determined by [0/#] **Locations/programs providing more than one service/in more than one category may be duplicated in the count of services

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# Diabetes-Related Health Care Services Services Disease/Disability Specific Screening/Diagnosis Diabetes Screening 80 Condition Specific Treatment 8 Diabetes Management Clinics 19 Adult Diabetes Management Clinics 8 Pediatric Diabetes Management Clinics 2 Wound Clinics 1 Number of Services Available for Diabetes Services 118 *Pathway: 2-1-1 Resources and Services Tab > Directory of Services > Outline of Categories > Health Care > Keywords "Diabetes" "Wound Clinics" "Insulin" "Insulin Injection Supplies" "Home Glucose Monitoring Systems" "Foot Screening" & "Diabetes Screening" used to locate diabetes specific programs > Removed those with '0' programs determined by [0/#] **Locations/programs providing more than one service/in more than one category may be duplicated in the count of services

# Obesity-Related Health Care Services Service s Weight Management 38 Weight Loss Assistance 12 Clinical Weight Loss Programs 3 Diet and Exercise Resorts 6 Non-Clinical Weight Loss Programs 2 Nutrition Education 147 Dietary Services 1 Healthy Eating Programs 3 Nutrition Assessment Services 36 Physical Activity and Fitness Education/Promotion 134 Number of Services Available for Services for Weight 382 Management *Pathway: 2-1-1 Resources and Services Tab > Directory of Services > Outline of Categories > Health Care > Keywords "Weight Management" "Eating Disorders Screening" "Eating Disorders Treatment" "Nutrition Education" "Body Image Education" "BMI/Body Composition Screening" "Weight Related Support Groups" "Fitness Equipment and Accessories" "Physical Fitness Referrals" "Healthy Eating Programs" "Physical Activity and Fitness Education/Promotion" "Nutrition Assessment Services" "Dietician/Nutritionist Referrals" "Physical Fitness" used to locate programs > Removed those with '0' programs determined by [0/#] **Locations/programs providing more than one service/in more than one category may be duplicated in the count of services

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# Cardiovascular-Related Health Care Services Service s Disease/Disability Specific Screening/Diagnosis Blood Pressure Screening 133 Cholesterol/Triglycerides Tests 10 Clinical Cholesterol/Triglycerides Tests 1 Health Education Chronic Disease Self-Management Programs 17 Number of Services Available for Cardiovascular Related 161 Needs *Pathway: 2-1-1 Resources and Services Tab > Directory of Services > Outline of Categories > Health Care > Keywords "Blood Pressure" "Cholesterol" "Chronic Disease" "Cardiovascular" "Heart Disease" used to locate programs > Removed those with '0' programs determined by [0/#] **Locations/programs providing more than one service/in more than one category may be duplicated in the count of services

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Appendix T Health Need Profiles

Cardiovascular Disease

Type 2 diabetes

Behavioral Health

Obesity

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Cardiovascular Disease

The World Health Organization defines cardiovascular disease (CVD) as a group of disorders of the heart and blood vessels that include coronary heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, deep vein thrombosis and pulmonary embolism.1 Coronary heart disease is the most common form of heart disease. 2 High blood pressure, high cholesterol, and smoking are all risk factors that could lead to CVD and stroke. About half of Americans (49%) have at least one of these three risk factors.2

2 Risk Factors for Cardiovascular Disease: DISPARITIES & CVD 4,8  Behaviors: Tobacco use, obesity, physical inactivity, poor diet that is high in saturated fats, and excessive Cardiovascular Disease & Race alcohol use. In 2012, thirty-five percent of non-Hispanic black  Conditions: High cholesterol levels, high blood women had hypertension compared with 22% of pressure and diabetes. non-Hispanic white women and 22% of Hispanic  Heredity: Genetic factors likely play a role in heart women. Thirty percent of non-Hispanic black men disease and can increase risk. had hypertension compared with 25% of non- Heart disease is the leading cause of death in the U.S.3 Hispanic white men and 19% of Hispanic men.  Heart disease is the leading cause of death for people Cardiovascular Disease & Gender of most racial/ethnic groups in the United States, Men are more likely than women to have ever including African Americans, Hispanics and whites. been told they have coronary heart disease or hypertension. Prevalence Data:4  In 2012, 11% of U.S. adults aged 18 and over had Cardiovascular Disease & Income ever been told by a doctor or other health professional Individuals with low incomes are much more that they had heart disease. likely to suffer from high blood pressure, heart  In 2012, 24% of U.S. adults 18 and over had been told attack, and stroke. on two or more visits that they had hypertension. Among adults aged 65 and over, those covered

San Diego Coronary Heart Disease by Medicare and Medicaid were more likely to have been told they had hypertension than those Hospitalization Rate by with either Medicare alone or private insurance Race/Ethnicity, 2010-2013 450 Cardiovascular Disease & Behavioral Health Depression occurs in up to 20% of people with 400 heart disease and has also been found to be a risk 350 factor for subsequent heart attack. 300 Coronary Heart Disease 250 Mortality Rate in San Diego 200 150 County, 2013 130.9 121.0 100 150 118.4 81.6 92.9 93.9 104.3 100 50 50 0 0 2010 2011 2012 2013 White Black Hispanic Asian/Pacific Islander Age Adjusted Death Rate per 100,000 Population. County age-adjusted rates per 100,000 2000 U.S. standard population. Source: Death Statistical Master Files (CDPH), County of San Diego, Health Coronary Heart Disease hospitalization refers to (principal diagnosis) ICD‐9 & Human Services Agency, Public Health Services, Epidemiology & codes 402, 410‐414, 429.2. Source: OSHPD, County of San Diego, Health & Immunization Services Branch; SANDAG, Current Population Estimates, Human Services Agency, Public Health Services, Community Health 10/2013. Statistics Unit, 2015.

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Characteristics of Residents, San Diego County Selected Elements from Cardiovascular Disease Pathway:9

Data Source: University of California Center for Data Source: Centers for Disease Control and Data Source: Centers for Disease Control and Health Policy Research, California Health Prevention, BRFSS 2006-2012. Prevention, BRFSS 2006-2010. Interview Survey 2011-2012.

Possible Intervention Opportunities  Clinical Decisions Support Systems: computer-based information systems designed to assist healthcare providers in implementing clinical guidelines at the point of care10  Behavioral Counseling for Overweight and Obese Individuals with other CVD Risk Factors: intensive counseling to promote a healthful diet and physical activity for CVD prevention11  Screening: Lipid disorder screenings are recommended for men 35 and over and women 45 and older; blood pressure screenings are recommended for individuals 18 and over11 For More Information, Visit the American Heart Association’s Website: http://www.heart.org/

1. WHO. Cardiovascular Diseases. http://www.euro.who.int/en/what-we-do/health-topics/noncommunicable-diseases/cardiovascular- diseases/definition 2. CDC. http://www.cdc.gov/heartdisease/facts.htm 3. CDC. http://www.cdc.gov/nchs/data/databriefs/db103.htm 4. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2012. http://www.cdc.gov/nchs/data/series/sr_10/sr10_260.pdf 5. Division for Heart Disease and Stroke Prevention: Data Trends & Maps Web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, 2010. Available at http://www.cdc.gov/dhdsp/ 6. County of San Diego. 3-4-50: Chronic Disease Deaths in San Diego County. http://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/documents/CHS-3-4-50DataReport_2013.pdf 7. County of San Diego Health and Human Services Agency, Public Health Services. Community Health Statistics Unit. (2009). Critical Pathways: the Disease Continuum, Coronary Heart Disease. January, 2012. Retrieved from http://www.sdcounty.ca.gov/hhsa/programs/phs/documents/CHS‐ Critical_Pathways_2012.pdf. 8. CDC. Million Hearts Initiative. http://millionhearts.hhs.gov/abouthds/risk-factors.html# 9. Kaiser Permanente CHNA Data Platform. 10. The Community Guide. Cardiovascular Disease Prevention and Control. http://www.thecommunityguide.org/cvd/index.html 11. U.S. Preventative Services Task Force. http://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

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Diabetes Mellitus (Type 2) Type 2 diabetes, once known as adult-onset or noninsulin-dependent diabetes, is a chronic condition that affects the way the body metabolizes sugar (glucose), which is the body's main source of fuel. With Type 2 diabetes, the body either resists the effects of insulin — a hormone that regulates the movement of sugar into the cells — or doesn't produce enough insulin to maintain a normal glucose level. If left untreated, Type 2 diabetes can be life-threatening. Clinical symptoms can include: frequent urination, excessive thirst, extreme hunger, sudden vision changes, unexplained weight loss, extreme fatigue, sores that are slow to heal, and increased number of infections.1 6,7 Some alarming facts about Type 2 diabetes: 2, 3 DISPARITIES & DIABET ES  About 1.7 million people aged 20 years or older were Diabetes & Race newly diagnosed with diabetes in 2012 in the U.S. Hispanics and African Americans have two times  Diabetes is a major cause of heart disease and stroke, th higher prevalence: 1 in 20 non-Hispanic whites have and is the 7 leading cause of death in the United Type 2 diabetes, compared with 1 in 10 Hispanics and States and California. 1 in 11 African Americans in 2011-2012.  More than 1 out of 3 adults have prediabetes and 15- In San Diego, whites and blacks had the highest 30% of those with prediabetes will develop Type 2 death rates due to diabetes in 2012. diabetes within 5 years. Diabetes & Gender Some risk factors for developing Diabetes include: The prevalence of Type 2 diabetes is 13 percent  Being overweight or obese. higher in men than women in California.  Smoking In San Diego, males had a higher death rate than  Having a parent, brother, or sister with females (22.5 per 100,000 versus 19.0 per 100,000 in diabetes. 2012).  Having high blood pressure measuring 140/90 or higher. Diabetes & Income   Being physically inactive—exercising fewer The percent of adults in Californians with diabetes is than three times a week. almost two times higher in those with family incomes below 200 percent of the federal poverty level 3 compared to those whose income is 300 percent Diabetes Prevalence: above.  U.S. Age-adjusted prevalence rate for adult diagnosed diabetes for the year of 2012 was 9.3%, with 90-95% of Diabetes & Co-Morbidities cases being Type 2 diabetes. In 2011-2012, the state Adults with diabetes are more likely to have arthritis, of California reported a rate of 6.9% of adults with 7 hypertension and cardiovascular disease than adults diabetes and this rate was the same for SDC. without diabetes. Diabetes is a leading cause of lower limb amputation Diabetes Prevalence Rate per 100 and kidney failure in the U.S. by Education Level, California, 2004- 20 2013 Diabetes Mortality Rate in San 15 Diego County, 2013 26.8 30 22.9 10 19.8 17.3 17.3 19 20 13.5 5 10 0 0

Total < High School High School > High School Age Adjusted Death Rate per 100,000 Population. Source: Death Statistical Master Files (CDPH), County of San Diego, Health & *Source: CDC National Health Interview Survey; National Center Human Services Agency, Public Health Services, Epidemiology & Immunization for Health Statistics; Division of Health Interview Statistics Services Branch; SANDAG, Current Population Estimates, 10/2013.

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Characteristics of Residents, San Diego County Selected Elements from Diabetes Pathway:10

Data Source: Dartmouth College Institute for Data Source: U.S. Census Bureau, American Data Source: U.S. Department of Agriculture, Health Policy & Clinical Practice, Dartmouth Community Survey 2010-2014. Economic Research Service, USDA - Food Atlas of Health Care 2012. Access Research Atlas 2010.

Possible Intervention Opportunities9  Combined Diet and Physical Activity Promotion Programs: trained providers in clinical or community settings who work directly with program participants for at least 3 months and include some combination of counseling, coaching, and extended support  Case Management Interventions to Improve Glycemic Control: appointing a professional case manager who oversees and coordinates all of the services received by someone with the disease  Disease Management Programs and Screening in High Risk Patients: integrating services to improve glycemic control and monitoring retinopathy and lower extremity neuropathy

For More Information, Visit the American Diabetes Association’s Website: http://www.diabetes.org/

1. CDC website: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf 2. CDC website: National Diabetes Statistics report: http://www.cdc.gov/diabetes/pdfs/data/2014-report-estimates-of-diabetes-and-its-burden-in-the- united-states.pdf 3. CDC website: http://www.cdc.gov/diabetes/data/statistics/2014StatisticsReport.html 4. State Health Facts Website: http://kff.org/other/state-indicator/diabetes-death-rate-per-100000/ 5. County of San Diego. Mortality Data. http://www.sdcounty.ca.gov/hhsa/programs/phs/community_epidemiology/epi_stats_mortality.html#regional_tables 6. County of San Diego: Non-Communicable (Chronic Disease) Profile. http://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/CHS/CHS_NonCommunicable_Disease_Profiles.pdf 7. California Department of Public Health: Burden of Disease Brief. http://www.cdph.ca.gov/programs/cdcb/Documents/FINAL%20Rpt%20%281877%29%20DM%20burden%202014_9-04-14MNR3.pdf 8. County of San Diego Health and Human Services Agency, Public Health Services. Community Health Statistics Unit. (2012). Critical Pathways: the Disease Continuum, Stroke. January 2012. http://www.sdcounty.ca.gov/hhsa/programs/phs/documents/CHS‐ Critical_Pathways_2012.pdf. 9. The Community Guide. Diabetes Prevention and Control. http://www.thecommunityguide.org/diabetes/index.html. 10. Kaiser Permanente CHNA Data Platform. 11. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2012. http://www.cdc.gov/nchs/data/series/sr_10/sr10_260.pdf

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Behavioral Health

Mental Health is defined as “a state of complete physical, mental and social well-being, and not merely the absence of disease”.1 Mental illness is defined as “collectively all diagnosable mental disorders” or “health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or 2 impaired functioning”. DISPARITIES & Mental and Behavior Health covers a broad range of topics: BEHAVIORAL  Substance abuse and misuse are one set of behavioral health 4 , 5 , 1 0 problems. Others include (but are not limited to) serious psychological H EALTH distress, suicide, and mental illness.7  Barriers can exist for patients across the lifespan. The National Survey Behavioral Health & Race for Children’s Health (HRSA, 2010) showed that among children with Compared with whites, African emotional, developmental, or behavioral conditions, 45.6% were Americans and Hispanic Americans 10 receiving needed mental health services. used mental health services at about  In 2014, among the 20.2 million adults with a past year substance use one-half the rate in 2010. disorder, 7.9 million (39.1 percent) had any mental illness in the past Black adults and adolescents were 7 year. less likely than their white Depression: counterparts to receive treatment for  Depression is the leading cause of disability worldwide and is a major depression. contributor to the global burden of disease.4 American Indian/Alaskan Native  In 2014, 11.4% percentage of adolescents aged 12 to 17 had a major adults and those of 2 or more races depressive episode. The percentage who used illicit drugs in the past had the highest prevalence of mental year was higher among those with a past year major depressive illness with 26% and 28% living with a episode than it was among those without a past year major mental health condition, respectively. depressive episode (33.0 vs. 15.2%).7 Behavioral Health & Housing Prevalence: An estimated 26% of homeless adults  In 2014, an estimated 43.6 million (roughly 18%) adults aged 18 or 7 staying in shelters live with serious older had any mental illness in the United States. mental illness and an estimated 46%  One-half of all chronic mental illness begins by the age of 14; three- 4 live with severe mental illness and/or quarters by the age of 24. substance use disorders. Behavioral Health & Gender Males commit suicide four times more than females. Adult males were less likely than adult females to receive treatment for

depression.

Behavioral Health & Sexuality LGBTQ individuals are 2 or more times more likely as straight

individuals to have a mental health

condition.

Behavioral Health & Chronic Disease Mental Illness is associated with

chronic diseases such as

cardiovascular disease, diabetes, and

obesity. *Data from National Survey on Drug Use and Health (NSDUH)3 Any Mental Illness: A mental, behavioral, or emotional disorder (excluding developmental and substance use disorders); diagnosable currently or in the past year

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Interaction of Substance Abuse and Mental Illness

Characteristics of Residents, San Diego County Selected Elements Contributing to Behavioral Health: 9

Data Source: University of Missouri, Center Data Source: Centers for Disease Control Data Source: Centers for Disease Control for Applied Research and Environmental and Prevention, BRFSS 2006-2012. and Prevention, BRFSS 2006-2012. Systems. CDPH-Death Public Use Data. 2010-12. Possible Intervention Opportunities8  Collaborative Care for the Management of Depressive Disorders: using case managers to link primary care providers, patients, and mental health specialists with the goal of improved screening and diagnosis and increased use of evidence-based best practices and patient engagement  Electronic Screening and Brief Intervention for Excessive Alcohol Consumption: screening individuals and delivering a brief intervention, which provides personalized feedback about the risks and consequences of excessive drinking with at least one part delivered on an electronic device For More Information, Visit the Substance Abuse and Mental Health Services Website: http://www.samhsa.gov/

1. World Health Organization. Strengthening Mental Health Promotion. Geneva, World Health Organization (Fact sheet no. 220), 2001. 2. CDC. Mental Health Basics. http://www.cdc.gov/mentalhealth/basics.htm 3. National Institute of Mental Health. Any Mental Illness (AMI) Among Adults. http://www.nimh.nih.gov/health/statistics/prevalence/any- mental-illness-ami-among-adults.shtml 4. National Alliance on Mental Illness. Mental Health by the Numbers. http://www.nami.org/Learn-More/Mental-Health-By-the-Numbers 5. Suicide. http://www.cdc.gov/ViolencePrevention/pdf/Suicide_DataSheet-a.pdf 6. CDC. BRFSS Trend Data. http://apps.nccd.cdc.gov/HRQOL/ 7. SAMHSA. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.htm 8. The Community Guide. Alcohol Consumption and Mental Health. http://www.thecommunityguide.org/ 9. Kaiser Permanente CHNA Data Platform. 10. National Health Care Disparities Report, 2013. http://www.ahrq.gov/research/findings/nhqrdr/nhdr13/chap2b.html

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Obesity

Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health. Overweight and obesity ranges are determined using weight and height to calculate a number known as "body mass index" (BMI). An adult with a BMI between 25 and 29.9 is considered overweight, while an adult who has a BMI of 30 or higher is considered obese.1 For children and adolescents aged 2-19, overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile for children of the same age and sex, while obese is defined as a BMI at or above the 95th percentile for children of the same age and sex.2 DISPARITIES & OBESIT Y 1 0 , 1 1 Some facts about Obesity in the United States:3  According to the 2013 BRFSS and the Youth Risk Obesity & Race Behavior Surveillance System, 28.3% of U.S. adults were According to the BRFSS, from 2012 through obese, 35.5% of adults were overweight, 13.7% of 2014, non-Hispanic blacks had the highest adolescents were considered obese and 16.6% of adolescents were overweight. prevalence of self-reported obesity (38.1%),  In 2013, 21.4% of adults reported in engaging in no followed by Hispanics (31.3%) and non- leisure time activity and the number of adults who report Hispanic whites (27.1%). eating less than 1 vegetable or fruit daily is 17.3% and In 2011-2012, the prevalence among 30.4% respectively. children and adolescents was higher among Hispanics (22.4%) and non-Hispanic blacks Health Consequences due to Overweight and Obesity: 4 (20.2%) than among non-Hispanic whites Research has shown that as weight increases to reach the (14.1%). levels of "overweight" and "obesity," the risks for the following conditions also increases: Obesity & Gender  Coronary heart disease Among men, 42% were considered to be  Type 2 diabetes overweight compared to 29% of women. The  Cancers (endometrial, breast, and colon) median percentage of obesity was similar  Hypertension (high blood pressure among men (28%) and women (27%) in the  Stroke U.S.  Liver and Gallbladder disease  Sleep apnea and respiratory problems Obesity & Income  Osteoarthritis Among non-Hispanic black and Mexican- Overweight and Obesity Associated Costs: 1 American men, those with higher incomes are more likely to have obesity than those In 2008, medical costs associated with obesity were estimated at with low income. $147 billion; the medical costs for people who are obese were Higher income women and women with $1,429 higher than those of normal weight. higher educational attainment are less likely Obese Weight Status Among San Diego to be obese than low-income women. County Adults by Region, 2011-2012 Obesity prevalence was the highest among children in families with an income-to- 30.0% 26.6% 26.8% poverty ratio of 100% or less. 23.7% 22.9% 24.8% 25.0% 22.1% 20.0% 17.5% 16.6% Obesity & Quality of Life 15.0% Obesity can affect the quality of life 10.0% 5.0% through limited mobility and decreased 0.0% physical endurance, in addition to social, North North Central South East North San CA academic, and job discrimination. Coastal Central Inland Diego State County

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Characteristics of Residents, San Diego County Selected Elements from Obesity Pathway:8

Data Source: Centers for Disease Control and Data Source: U.S. Census Bureau, County Data Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Business Patterns 2011. Prevention, BRFSS 2011-2012. Prevention and Health Promotion 2012.

Possible Intervention Opportunities9  Behavioral Interventions that Aim to Reduce Recreational Sedentary Screen Time Among Children: teaching behavioral self-management skills to initiate or maintain behavior change including the use of an electronic monitoring device to limit screen time; TV Turnoff Challenge; screen time contingent on physical activity; or small media.  Worksite Programs: using one or more approaches to support behavioral change at employee worksites including informational and educational, behavioral and social, and policy and environmental strategies

For More Information, Visit Medline’s Obesity Page: http://www.nlm.nih.gov/medlineplus/obesity.html

1. CDC Website: Centers for Disease Control and Prevention. Def. Obesity and Overweight: http://www.cdc.gov/obesity/adult/defining.html 2. Barlow SE and the Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120 Supplement December 2007:S164—S192. 3. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition, Physical Activity and Obesity. Nutrition, Physical Activity and Obesity Data, Trends and Maps. http://www.cdc.gov/nccdphp/DNPAO/index.html 4. NIH, NHLBI Obesity Education Initiative. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf 5. CDC Website: NCHS Factsheet: http://www.cdc.gov/nchs/data/factsheets/factsheet_disparities.htm 6. CDC Website: Centers for Disease Control and Prevention. Adult Obesity facts: http://www.cdc.gov/obesity/data/adult.html. 7. County of San Diego HHSA, Community Health Statistics Unit, Obesity Brief, http://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/documents/CHS-Obesity_Brief.pdf 8. Kaiser Permanente CHNA Data Platform. 9. The Community Guide. Obesity Prevention and Control. http://www.thecommunityguide.org/obesity/index.html 10. CDC Website: Centers for Disease Control and Prevention. Childhood Obesity facts: http://www.cdc.gov/obesity/data/childhood.html 11. CDC Website: Centers for Disease Control and Prevention. Adult Obesity facts: http://www.cdc.gov/obesity/data/adult.html

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Appendix U Map of Sharp HealthCare Locations

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Appendix Sharp HealthCare Involvement in V Community Organizations The list below shows the involvement of Sharp executive leadership and other staff in community organizations and coalitions in Fiscal Year 2015. Community organizations are listed alphabetically.

. 2-1-1 San Diego Board . A New PATH (Parents for Addiction, Treatment and Healing) . Adult Protective Services . Aging and Independence Services . Alzheimer’s Association . American Association of Colleges of Nursing . American Association of Critical Care Nurses, San Diego Chapter . American Cancer Society . American College of Healthcare Executives . American Diabetes Association . American Foundation for Suicide Prevention . American Health Information Management Association . American Heart Association . American Hospital Association . American Psychiatric Nurses Association . American Red Cross of San Diego . Arc of San Diego . Asian Business Association . Association for Ambulatory Behavioral Healthcare . Association for Clinical Pastoral Education . Association of Women’s Health, Obstetric and Neonatal Nurses . Azusa Pacific University . Beacon Council’s Patient Safety Collaborative . Boys and Girls Club of San Diego . Bonita Business and Professional Organization . California Association of Health Plans . California Association of Hospitals and Health Systems . California Association of Marriage and Family Therapists . California Association of Physician Groups . California Board of Behavioral Health Sciences . California Coalition for Mental Health . California College, San Diego . California Maternal Quality Care Collaborative . California Council for Excellence . California Department of Public Health . California Dietetic Association, Executive Board . California HealthCare Foundation

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. California Health Information Association . California Hospice and Palliative Care Association . California Hospital Association Center for Behavioral Health . California Hospital Association . California Library Association . California Perinatal Quality Care Collaborative . California State University San Marcos . California Teratogen Information Service . Caregiver Coalition of San Diego . Caring Hearts Medical Clinic . Centers for Community Solutions . Chelsea’s Light Foundation . Chicano Federation of San Diego County . Community Health Improvement Partners (CHIP) Behavioral Health Work Team . CHIP Board . CHIP Health Literacy Task Force . CHIP Suicide Prevention Work Team . CHIP Independent Living Association Advisory Board and Peer Review Advisory Team . Chula Vista Chamber of Commerce . Chula Vista Community Collaborative . Chula Vista Family Health Center . Chula Vista Rotary . City of Chula Vista Wellness Program . Coalition to Transform Advanced Care . Combined Health Agencies . Community Emergency Response Team . Consortium for Nursing Excellence, San Diego . Coronado Chapter of Rotary International . Coronado Fire Department . Council of Women’s and Infants’ Specialty Hospitals . Cycle EastLake . Downtown San Diego Partnership . East County Senior Service Providers . El Cajon Fire Department . Emergency Nurses Association, San Diego Chapter . Employee Assistance Professionals Association . EMSTA College . Family Health Centers of San Diego . Feeding America San Diego . Gardner Group . Gary and Mary West Senior Wellness Center . Girl Scouts of San Diego Imperial Council, Inc. . Greater San Diego East County Advisory Board . Grossmont College . Grossmont Healthcare District . Grossmont Health Occupations Center

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. Grossmont Union High School District . Health Care Communicators Board . Health Insurance Counseling and Advocacy Program . Health Sciences High and Middle College . Health Volunteers Overseas . Heart to Heart International . Helen Woodward Animal Center . Helix Charter High School . Helps International . Home of Guiding Hands . Hospice-Veteran Partnership . Hospital Association of San Diego and Imperial Counties . HASD&IC Community Health Needs Assessment Advisory Group . HSHMC Board . Hunger Advocacy Network . I Love a Clean San Diego . International Association of Eating Disorders Professionals . International Lactation Consultants Association . International Relief Team . Ioamai Medical Ministries . Jewish Family Service of San Diego . Jewish Federation of San Diego County – Jewish Senior Services Council . John Brockington Foundation . Journal for Nursing Care Quality Editorial Board . Kaplan College Advisory Board . Kiwanis Club of Chula Vista . Komen Latina Advisory Council . Komen Race for the Cure Committee . La Maestra Community Health Centers . La Mesa Lion’s Club . La Mesa Park and Recreation Foundation Board . Las Damas de San Diego International Nonprofit Organization . Las Patronas . Las Primeras . March of Dimes . Meals-on-Wheels Greater San Diego . Medical Library Group of Southern California and Arizona . Mended Hearts . Mental Health America . Mental Health Coalition . Mental Health First Aid Program — Mental Health America of San Diego . Miracle Babies . MRI Joint Venture Board . National Active and Retired Federal Employees Association . National Alliance on Mental Illness . National Association of Neonatal Nurses

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. National Association of Hispanic Nurses, San Diego Chapter . National Hospice and Palliative Care Organization . National Institute for Children’s Health Quality . National Kidney Foundation . National University . Neighborhood Healthcare Community Clinic . North County Health Project . Peninsula Shepherd Senior Center . Perinatal Safety Collaborative . Perinatal Social Work Cluster . Planetree Board of Directors . Professional Oncology Network . Public Health Nurse Advisory Board . Recovery Innovations – California . Regional Perinatal System . Residential Care Council . Rotary Club of Chula Vista . Rotary Club of Coronado . Safety Net Connect . San Diego Community Action Network . San Diegans for Healthcare Coverage . San Diego Association of Diabetes Educators . San Diego Association of Directors of Volunteer Services . San Diego Association of Governments Public Health Stakeholder Group . San Diego Black Nurses Association . San Diego Blood Bank . San Diego Brain Injury Foundation . San Diego Coalition of Mental Health . San Diego Council on Suicide Prevention . San Diego County Breastfeeding Coalition Advisory Board . San Diego County Coalition for Improving End-of-Life Care . San Diego County Council on Aging . San Diego County Emergency Medical Care Committee . San Diego County Health and Human Services Agency . San Diego County Hospice-Veteran Partnership . San Diego County Older Adult Behavioral Health System of Care Council . San Diego County Perinatal Care Network . San Diego County Social Services Advisory Board . San Diego County Stroke Consortium . San Diego County Suicide Prevention Council . San Diego County Taxpayers Association . San Diego Covered California Collaborative . San Diego Dietetic Association Board . San Diego East County Chamber of Commerce Health Committee . San Diego Emergency Medical Care Committee . San Diego Eye Bank Nurses Advisory Board

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. San Diego Food Bank . San Diego Food System Alliance, Healthy Food Access Committee . San Diego Half Marathon . San Diego Health Information Association . San Diego Healthcare Disaster Council . San Diego Hospice and Palliative Nurses Association . San Diego Housing Commission . San Diego Hunger Coalition . San Diego Imperial Council of Hospital Volunteers . San Diego Lesbian, Gay, Bisexual, and Transgender Community Center, Inc. . San Diego Mental Health Coalition . San Diego Mesa College . San Diego Military Family Collaborative . San Diego North Chamber of Commerce . San Diego Older Adult Council . San Diego Organization of Healthcare Leaders, a local American College of Healthcare Executives Chapter . San Diego Patient Safety Consortium . San Diego Physician Orders for Life-Sustaining Treatment Coalition . San Diego Regional Home Care Council . San Diego Rescue Mission . San Diego River Park Foundation . San Diego-Imperial Council of Hospital Volunteers . San Diego Regional Chamber of Commerce . San Diego Rescue Mission . San Diego Science Alliance . San Diego State University . San Ysidro High School . Santee Chamber of Commerce . SAY San Diego . Second Chance . Serving Seniors . Sigma Theta Tau International Honor Society of Nursing . Society of Trauma Nurses . South Bay Community Services . South County Action Network . South County Economic Development Council . Southern California Association of Neonatal Nurses . Southern California Earthquake Alliance . Southern Caregiver Resource Center . Special Olympics . St. Paul’s Retirement Homes Foundation . St. Vincent de Paul Village . Susan G. Komen Breast Cancer Foundation . Sweetwater Union High School District . The Meeting Place

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. Third Avenue Charitable Organization . Trauma Center Association of America . United Service Organizations Council of San Diego . University of California, San Diego . University of San Diego . VA San Diego Healthcare System . Veterans Home of California, Chula Vista . Veterans Village of San Diego . Vista Hill ParentCare . Walk San Diego . Women, Infants and Children Program . YMCA . YWCA Becky’s House® . YWCA Board of Directors . YWCA Executive Committee . YWCA Finance Committee . YWCA In the Company of Women Event

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Appendix W SGH FY 2017 – 2020 Implementation Plan

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Identified Community Objectives/Anticipated Responsible Identified Evaluation Methods, Measurable Targets, Action Items Health Need: Impact Party/ies Themes in and Other Comments Access to 2016 CHNA Care

1. Increase coverage for a. Continue to provide services to Navigators Access to Care The PointCare program continues to collect metrics on patients seen in the help every unfunded patient Patient Access Education number of individuals served and cost savings. Via this Emergency Room by received in the Emergency Service program, Sharp served 9,384 self‐pay patients since providing assistance to Department find coverage October 01, 2015 through 07/31/2016. secure health coverage for options ‐ including PointCare Representatives all individuals entitled to the questionnaire to generate Patient Access PointCare has expanded its website to also provide linkage benefit; also provide personalized coverage options Services to Covered CA as appropriate. The tool interfaces patient payment options for that are filed in patients' screening information in the GE record. individuals that chose not to accounts for future reference and Public Resource secure coverage or are not accessibility. Specialist Sharp Healthcare’s Patient Access Services department currently eligible for health Patient Access has processed real‐time Medi‐Cal eligibility benefits. Secure benefit In addition, Sharp staff use the Service determinations under the Hospital Presumptive Eligibility concurrent with stay when PointCare on‐line survey to direct Program for 234 unfunded patients, YTD FY 2016. Medi‐Cal Presumptive patients to the Covered California Self‐Pay Team Eligibility rules apply. website for health coverage or Manager Thus far in FY 2016, Sharp Healthcare’s Patient Access Medi‐Cal enrollment as Services department has assisted 309 recipients in Presumptively Eligible and/or full maintaining Medi‐Cal eligibility after the HPE period lapse scope benefits. via advanced advocacy efforts.

Continued unknowns in understanding the efficacy of our efforts are the increase in the patient out of pocket responsibility resulting from health plan coverage purchased off the exchange and the transition of qualified unfunded patients directly to Medi‐Cal.

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Sharp has initiated a process of trending straight self‐pay collections separate from balance after insurance collections in an effort to closely monitor these two distinct populations. 2. Provide payment options a. Provide the Maximum Out of Financial Access to care The Maximum Out of Pocket Program was launched in and support high‐risk, Pocket Program to patients who Counselor Financial October 2014. Sharp provides one‐on‐one interviews uninsured, underinsured, express an inability to pay their assistance during the hospital stay focusing on educating the patient and patients admitted to financial responsibility after health Provide regarding their health insurance benefits, accessing care, hospital facilities with an insurance. education on and payments options with a compassionate approach inability to pay their financial patient financial while promoting healing. responsibility after health services insurance.

b. Provide a Public Resource Patient Access Access to care In 2015, a new position was created – the Public Resource Specialist for uninsured and Services; Financial Specialist – to support to patients needing extra guidance underinsured patients, to offer assistance on available funding options. These individuals will also support patients needing advanced Public Resource Provide perform what is traditionally called “field calls” (home guidance on available funding Specialist education on visits) to patients who have left the hospital and require options. Patient Access patient financial assistance in completing a process to facilitate coverage.

Service services These positions were deployed in fiscal year 2016.

Self‐Pay Team Manager

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c. Provide specialized financial Patient Access Access to care In Summer 2015, a pilot program was launched at Sharp assistance and support program to Services Financial Mary Birch Hospital for Women & Newborns in support of families with children in a Sharp assistance Sharp’s NICU babies. This process includes a meeting with NICU. Public Resource families where a newborn that has been diagnosed with a Specialist devastating medical condition or extremely low birth Patient Access weight is evaluated for eligibility for Supplemental

Service Security Income (SSI).

Self‐Pay Team Manager d. Patient Assistance Team will Supervisor, Access to care Cost savings for replacement drugs is monitored through continue to assist patients in need Patient Provide pharmacy and supply chain. The patient accounting staff of assistance gain access to free or Assistance education on remove the charges from the patient statement. low‐cost medications. Patients are Navigators patient financial identified through usage reports, services Sharp was the first hospital in San Diego to gain or referred through case Manager Certification through the Covered CA program, training management, nursing, physicians Patient Financial over 20 employees to become Certified Enrollment or even other patients. If eligible, Services, Self‐ Counselors for Covered CA. This, along with Hospital uninsured patients are offered Pay Patients Presumptive Eligibility, has reduced the unfunded assistance, which can help population at our hospitals significantly. With the ending decrease readmissions due to lack of the In‐Person assistance program in July 2015, entity of medication access. The team counselors will be transitioned to the Certified Application members research all options Assistance Program. available including programs offered by drug manufacturers, Sharp also tracks each individual that has applied for

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grant‐based programs offered by financial assistance. The patient account is noted with the foundations, copay assistance, low‐ findings, and a specific adjustment code is used to track cost alternatives, or research the dollars associated with these reviews. where the patient might find their medication at a lower cost.

e. Continue to offer ClearBalance – a Supervisor, Access to Care To date in FY16, more than 1,830 Sharp patients been specialized loan program for Patient assisted through the ClearBalance loan program. patients facing high medical bills. Assistance Through this collaboration with Navigators San Diego‐based CSI Financial Services, both insured and Manager uninsured patients have the Patient Financial opportunity to secure small bank Services, Self‐ loans in order to pay off their Pay Patients medical bills in low monthly payments.

f. Continue to provide Project HELP Sharp Access to Care Project HELP funds are tracked though an internal funds for pharmaceuticals, Grossmont database. From FY10‐FY15, Project HELP funds totaled transportation vouchers and other Hospital (SGH) ~$792.8 K, and increased 58.4%. needs for economically Chief Financial disadvantaged patients. Officer

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3. Improve access and health a. Provide data to St. Vincent de Paul Vice President, Access to Care This effort concluded in 2015, and has led to the state’s outcomes for high‐risk for Permanent Supportive Housing Sharp Collaboration adoption of the model for distribution in other regions, via community members, Cost Effectiveness Study– which HealthCare Care the Whole Person Care program funded by the Medicaid particularly San Diego’s provides housing and social (SHC) Management Waiver; and continuation (via the City/County Project One homeless population. services San Diego’s chronically Government for All which will include wraparound services for defined homeless community members. Relations population of homeless.

b. Participate in collaboration with Vice President, Access to Care This project concluded in 2016. the San Diego Organizing Project SHC Collaboration and Multicultural Primary Group to Government Care This project tracks hospital service utilization and cost provide follow‐up medical and Relations Management savings. Currently (as of July, 2015) Sharp is tracking case management services to high‐ service utilization for 50 individuals. Program began in risk patients (homeless, etc.) Care Transitions spring, 2013. Program Manager

c. Continue to collaborate with the Care Transitions Access to Care Program tracks the number of referrals made to the San Diego Rescue Mission to Program Care Rescue Mission as well as cost data for patients for whom discharge chronically homeless Manager Management Sharp covers the cost of post‐discharge treatment (at a patients to the Rescue Mission’s Collaboration Sharp facility). Data for the latter are tracked via Sharp’s Recuperative Care Unit. These Case Management Department’s cost reports. patients receive follow‐up care through SGH in a safe space, in addition to psychiatric care, substance abuse counseling and

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other services through the San Diego Rescue Mission.

d. Continue to partner with Father Care Transitions Access to Care Eligibility for Project SOAR’s programming is incorporated Joe’s Villages to support Project Program Collaboration into Sharp’s current eligibility review process for all SOAR ‐ designed to facilitate and Manager Care patients; patient files are assessed for Project SOAR expedite the processing of social Management eligibility and then referrals are conducted for qualified security and disability applications patients. for homeless individuals with urgent health care needs. Currently there are no mechanisms in place to track cost or volume on this program, as it is a cooperative with no direct costs for Sharp. Thus, it is difficult to measure any savings that Sharp might experience.

e. Continue to explore opportunities Vice President, Access to Care With the success of Sharp Grossmont Hospital’s Care for collaboration with community SHC Collaboration Transitions Intervention (CTI) pilot (see line item below), organizations to provide medical Government Care Sharp is exploring the concept of expanding this model of care, financial assistance, Relations Management care (connection to resources for food insecurity, psychiatric and social services to transportation, and other social supports) to other high‐ high‐risk, chronically ill, and/or Care Transitions risk patient populations at Sharp’s hospital entities. In

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chronically homeless patients Program progress. Manager

Program Manager, Community Benefits and Health Improvement

f. Continue to offer high‐risk, Care Transitions Access to Care The CTI© program focuses on transitioning patient home vulnerable SGH patients (Self‐Pay, Program Care safely by reviewing Medications, early recognition of Medi‐Cal, Medi‐Cal Presumptive, Manager Management symptoms, establishing a Medical Home, providing with complex chronic health Collaboration Advanced Care Planning choices and ensuring the patient conditions and limited social has a plan for managing their care across the care support) health coaching and Program continuum. Part of this is accomplished by connecting to resources (through multiple Manager, patients to community resources (e.g., the San Diego Food community partnerships) upon Community Bank, 2‐1‐1 San Diego, Feeding America) that help them discharge to help ensure safe Benefits and maintain their health and safety, including: food (directly), transition from hospital to home, Health hunger relief organizations, transportation resources, and improve their quality of life; a Improvement access to a primary care physician for follow up care, Care Transitions Intervention (CTI) medical equipment, and other social supports. In FY model pilot. 2015, connections with Feeding America, San Diego and 211 San Diego were established with success.

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With support for SGH Foundation, Wal Mart, SDGE and individual donors, the program has been able to support these patients with food, blood pressure cuffs, diabetes kits, pulse oximeters and pill boxes. The program is also able to assist with co‐pays for medications should the need arise.

Metrics since the inception of CTI (June, 2014):  950 patients served  457 (48%) required social support  82 required food support (since Sept., 2014)  55 received emergency food boxes (since March, 2015)  25 received diabetes kits (since 2015)  92 assist with PCP appt o 75% patients made appts. o 85% kept PCP appt.  74 community clinic referrals  83 Pharmacy support  351 community resource information  30 referral to 2‐1‐1  Readmission rates (30‐day): o Inpatient: 13.4 % average o ED, post‐discharge: 10.02%

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o IP for those referred to 2‐1‐1: 4.7%

For 2‐1‐1 partnership, also collecting metrics on social determinants of health and self‐efficacy. Data forthcoming.

A goal for the program is to integrate more Behavioral Health support as these are the patients that so often cannot be coached and need a specific Care Pathway.

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1. Provide comprehensive a. Continue to provide a dedicated Director, SGH Behavioral SGH is the only hospital in East County to provide this behavioral health programs psychiatric assessment team in Behavioral Health assessment to patients in the ED. Psychiatric consultations to adults and older adults in the Emergency Department (ED) Health Services Screening in the ED have increased approximately 117% from 2007 East County with acute or and acute care. Access to Care (294 consults) to mid‐2016 (637 consults). persistent psychiatric Chief Medical Co‐occurring disorders. Programs will Officer, SHC disorders Although Behavioral Health is identified as a health need help individuals in crisis Behavioral Senior Health in the communities served by SGH, beyond clinical regain their optimal level of Health services, the facility does not have the resources to functioning and achieve a comprehensively address the elements of community renewed sense of emotional education and support around this health need. stability and wellness. Consequently, the community education and support elements of behavioral health care are addressed through the programs/services provided through Sharp Mesa Vista Hospital and Sharp McDonald Center, which are the major providers of behavioral health and chemical dependency services in San Diego County.

b. Continue to provide hospital‐ Director, SGH Behavioral Current outpatient programs include: Adult Mental Health based outpatient programs that Behavioral Health Program for adults with acute and chronic disorders such serve individuals dealing with a Health Services Screening as schizophrenia and bipolar disease; Bridges Program, variety of behavioral health Access to Care based on the Recovery Model for adults diagnosed with issues, including schizophrenia, Chief Medical Co‐occurring schizophrenia and bipolar disorder; Dual Recovery depression and bipolar or anxiety Officer, SHC disorders Program, for adults with co‐existing mental illness and disorders. Behavioral Senior Health chemical‐use/addictive behavior disorder; Older Adults Health (Senior) Mental Health Program, for adults age 60 and

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older experiencing anxiety, depression and other behavioral health issues often associated with challenging, age‐related life transitions; Outpatient Electroconvulsive Therapy (ECT) Program.

c. Continue to offer specialized Director, SGH Behavioral Current inpatient programs include: FOCUS program for inpatient treatment programs Behavioral Health adults suffering from psychiatric illness such as psychosis, designed to address the specific Health Services Screening delusions, depression, grief, anxiety, panic, obsessive‐ needs and conditions of patients. Access to Care compulsive disorder, and traumatic stress syndromes; Chief Medical Co‐occurring Intensive treatment programs for short‐term crisis Officer, SHC disorders intervention, rapid recovery and return home; Medical Behavioral Senior Health Psychiatric Program and an Older Adult Program Health specifically for individuals age 60 and over.

d. Explore collaboration with MHA’s SGH Chief Behavioral In Fall 2015, Sharp Grossmont Hospital staff attended a Mental Health First Aid Training to Nursing Officer Health Sharp‐hosted training with Mental Health First Aid– an provide training to front‐line SGH Education internationally‐renowned program that teaches front‐line staff for improved management Program Stigma Reduction staff the signs and impacts of addiction and mental illness, Manager, Workforce including a 5‐step action plan to assess and de‐escalate Community Development situations, and local resources. This is a peer‐reviewed, Benefits and proven‐effective program and is listed in the Substance Health Abuse and Mental Health Services Administration’s Improvement National Registry of Evidence‐based Programs and Practices. Sharp HealthCare is the first hospital/health system to participate in this training, currently funded by

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the County of San Diego.

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Identified Objectives/Anticipated Responsible Identified Evaluation Methods, Measurable Targets, Community Action Items Impact Party/ies Themes in and Other Comments Health Need: 2016 CHNA Cancer 1. Improve navigation of the a. Continue to offer the cancer SGH Cancer Access to Care In FY 2015, the Breast CPN facilitated access to care for health care system for patient navigator program to SGH Patient Care more than 180 breast cancer patients in need — many cancer patients in San cancer patients; facilitate Navigator Management with late‐stage cancer diagnoses — through the provision Diego’s east region connection to community Coordinator of referrals to various community and national through patient navigation resources via the navigator organizations. services. program. Navigation Resources: In FY 2016, due to a vacancy in Sharp’s cancer navigator position, it was decided to replace the position with a navigator who was a social worker to better address patient needs. The position was filled with an LCSW in January, 2016. Later in 2016 with growing clinical needs, approval was secured to hire an RN to meet both Navigator and Radiation Oncology needs. That position will start in August, 2016. This team will cover all cancer sites, but will focus on those patients receiving radiation therapy. Metric: Navigation FTEs.

Identification and Prioritization of Needs: Distress Screening to assess practical and emotional issues contributing to cancer patient distress has been conducted at Sharp Chula Vista Medical Center over the past few years. A recent effort was initiated by Sharp Cancer Outpatient social workers to develop a consistent tool across the Sharp system that would evaluate these needs in greater detail in order to make them actionable and rate them by intensity so that they may be prioritized

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Identified Objectives/Anticipated Responsible Identified Evaluation Methods, Measurable Targets, Community Action Items Impact Party/ies Themes in and Other Comments Health Need: 2016 CHNA Cancer

and addressed appropriately. Metrics: Routine reports including number of patients screened, information on the issues that are most challenging for patients and the percentage of patients rated in high distress will be provided to the Integrated Network Cancer Program and to individual entities. The information will drive efforts to target and provide additional support and resources to better meet our patient needs.

Navigation Communication: Currently patient navigation is not consistently documented and easily accessible to all care team members. Often patients share valuable information with Navigators that can be useful to other team members for care coordination as well as identifying concerns about treatments and side effects that can be addressed by physicians and other staff for a more personalized approach to care and presenting options that may be more acceptable for cultural or personal beliefs. A project is planned for integrating Navigator care documentation in Cerner EMR to provide improved communication among all cancer team members. Metric: Implementation of Navigator documentation in Cerner.

Timely Access to Care: Navigators have identified that timely access to specialist appointments and imaging

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Identified Objectives/Anticipated Responsible Identified Evaluation Methods, Measurable Targets, Community Action Items Impact Party/ies Themes in and Other Comments Health Need: 2016 CHNA Cancer

studies is a consistent issue among our cancer patients with delays that feed patient anxiety and is a clinical concern for impacting maximum effectiveness of cancer treatment. This will be a focus for our cancer navigators and the cancer program in identifying performance improvement initiatives to reduce the time from diagnosis to treatment for our cancer patients. Metrics: Calculation of the time from diagnosis to treatment for key sites that will capture the predominant issues and annual evaluation of the change in number of days to treatment at least annually. Also measured will metrics specific to focused projects on key processes identified that are contributing to delays in care.

The Breast CPN is an RN certified in breast health who personally assists breast cancer patients and their families in their navigation of the health care system. The Breast CPN offers support, guidance, financial assistance referrals and connection to community resources. Through collaboration with community clinics — including FHCSD, Neighborhood Healthcare and Borrego Health — the Breast CPN refers unfunded or underfunded women for a covered diagnostic mammogram or immediate Medi‐Cal insurance should their biopsy prove positive and require treatment. The Breast CPN also identifies patients who may benefit from the Breast and Cervical Cancer

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Identified Objectives/Anticipated Responsible Identified Evaluation Methods, Measurable Targets, Community Action Items Impact Party/ies Themes in and Other Comments Health Need: 2016 CHNA Cancer

Treatment Program, a program offered through the California Department of Health Care Services to provide urgently needed cancer treatment coverage, including referring patients to local clinics who help complete the enrollment process. Patients needing psychosocial support may be referred to various local or national support groups, the Jewish Family Service of San Diego’s Breast Cancer Case Management program or the SGH Cancer Center Radiation Oncology Department’s LCSW.

Since 2014, a CPN at SGH has been designated for patients with cancers other than breast. The CPN primarily serves patients with head and neck cancers and lung cancer, but also assists those with anal and esophageal cancers as well as any cancer patient with complex care needs. The CPN supports patients and their family members through care coordination and connection to needed resources, including transportation, translation needs, financial assistance, speech therapy, nutritional support, feeding tube support, social work services and more. In addition, the CPN offers psychosocial support and education about the side effects of radiation therapy. The CPN has assisted nearly 160 patients and their families since the inception of the program.

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Identified Objectives/Anticipated Responsible Identified Evaluation Methods, Measurable Targets, Community Action Items Impact Party/ies Themes in and Other Comments Health Need: 2016 CHNA Cancer b. Seek funding for the cancer SGH Patient Access to Care No current updates. patient navigator program and Navigator Care expand navigator services to all Management cancers.

2. Increase cancer education a. Continue to provide free support SGH Cancer Cancer In FY 2015, a variety of free support groups reached and support for community programs for community Patient Education approximately 1,000 community members In SDC’s east members in the east region members with cancer diagnoses. Navigator Care region impacted by cancer, including: bi‐monthly breast with cancer diagnoses. Coordinator Management cancer support group; monthly lung cancer support group; monthly brain cancer support group. In addition, beginning in the spring of 2015, the weekly Art and Chat support group offered cancer patients, survivors and their loved ones a combination of chat and relaxing drawing methods to increase focus, creativity, self‐confidence and personal well‐being. The SGH Cancer Center also offered the weekly chaplain‐led Sacred Circle: Spirituality and Cancer support group, through which cancer patients used a mixture of expressive arts modalities, prayer, and discussion of personal and spiritual topics to restore their spirits.

Development of programs and services driven by Distress Screening (see action item “Cancer: a” above) and feedback from navigators, social workers and other staff will be ongoing.

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Expansion of Sharp partnership with the American Cancer Society to provide education and support materials and community support connections to ACS Patient Organizers. This will be in conjunction with Sharp information for patient education, services offered, information specific to care at SGH and additional connections to community and national organizations that provide assistance to cancer patients. A specific portion of Sharp’s website (sharp.com) is planned for cancer patients to provide information and tools that will be helpful to patients during the course of their cancer journey.

Metrics (forthcoming): Number of Patient Organizers delivered (?); initiation of patient information website section; number of hits on the patient website indicating use.

b. Continue to provide Look Good… SGH Cancer Cancer In FY 2015, six Look Good…Feel Better classes taught Feel Better classes to community Patient Education approximately 30 women techniques to manage members with cancer diagnoses. Navigator Care appearance‐related side effects of cancer treatment and Coordinator Management boost self‐confidence. Offered through the ACS, the Look Collaboration Good…Feel Better classes included a complimentary makeup kit for attendees and instruction from a licensed beauty professional on makeup application, skin care, and wearing wigs and headwear.

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Identified Objectives/Anticipated Responsible Identified Evaluation Methods, Measurable Targets, Community Action Items Impact Party/ies Themes in and Other Comments Health Need: 2016 CHNA Cancer c. Continue to provide ongoing SGH Cancer Cancer In FY 2015, SGH’s Cancer LCSW offered psychosocial social and psychosocial supports Licensed Clinical Education services (assessments, crisis intervention, counseling and to community member with Social Worker Care stress management), support group leadership, and cancer diagnoses. Management advocacy and resources for transportation, palliative care and hospice, food and financial assistance. In FY 2015 this included improving patient and family connections to community services such as ACS, San Diego Brain Tumor Foundation, Leukemia and Lymphoma Society, Lung Cancer Alliance, Mama’s Kitchen, 2‐1‐1 San Diego, Feeding America San Diego, SDFB and Jewish Family Service of San Diego’s Breast Cancer Case Management program, and other food and financial assistance programs.

The LCSW served approximately 230 patients and family members in FY 2015, and an additional 25 community members contacted the LCSW for consultation regarding support groups and other SGH Cancer Center services and community resources.

3. Increase community a. Continue to conduct Manager, SGH Cancer Education In FY 2015, the SGH Cancer Center provided breast self‐ education on the signs and comprehensive community cancer Radiation Collaboration examinations and cancer education and resources from symptoms of cancer health seminars with screenings. Oncology Screenings the ACS and National Cancer Institute (NCI) to more than through education and HBO/WHC 500 individuals at community events, including the screening events. Cuyamaca College Health & Wellness Fair, East County Senior Service Providers 16th annual Senior Health Fair at SGH Cancer Santee Trolley Square, the Southern Indian Health Council,

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Patient Inc. Women’s Wellness Health Fair, Sharp’s annual Navigator Women’s Health Conference, Sharp HospiceCare Coordinator Resource & Education Expo and the Waterford Terrace Retirement Community Health Fair. In addition, SGH Cancer Center staff walked alongside cancer patients and families in the ACS Making Strides Against Breast Cancer Walk in October.

The SGH Cancer Center also hosted educational classes at no cost for patients and community members facing cancer. Offered monthly between June and September, the Chair Yoga and Relaxation class taught individuals in all stages of cancer yoga postures, breathing and meditation techniques to help lower stress and calm the nervous system. The SGH Cancer Center also offered a 12‐month Survivorship Lunch and Learn series in FY 2015, reaching approximately 10 individuals per session. Once a month, community members, patients and families were invited to hear local experts speak about a unique cancer‐related topic — such as coping with the holidays, approaching survivorship with confidence, and complementary therapies – and participate in a Q&A session.

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1. Empower community a. Continue to provide free Manager, SGH 5 Cardiovascular A free Heart and Vascular Risk Factors Education class was members with bimonthly cardiac education West, Cardiac Disease offered twice a month to individuals who were cardiovascular and classes. Rehabilitation Education hospitalized within the last six months due to select heart cerebrovascular disease conditions, reaching nearly 180 individuals in FY 2015. through education, Director, SGH screening and support; Cardiac/ SGH educational programs are evaluated by participants promote accountability Vascular through survey. and behavioral change Services through education on chronic disease self‐ Director, SGH management. Marketing and Communication b. Continue to provide free Manager, SGH 5 Cardiovascular In FY15, a free, monthly CHF class and support group, held congestive heart failure education West, Cardiac Disease at the Grossmont Healthcare District Herrick Community classes and support groups. Rehabilitation Education Health Care Library, provided approximately 45 community members with a supportive environment to Director, SGH discuss various topics about living well with CHF, covering Cardiac/ topics such as exercise, nutrition, treatment plans and Vascular symptoms. Services SGH educational programs are evaluated by participants Director, SGH through survey. Marketing and Communication

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c. Educational sessions focused on Manager, SGH 5 Cardiovascular Target is at least one to two community events per year – heart disease and cardiovascular West, Cardiac Disease including health fairs and lectures. Past event have health for the east region Rehabilitation Education included: December Nights, Sharp Women’s Health communities. Conference and Celebrando. SGH educational programs Director, SGH are evaluated by participants through survey. Cardiac/ Vascular In FY 2015, SGH’s Cardiac Training and Cardiac Services Rehabilitation Departments provided education and free cardiovascular screenings at various community events Director, SGH throughout San Diego. Events included cardiopulmonary Marketing and resuscitation (CPR) demonstrations and education and Communication resources on cardiac health, including prevention, evaluation and treatment. Locations included the Summer Healthcare Saturday Health Fair at Grossmont Center, the SGH Women’s Heart Health Expo, Celebrando Latinas Conference at the Hilton San Diego Bayfront, December Nights, the Sharp Women’s Health Conference, and the American Heart Association (AHA) Heart & Stroke Walk.

The team also collaborated with the SGH Senior Resource Center to educate 20 seniors at the Herrick Community Health Care Library about the importance of exercise and nutrition to maintain a healthy heart.

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SGH educational programs are evaluated by participants through survey.

d. Continue to provide educational Director, SGH Cardiovascular In FY 2014, SGH’s Cardiac Training and Cardiac resources on cardiac health at Cardiac/ Disease Rehabilitation Departments provided education and free community events throughout Vascular Education cardiovascular screenings at various community events San Diego. Services throughout San Diego (see item 1c above).

Preventive cardiovascular screenings (fee‐based) are comprehensive, include ultrasound, lab tests, and offer a calcium scoring option as well as assessing and educating the patient on his or her risk of a heart attack or stroke. SGH has screened approximately 900 individuals to date.

e. Continue to provide preventative Director, SGH Cardiovascular Preventive cardiovascular screenings (fee‐based) are cardiovascular screenings to Cardiac/ Disease comprehensive, include ultrasound, lab tests, and calcium community members in San Vascular Screenings scoring as well as assessing and educating the patient on Diego’s east region. Services his or her risk of a heart attack or stroke.

Director, SGH From FY 2008 to FY 2012, 634 individuals received these Marketing and vascular screenings and 92 were referred for follow‐up Communication care, resulting in 869 outpatient visits. s

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f. Continue to participate in stroke Vice President, Cardiovascular Educational events conducted in collaboration with screening & education events in SHC Disease the Sharp Senior Resource Center collect evaluation San Diego, including events Ortho/Neuro Education forms to assess the quality of education/screening targeting seniors & high‐risk Service Line Screening events. Feedback from these evaluations is adults as well as individuals with Collaboration incorporated for future planning. identified risk factors. Program

Coordinator, Sharp Senior In addition, Sharp’s Senior Resource Centers track Resource Center attendance for each educational event and screening. Metrics on community members referred for follow‐ up are also tracked, and often participant’s name and phone number are collected in order to facilitate follow‐up. Often the community member talks to the department directly, or their provider (if a Sharp provider) is forwarded the information directly. Community members receive their results and feedback to take to their doctor on their own time.

2. Collaborate with other a. Continue participation in San Vice President, Cardiovascular Sharp team members continue to serve as part of the San health care organizations Diego County Stroke Consortium SHC Disease Diego County Stroke Consortium and the Sharp in San Diego on stroke Ortho/Neuro Education HealthCare Stroke service line team once again education and prevention Service Line Collaboration participated in the “Strike Out Stroke” event at the Padres efforts. in June 2016, with more than 25,000 attendees.

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Identified Community Objectives/Anticipated Responsible Identified Evaluation Methods, Measurable Targets, Action Items Health Need: Impact Party/ies Themes in and Other Comments Diabetes 2016 CHNA

1. Increase education of signs a. Participate in educational forums, SHC Diabetes Diabetes In FY 2015, the SGH Diabetes Education Program reached and symptoms of diabetes health fairs and events in San Leadership Education more than 1,770 community members through in East County. Diego’s east region. Team Collaboration educational lectures and blood glucose screenings at hospital and off‐site locations. Diabetes lectures were held at libraries, community centers, educational institutions and national conferences. Blood glucose screenings were provided at six community events including the Health & Wellness Fair at College Avenue Center, the Santee Cameron Family Health Fair at the Cameron Family YMCA, the Healthy Food Choices & Diabetes screening and lecture at the Dr. William C. Herrick Community Health Care Library, the Cuyamaca College Health Fair, the Waterford Terrace Health Fair and the 16th annual Senior Health Fair at the Santee Trolley Square.

Collect feedback from community members on educational courses provided, in order to improve and refine educational resources tailored to community member needs. In addition, the SHC Diabetes Leadership team meets annually to evaluate the programs over the previous year.

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b. Explore opportunities with new SHC Diabetes Diabetes SHC Program Manager, Community Benefits and Health venues/ community groups to Leadership Education Improvement meets with SHC Diabetes Leadership Team provide additional resources. E.g. Team Access to Care regularly to assess, grow and support additional churches, YMCA’s and schools. Collaboration opportunities for outreach and education. SHC Program Manager, Community Benefits and Health Improvement c. Utilize findings in the FY 2016 SHC Program Diabetes SHC Program Manager, Community Benefits and Health CHNA to assess existing Manager, Food Insecurity Improvement meets with SHC Diabetes Leadership Team community resources and explore Community Education regularly to assess, grow and support additional areas where additional diabetes Benefits and Access to Care opportunities for outreach and education. education and resources may be Health needed in SDC’s east region. Improvement Current discussions focus on clinic collaborations (Family Health Centers Partnership continuance) and exploring partnerships to address food insecurity as part of nutrition SHC Diabetes education, similar to Feeding America San Diego Leadership Partnership (see action item “Diabetes, d” below). Team

d. Provide diabetes education to SHC Diabetes Uncontrolled New in FY15‐FY16, the SHC Diabetes Education Program food‐insecure adults enrolled in Leadership Diabetes provided diabetes education to food insecure adults Feeding America San Diego’s Team Education enrolled in Feeding America San Diego’s (FASD) Diabetes

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Diabetes Wellness Project – a Access to Care Wellness Project, a randomized, controlled trial and collaboration including UCSD’s SHC Program Collaboration collaboration between UCSD’s Student‐Run Free Clinic Student Run Health Clinic. Manager, Food Insecurity Project, the Third Avenue Charitable Organization (TACO) Community and Baker Elementary School in Southeast San Diego. The Benefits and Diabetes Wellness Project screens adult clinic patients Health with Type 2 diabetes for food insecurity, and provides Improvement them with ongoing medical treatment and diabetes management through the clinic. In addition, FASD provides Diabetes Wellness Food Boxes to project participants, in conjunction with a monthly diabetes and nutrition education course. Provided by an SHC Diabetes Educator ‐ as well as CalFresh outreach. Approximately 200 participants enrolled in the one‐year Diabetes Wellness Project.

Data forthcoming, results to be published in Fall, 2016. However initial results reveal correlation of food insecurity with increased depression and decreased fruit/vegetable intake, with program participants at baseline. In addition, statistically significant positive impacts on food insecurity, depression, and HbA1c levels of uncontrolled diabetics enrolled in the program were observed.

2. Reduce incidence of Type 2 a. Provide free prediabetes classes SHC Diabetes Diabetes New in August, 2016, the SGH Diabetes team began diabetes through education to community members in SDC’s Leadership Uncontrolled offering prediabetes classes to patients and community

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and resources provided to east region. Team Diabetes members in the east region who are either diagnosed with individuals in SDC’s east Education or at‐risk for prediabetes. Metrics forthcoming. region with prediabetes. Care Management Sharp Program Manager, Community Benefits and Health Improvement to work with Diabetes Education Team on expanding prediabetes classes out to community organizations and clinics. 3. Improve identification of a. Continue to coordinate and SHC Diabetes Uncontrolled In FY 2015, the SGH Diabetes Education Program reached pre‐diabetes and diabetes implement blood glucose Leadership Diabetes more than 1,770 community members through in community members screenings at community and Team Screening educational lectures and blood glucose screenings at through screening. hospital sites in SDC’s east region. Access to Care hospital and off‐site locations. More than 250 community members were screened during these events and, as a result, more than 30 community members were identified with elevated blood glucose levels and were provided with follow‐up resources. Of these individuals, more than 50 did not have a preexisting diagnosis of diabetes.

Screenings Discontinued in 2016: Various regulatory and logistical challenges contributed to the discontinuance of screenings in FY 2016, which are detailed below. In summary, in light of the changes, Sharp’s Diabetes Leadership took a hard look at the benefits of providing screening events, and found that very few of the elevated BG levels were due to people who were unaware they had diabetes, rather they were

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diagnosed but wanted to get there BG checked; thus, it seemed we were not reaching our target audience. It was then decided to focus our efforts by providing education to the underserved who had no access to education due to lack of insurance or funding, and provide classes that would benefit and educate in a more meaningful manner.

As a result, Sharp’s Diabetes Education team has focused efforts on working in partnership with Feeding America and local community clinics (e.g., FHCSD) providing classes in both Spanish and English to patients diagnosed with diabetes who would have no access to this service by usual means. This has been well received by the community and also Sharp Diabetes educators who feel that they are truly meeting the needs of the community and making a difference in the lives of those impacted by diabetes.

Regulation details: • In January 2014, the FDA issued the Draft Guidance entitled: Blood Glucose Monitoring Test Systems for Prescription Point‐of‐Care Use. Since its release, the uncertainty has been building among hospital laboratory management and point of care coordinators over the future of point of care glucose meter use. Because of the

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potential impact of the outcome of the decision on the clinical laboratory and point of care community, there was a lot of speculation as to what POCT meter we would be able to use for community screenings as current POCT meters are approved for home use by FDA, and If we use meters outside of manufacturers recommendations it is considered “Off Label”. CLIA REG ‐ 1253 b 2 requires establishment of performance specification (sensitivity and specificity) if we use meters “Off Label”. During 2015 the controversy continued and we explored any POCT meters that were approved for multiple use that we could use at community events.

• In addition, in 2015 the Department of Health and Human Agency (DHHA) required a permit request 1 month prior to any requested screenings as well as staff names and competency. If a staff member became sick just prior to an event we were not able to substitute with another staff member as this had not been submitted to DHHA. Screening permits cost $1,000 which in previous years was supported by Roche Diagnostics who is no longer able to provide financial support, nor can they provide the test strips free of charge for these community events.

• Another change in late 2015: AB 333 ‐ LQHE

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discontinuation (Limited Quantity Hauler Exemption) and medical waste temporary events registration. Any BG screening operators are required to notify San Diego County department of Environmental Health (DEH) for each temporary event through Citizen Access Portal. Due to this change we were also required to print out the record number and send along with the permit request to the DHHA.

b. Explore potential partnerships SHC Diabetes Access to Care This past year, the SHC Diabetes Education Program with the community clinics in Leadership Collaboration collaborated with Family Health Centers of San Diego order to offer diabetes classes at Team Community (FHCSD) to conduct outreach and education to vulnerable their clinic locations Clinics community members in SDC’s east region, specifically the SHC Program FHCSD site in Lemon Grove. Sharp Diabetes educators Manager, supported the expansion of FHCSD’s Diabetes Community Management Care Coordination Project (DMCCP), which Benefits and provides FHCSD patients with group diabetes education Health and encourages peer support and education from project Improvement “graduates” to current patients/project enrollees. In 2016:  4 sessions held in Lemon Grove  61 attendees

Overall through the partnership, Sharp Diabetes Educators

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have provided 12 lectures from Jan through June 2016, including classes in English and Spanish. Classes have served 92 attendees at the Lemon Grove, North Park, Chula Vista and Logan Heights FHCSD sites. Classes briefly paused in June, 2016 and will resume in August, 2016.

The project monitors enrollees’ A1C levels, and has proven successful outcomes in lowering and maintaining these levels through education and peer support. The SHC Diabetes Education Program supports the project through the provision of diabetes lectures at multiple FHCSD sites. In SDC’s east region, the SHC Diabetes Education Program provided a diabetes lecture to nearly 15 attendees at the FHCSD Lemon Grove site. Topics included nutrition, physical activity, diabetes mellitus, self‐management and goal setting. Outcomes data forthcoming.

In Summer, 2016 Sharp Program Manager, Community Benefits and Health Improvement to work with Diabetes Education Team to support FHCSD partnership. In addition, the SHC Diabetes Leadership team meets annually to evaluate the programs over the previous year.

4. Improve access to diabetes a. Create language‐appropriate and SHC Diabetes Diabetes Materials have been updated for both Type 1 and 2 educational resources for culturally sensitive diabetes Leadership Education Diabetes, as well as Gestational Diabetes Mellitus post‐

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underserved populations in educational materials. Team Care discharge. Materials are designed to assist mothers after SDC’s east region. Management delivery as well as to advise on how to manage blood Collaboration sugars while breast feeding.

Materials have also been completed for the Chaldean and Vietnamese populations in San Diego. Materials for Vietnamese populations include gestational diabetes, as well as a culturally‐appropriate 7‐day meal plan.

Also exploring new opportunities for more effective methods and resources for properly translated educational materials (e.g. multi‐lingual interns, etc.).

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Identified Objectives/Anticipated Responsible Identified Evaluation Methods, Measurable Targets, Community Action Items Impact Party/ies Themes in and Other Comments Health Need: 2016 CHNA Obesity 1. Provide free biometric a. In 2013, Sharp HealthCare began Sharp HealthCare Obesity In FY 2015, Sharp HealthCare hosted 75 community health screenings for community a community‐wide effort to Chief Experience Screening screening events throughout SDC, including the east members that address risk increase the early identification of Officer Education region, screening more than 5,200 San Diegans and factors for obesity. health issues in the San Diego Collaboration providing more than 110,000 hours in support of the community through the provision effort. of free health screenings for: cholesterol, blood sugar, body From the inception of the screenings Sharp HealthCare mass index (BMI), blood pressure participated in nearly 200 community health screenings and tobacco use. Locations in San events across San Diego – ultimately screening more than Diego’s east region included: El 14,000 San Diegans. Cajon Jamboree, East County YMCA, Grossmont College Health The screening program concluded in early 2016. Fair, East county Chamber Health Fair, Hatfield Park (Spring Valley), Screenings provided personalized health information at no Santee Library, and the Westfield charge to community members over the age of 18. Parkway Shopping Center (El Participants were not asked to provide personal Cajon). information, nor were they required to show proof of insurance or have any relationship with Sharp to be eligible for the screening. To encourage participation, identifying and follow‐up information was not collected. Appointments were not required, and community members retained the only copy of their results. Community members also received personalized strategies to improve their overall health and well‐being.

Though Sharp’s hospitals, including Sharp Grossmont

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provide various nutrition education opportunities for the community, i general, resource limitations restrict growth beyond current programs and services that specifically address obesity at this time.

b. Coordinate and provide various Manager, SGH Screenings In FY 2015 SGH participated in a variety of community health screenings, including BMI Community Collaboration events and provided education and health screenings for and blood pressure screenings at Relations diabetes, stroke and heart health. Education and community events. screenings include nutrition, and exercise education, as well as emphasis on maintaining a healthy weight and lifestyle. SGH also provides educational resources on risk factors for obesity and resulting chronic diseases.

Education and programs provided by SGH are evaluated by participants through survey.

Community screening participants receive their screening results, however additional follow‐up, feedback and tracking is not conducted at this time.

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Identified Objectives/Anticipated Responsible Identified Evaluation Methods, Measurable Targets, Community Action Items Impact Party/ies Themes in and Other Comments Health Need: 2016 CHNA Obesity 2. Provide care management a. NA NA Obesity In general, resource limitations restrict growth beyond in support of weight loss Cardiovascular current programs and services provided at Sharp and healthy life style Hypertension Grossmont Hospital that specifically address obesity at this choices for San Diego Diabetes time. community members. Chronic Disease Care However, free, Healthier Living Workshops are provided to Management community members through Sharp HealthCare’s medical group, Sharp Rees‐Stealy, including sites in SDC’s east region. The six‐week class teaches how to manage the challenges of living with a chronic disease, including diabetes, high blood pressure, asthma, arthritis and other conditions. Topics include: appropriate exercise for maintaining and improving strength, flexibility and endurance; appropriate use of medications; communicating effectively with family, friends and health professionals; nutrition to improve well‐being; techniques to deal with frustration, fatigue, pain and isolation often associated with chronic disease. Family members or friends of someone with an ongoing health condition, as well as community members interested in becoming more physically and socially active, are welcome to attend.

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Identified Objectives/Anticipated Responsible Identified Evaluation Methods, Measurable Targets, Community Action Items Impact Party/ies Themes in and Other Comments Health Need: 2016 CHNA Senior Health 1. Increase access for seniors a. Continue to provide seasonal flu Program Senior Health In FY 2016, the SGH Senior Resource Center (SRC) and other high‐risk vaccinations at community sites for Coordinator, Access to Care provided 588 flu shots to seniors and high risk adults at 11 populations to flu vaccines. seniors with limited mobility and SGH Senior Transportation different sites including senior centers and three food access to transportation, as well as Resource Center banks. Because of increased availability of flu vaccine at for high‐risk adults, including low‐ grocery stores and pharmacies, numbers served by the income, minority, chronically ill and SRC have decreased. However, the SRC is investing refugee populations. additional effort to reach the uninsured.

For FY17: provide flu vaccinations to at least ten community sites. Provide flu clinics to at least three food bank sites. Track and evaluate trends in flu clinic attendance. b. Continue to coordinate the Program Senior Health Seniors were alerted through activity reminders, notification of seniors regarding Coordinator, Access to Care collaborative outreach conducted by the flu clinic site, the availability of seasonal flu SGH Senior Sharp.com and both paper and electronic newspaper vaccines and the provision of flu Resource Center notices. vaccines to high‐risk individuals in selected community settings. The flu clinic sites assisted in distributing flu clinic Publicize flu clinics through media information and encouraged their clients to get and community partners. vaccinated.

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c. Continue to direct seniors and Program Senior Health Provided reminders to seniors who attend the SRC other chronically ill adults to Coordinator, Access to Care programs that flu vaccination is important for themselves available seasonal flu clinics, SGH Senior and their families. including physicians’ offices, Resource Center pharmacies and public health centers.

2. Support the safety net for a. Maintain daily contact through Program Senior Health For FY 2016, through July 2016, 4,246 calls were made seniors living alone in East phone calls with East County Coordinator, Care through the daily telephone reassurance call program with County. individuals (often elderly and Sharp Senior Management 42 alerts. In FY2016, 2 seniors were found on the floor home‐bound) in rural and Resource Center Access to Care and paramedics transferred them to area hospitals. One suburban settings who are at risk had fallen and the other fainted after not managing her for injury or illness, and continue diabetes well. supporting telephone reassurance call services for East Telephone reassurance call data are tracked internally by County residents. the Program Coordinator for the Sharp Senior Resource Center.

3. Continue to host a variety a. Provide information on various Program Senior Health In FY 2016 through July 2016, the SGH Senior Resource of senior health education senior issues such as senior Coordinator, Education Center provided 45 free health education programs to and screening programs, in mental health, memory loss, SGH Senior Screenings nearly 988 community members. Nine screening events

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order to raise awareness, hospice, senior services, nutrition, Resource Center Collaboration were provided in FY 2016 through July 2016 to 153 identify risk factors, and healthy aging and balance and fall seniors and as a result 14 attendees were referred to connect seniors to helpful prevention. physicians for follow‐up on their screening results. resources. Each education program provided by or in collaboration with the Senior Resource Center is evaluated by participants. Evaluations include point scores and average evaluation scores, as well as open‐ended questions such as: what was the most important thing participants learned, what other programs seniors (participants) would like. This feedback is provided to speakers so that they may refine future educational offerings.

In addition, Sharp’s Senior Resource Centers track attendance and for each educational event, flu vaccination event and screening held throughout the year. Metrics on community members referred for follow‐up are also tracked, and often participants’ names and phone numbers are collected in order to facilitate follow‐up. Often the community member talks to the department directly, or their provider (if a Sharp provider) is forwarded the information directly. In addition, community members receive their results and feedback to take to their doctor on their own time.

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b. Continue to participate in Program Senior Health In FY 2016 through July 2016, the SGH Senior Resource community health fairs for seniors Coordinator, Education Center participated in health fairs in El Cajon, Rancho San SGH Senior Collaboration Diego, Lakeside, Santee, La Mesa, Lemon Grove, the Resource Center College Area and San Diego. Populations served at these fairs included seniors and caregivers; Parkinson’s patients and caregivers, Dementia patients and caregivers, veterans and those caring for veterans, and Lesbian, Gay, Bisexual and Transgender (LGBT) seniors. In addition, the SGH Senior Resource Center event provided blood pressure screenings as well as educational resources on senior and caregiver services. Through participation in these events, the SGH Senior Resource Center provided education and resources to more than 1,813 community members through July 2016.

c. Coordinate two conferences – Program Senior Health In collaboration with the Caregiver Coalition of San Diego, one dedicated to family caregiver Coordinator, Education the SGH Senior Resource Center provided two conferences issues in collaboration with the SGH Senior Collaboration to more than 100 family caregivers: one focused on caring Caregiver Coalition of San Diego Resource Center for veterans; and the other focused on caring for and one focused on chronic care dementia. Conferences provided education on emotional and advanced illness issues, resources available in the community and legal management in collaboration issues. with Sharp HospiceCare. The SGH Senior Resource Center also partnered with Sharp HospiceCare and provided a conference to seniors and their families titled Life’s Transitions: Changing Health

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Care Needs through the Years. Held at the La Mesa Community Center the conference reached more than 80 community members and provided education on: Miscommunications in Health Care, Quality of Life Conversations, Legacy Planning and Coping with Life’s Challenges.

4. Engage and partner with a. Maintain active relationships with Program Senior Health As the Senior Resource Center increases the number of local community community organizations serving Coordinator, Collaboration community partners it collaborates with, it is expected organizations that address seniors throughout San Diego. SGH Senior that additional opportunities will arise. senior health issues in Organizations include: East Resource Center order to foster future County Senior Service Providers, In FY2016, the SGH Senior Resource Center attended opportunities for Meals on Wheels, Caregiver meetings for East County Senior Service Providers, Aging collaboration in provision Coalition, and the Caregiver Disability Resource Connection (ADRC) Advisory Board, of education, screening, Education Committee. Project CARE, Meals on Wheels Greater San Diego East and other resources to County Advisory Board, Caregiver Coalition, and the seniors and high‐risk Caregiver Education Committee throughout the year. populations.

5. Provide coordinated care a. Continue collaboration with Sharp Vice President, Senior Health Patient and Family Satisfaction Surveys provided to all to patients with advancing HospiceCare to offer Sharp Sharp Care Transition participants at the end of the program’s “Active progressive chronic patients the Transitions program: HospiceCare; Management Phase” (six weeks). disease, in order to a "pre‐hospice" program designed improve the individual to provide home‐based palliative Utilization Performance Target: 200 admissions across the system experience as they near care and management for Review, Sharp each year. In FY 2015, 300 admissions across the system; end‐of‐life. patients with advanced HospiceCare YTD FY 2016, 178 admissions.

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progressive chronic illness. The program is adapted to match each patient’s unique physical, emotional and spiritual needs.

6. Increase the availability of a. Provide 13 mailings of Bereavement Senior Health Track number of mailings annually through internal education, resources and bereavement support newsletters Dept., Sharp Education Access/Excel database. In FY 2015, approximately 1,300 support to community HospiceCare; community members received bereavement support members with life‐limiting newsletters. illness and their loved ones.

b. Support the unique advanced Bereavement Senior Health  In June, participated in the Operation Engage illness management and end‐of‐ Dept., Sharp Veterans America Resource Fair, hosted by Operation life care needs of military HospiceCare; Education Engage America, at Liberty Station, providing veterans and their families resources to nearly 200 veterans, families, through participation in veteran‐ caregivers and other community members. oriented community events and  Provided end‐of‐life care resources to ~ 100 services, and attendees at the SCRC’s Operation Family Caregiver conference at Camp Pendleton in October.  In August and October, provided education and resources at the Veterans, Military and Families Expos at the War Memorial Building at Balboa Park, to ~ 240 community members.  In November, provided education on ACP and

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integrative therapies to ~ 50 veterans /families members at the VA San Diego Healthcare System’s health fair  Since 2010, member of the San Diego County Hospice Veterans Partnership ‐ a coalition of VA facilities and community hospices working together to ensure excellent end‐of‐life care for veterans and their families.  Participation on the advisory board for the SCRC’s Operation Family Caregiver.  Currently a Level 1 Partner (4 levels available) in We Honor Veterans (WHV), a national program developed by the NHPCO in collaboration with the U.S. Department of Veterans Affairs (VA) to empower hospice professionals to meet the unique end‐of‐life needs of veterans and their families. As WHV partners, hospice organizations can achieve up to four levels of commitment in serving veterans. Level 1 partners are equipped to provide veteran‐centric education to its staff and volunteers, including training them to identify patients with military experience.

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c. Continue to provide community Business Senior Health Track number of community education events through education and resource services Development, Education internal database. throughout San Diego Sharp Collaboration HospiceCare In FY 2015, Sharp HospiceCare collaborated with community organizations to provide more than 2,400 community members with end‐of‐life education and outreach at a variety of churches, senior living centers, and community health agencies and organizations throughout SDC, as well as through participation in community health fairs and events.

d. Continue to offer individual and Bereavement Senior Health Track number of individual and group counseling sessions family bereavement counseling Dept., Sharp Care through internal database. and support groups HospiceCare Management In FY 2015, the Healing After Loss and the Widow’s and Widower’s ongoing bereavement support groups served approximately 200 community members.

e. Provide Advance Care Planning Advance Care Senior Health Track number of sessions and individual consultations (ACP) for community groups as Planning Dept., Education through Allscripts Business Unit, Excel spreadsheet and well as individual consultations Sharp Care participant evaluations. Quarterly community HospiceCare Management presentations offered throughout San Diego County.

In FY 2015, the program engaged approximately 2,500 community members in free ACP and POLST (Physician Orders for Life‐Sustaining Treatment) education at a

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variety of community sites, including health fairs, senior centers, homecare agencies, churches and seminars.

f. Continue to conduct outreach Medical Senior Health Presentations provided to the health care community are activities and provide professional Director, Sharp Education evaluated through survey and tracked through an internal education on hospice‐related HospiceCare Collaboration Excel database. Survey and data tracking serve to evaluate topics to community agencies, effectiveness and to document activities for Sharp’s health care facilities, colleges and Business annual Community Benefit Plan and Report. universities on hospice and Development, palliative care. Sharp In FY 2015, Sharp HospiceCare provided: HospiceCare  Introductory education on hospice, bioethics and ACP to 36 advanced psychology students at Program Valhalla High School Coordinator,  Lectures on hospice, bioethics, ACP and advance Sharp Senior directives to ~ 180 nursing students from Azusa Resource Center Pacific University  Lectures on spiritual care in hospice to ~ 50 students in the Certified Hospice and Palliative Nursing Assistant training program through the HPNA.  Education to ~ 500 local, state and national health professionals on ACP and POLST, including, but not limited to case managers from the San Diego Care Transitions Partnership, Senior Care Action Network (SCAN) Health Plan, the Center to

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Advance Palliative Care (CAPC) National Conference, Caregiver Coalition of San Diego, etc.  A POLST Train‐the‐Trainer workshop to community health care providers  Educational outreach to local and national organizations (e.g., Good Samaritan Medical Center, Saddleback Memorial Medical Center, Highmark Health, Baylor Scott and White Health, Family Medicine Education Consortium, American Hospital Association (AHA) Leadership Summit, West Health Institute, etc.). Topics ranged from successful aging to ACP.  Sixth annual Resource and Education Expo titled Advanced Illness Management: Preserving Quality of Life for ~200 community health professionals.

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7. Provide education and a. Provide Advance Care Planning Advance Care Senior Health In FY 2015, HospiceCare educated more than 500 local, outreach to the San Diego (ACP) Training to physicians, case Planning Education state and national health professionals on ACP and POLST, health care community managers and other health care Coordinator including, but not limited to case managers from the San concerning hospice and professionals Diego Care Transitions Partnership, Grossmont Post Acute palliative services within the Care, Continuum Healthcare, Senior Care Action Network care continuum, in order to (SCAN) Health Plan, the Center to Advance Palliative Care raise awareness of the (CAPC) National Conference, SDRHCC, Caregiver Coalition choices available towards of San Diego, SDCCEOLC, San Diego Dementia Consortium, the end of life and the Sharp HospiceCare Resource & Education Expo, empower community Greater San Diego Business Association and the County of members so that they and San Diego Ombudsmen Program. In collaboration with the their family members may Coalition for Compassionate Care of California (CCCC), the take an active role in their Sharp ACP team also offered a POLST Train‐the‐Trainer treatment. workshop to train community health care providers on POLST. b. Continue active involvement with Vice President, Senior Health Sharp HospiceCare provides approximately six and participation on state and Sharp Education presentations provided each year in collaboration with national hospice organizations HospiceCare Collaboration state and national organizations. (California hospice and Palliative Care Association (CHAPCA) the Medical Sharp HospiceCare leadership continues to serve as part of NHPCO Leadership etc.) included Director, the CHCF Palliative Care Action Community, as well as the presentations on understanding Sharp board, and as a state hospice representative, for NHPCO late‐stage illness, changing our HospiceCare and CHAPCA. culture of Care to one of partnership and a continuum of Community presentations provided through Sharp

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Care perspective, advanced Care HospiceCare– including those to professional planning, etc. organizations – are evaluated through survey to evaluate effectiveness and revise program content.

8. Collaborate with a. Explore partnership with Business Senior Health New community partnership: Lantern Crest in Santee; community, state and community organizations Development Collaboration Elmcroft of San Diego (throughout the County as well as national organizations to designed specifically to meet the Dept., Sharp additional home care facilities. develop and implement needs of caregivers. HospiceCare appropriate services for the needs of the aging population. b. Continue to collaborate with a Business Senior Health variety of local networking groups Development, Education and community‐oriented agencies Sharp Collaboration to provide caregiver classes, end‐ HospiceCare of‐life programs, Advance Care Planning seminars and web presentations for consumers and health care professionals

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Appendix X Glossary of Abbreviations

ACS American Community Survey ADOD Alzheimer’s Disease or Other Dementia Affordable Care Act Patient Protection and Affordable Care Act AHRQ Agency for Healthcare Research and Quality AI/AN American Indian/Alaskan Native AIS HHSA Aging & Independence Services BMI Body Mass Index BRFSS Behavioral Risk Factor Surveillance System CAP San Diego San Diego County Community Action Partnership CCS Clinical Classifications Software CCTP Community-based Care Transitions Program CDC Centers for Disease Control and Prevention CDPH California Department of Public Health CHA Community Health Assessment CHIP Community Health Improvement Partners CHIS California Health Interview Survey CHNA Community Health Needs Assessment CMS Centers for Medicare and Medicaid Services CNI Community Need Index COPD Chronic Obstructive Pulmonary Disease CRDP California Reducing Disparities Project CTI Care Transitions Intervention CUPID California Universal Patient Information Discovery CVD Cardiovascular Disease CY Calendar Year DUI Driving Under the Influence ECAN East County Action Network for Older Adults and Adults with Disabilities ED Emergency Department FPL Federal Poverty Level FQHC Federally Qualified Health Centers FY 2016 Fiscal Year 2016 GIS Geographic Information Systems HASD&IC Hospital Association of San Diego and Imperial Counties HASD&IC 2016 CHNA Hospital Association of San Diego and Imperial Counties 2016 Community Health Needs Assessment

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HHSA County of San Diego Health and Human Services Agency HP 2020 Healthy People 2020 HRO High Reliability Organization ICU Intensive Care Unit IPH Institute for Public Health IRS Internal Revenue Service KP Kaiser Permanente LGBTQ Lesbian, Gay, Bisexual, Transgender and Queer LTCIP Long Term Care Integrated Project NCQA National Committee for Quality Assurance NHIS National Health Interview Survey NHPI Native Hawaiian and other Pacific Islander OSHPD Office of Statewide Health Planning and Development RLA San Diego County Resident Leadership Academy SAMHSA Substance Abuse and Mental Health Services Administration SANDAG San Diego Association of Governments SanDi-Can San Diego Community Action Network SCHHC Sharp Coronado Hospital and Healthcare Center SCVMC Sharp Chula Vista Medical Center SDAIHC San Diego American Indian Health Center SDC San Diego County SDDC San Diego Dementia Consortium SDSU San Diego State University SGH Sharp Grossmont Hospital SGH 2016 CHNA Sharp Grossmont Hospital 2016 Community Health Needs Assessment Sharp Sharp HealthCare SHP Sharp Health Plan SMBHWN Sharp Mary Birch Hospital for Women & Newborns SMC Sharp McDonald Center SMH Sharp Memorial Hospital SMMC Sharp Metropolitan Medical Campus SMV Sharp Mesa Vista Hospital SNAP Supplemental Nutrition Assistance Program UC University of California U.S. United States

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~ A Health Care Organization Designed Not For Profit, But For People ~