Community Needs Assessment for New York State DSRIP Project Plan Application Prepared for Advocate Community Providers (ACP) / New York Community Preferred Providers By VERITÉ HEALTHCARE CONSULTING, LLC December 15, 2014 Table of Contents1 About Advocate Community Providers (ACP) / New York Community Preferred Providers ........... 1 About Verité Healthcare Consulting ......................................................................................................... 2 Executive Summary .................................................................................................................................... 3 DSRIP Program and Needs Assessment Purpose .................................................................................... 3 Community Served .................................................................................................................................. 3 Documentation of the Process and Methods Used (Section F) ................................................................ 4 Summary Description of Main Health and Health Service Challenges (Section C) ................................ 6 Cardiovascular Diseases .................................................................................................................... 7 Diabetes .............................................................................................................................................. 9 Asthma ............................................................................................................................................... 11 Mental and Behavioral Health and Access to Care .......................................................................... 12 Sexually Transmitted Diseases including HIV/AIDS ........................................................................ 14 Insufficient Delivery System Coordination, Integration, and Navigation ......................................... 15 Health Literacy and Knowledge of the Health Care System ............................................................. 17 Language and Cultural Barriers to Care .......................................................................................... 18 Description of Health Care and Community Resources (Section A) .................................................... 20 Health Care Resources (Section A.i.) .................................................................................................... 20 Hospitals ........................................................................................................................................... 20 Ambulatory Surgical Centers ............................................................................................................ 23 Urgent Care Centers ......................................................................................................................... 23 Health Homes .................................................................................................................................... 24 Federally Qualified Health Centers .................................................................................................. 26 Primary Care Providers .................................................................................................................... 28 Specialty Medical Providers ............................................................................................................. 31 Dentists .............................................................................................................................................. 31 1 Parenthetical “Section” references in the table of contents and associated headings correspond to the “Components of a Community Needs Assessment” sections in “Guidance for Conducting Community Needs Assessment Required for DSRIP Planning Grants and Final Project Plan Applications” (the “Guidance document”) June 6, 2014. Rehabilitative Services ...................................................................................................................... 33 Behavioral Health Resources ............................................................................................................ 33 Specialty Medical Programs ............................................................................................................. 39 Skilled Nursing Homes and Assisted Living Facilities ...................................................................... 40 Home Care Services .......................................................................................................................... 42 Laboratory and Radiology Services .................................................................................................. 44 Specialty Development Disability Services ....................................................................................... 44 Pharmacies ........................................................................................................................................ 45 Local Health Department .................................................................................................................. 45 Managed Care Organizations ........................................................................................................... 46 Area Health Education Centers ........................................................................................................ 46 Medically Underserved Areas and Populations ................................................................................ 47 Health Professional Shortage Areas ................................................................................................. 48 Advocate Community Providers / NYCPP Emerging PPS ............................................................... 51 Community-Based Resources (Section A.ii.) ........................................................................................ 51 Housing Services ............................................................................................................................... 53 Food Banks, Community Gardens, and Farmers Markets ................................................................ 53 Financial Assistance, including Clothing and Furniture Banks ....................................................... 54 Transportation Services .................................................................................................................... 54 Services for Individuals with Intellectual or Developmental Disabilities ......................................... 56 Peer and Family Mental Health Advocacy Organizations and NAMI .............................................. 56 Youth Development Programs .......................................................................................................... 57 Education Facilities and Institutions, and Libraries with Open Access Computers ......................... 57 Local Governmental Social Service Programs ................................................................................. 57 Family Support and Training ............................................................................................................ 58 Foster Children Agencies .................................................................................................................. 58 Individual Employment Support Services ......................................................................................... 59 Community Outreach, Welfare Agencies, and Religious and Community Service Organizations ... 59 Alternatives to Incarceration/Offender Services ............................................................................... 59 Ryan White programs and HIV Prevention, Outreach, and Social Service Programs ..................... 60 Domain 2: System Transformation Metrics (Section A.iii.) .................................................................. 60 Description of the Community to be Served (Section B) ....................................................................... 70 Demographics of the Population (Section B.i.) ..................................................................................... 70 Population by Age, Gender, and Race/Ethnicity ............................................................................... 70 Immigrants, Citizenship, and Language ........................................................................................... 78 Household Income, Poverty, Unemployment, and Educational Attainment ..................................... 82 Insurance Status and Medicaid Members ......................................................................................... 89 Housing and Homelessness ............................................................................................................... 93 Food Deserts (Lack of Access to Nutritious and Affordable Food) .................................................. 95 Disability and Mobility ..................................................................................................................... 96 Health Literacy.................................................................................................................................. 97 Institutionalized and Criminal Justice System Population................................................................ 98 Health Status and Health Issues: Secondary Data (Section B.ii.) ........................................................ 100 Leading