THE INFLUENCE OF NEIGHBORHOOD-LEVEL FACTORS ON EMERGENCY DEPARTMENT VISITS: AN ASSESSMENT OF TWO POPULATIONS IN THE HUDSON VALLEY REGION, NEW YORK by Thao Minh Doan MPH, New York Medical College, School of Public Health, 2003 BS, College of Mount Saint Vincent, 1999 A Doctoral Dissertation in Health Policy and Management, School of Health Sciences and Practice, Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Public Health at New York Medical College 2016 Acknowledgment Thank you to the people who have been invaluable during my DrPH studies: Dissertation Committee Members: Kenneth Knapp, PhD Deborah Viola, PhD Andrew Maroko, PhD Advisor: Pedro Laureano, PhD For my children, Jonathan Hien and Sophia Minh Tam, you are my life. I love you. i Table of Contents List of Tables ..................................................................................................................... iv List of Figures ......................................................................................................................v Chapter 1: Introduction to the Study ....................................................................................1 Background ....................................................................................................................1 Chapter 2: Literature Review ...............................................................................................6 Conceptual Models ......................................................................................................12 Theoretical Framework ............................................................................................... 13 Study Design ................................................................................................................14 Chapter 3: Research Methods ............................................................................................17 Neighborhood/Population Selection ............................................................................17 Neighborhood Assessment ...........................................................................................20 Key Informant Interviews and Focus Group ...............................................................22 Data Sources and Data Variables .................................................................................23 Description of Major Variables .................................................................................. 25 ii Chapter 4: Results ..............................................................................................................29 Chapter 5: Discussion, Policy Implications, Future Research Studies, Limitations, and Conclusion.......................................................................................................50 Policy Implications ......................................................................................................51 Future Research Studies ...............................................................................................54 Study Limitations .........................................................................................................54 Conclusion ...................................................................................................................55 References ..........................................................................................................................57 Appendix A. Key Informant Interviews and Focus Group Questioning Areas .................76 Appendix B. ZIP 12550 (Newburgh) Community Based Organizations ..........................77 Appendix C. ZIP 10801 (New Rochelle) Community Based Organizations ....................83 Appendix D. ZIP 12550 (Newburgh) Health Care Resources ...........................................88 Appendix E. ZIP 10801 (New Rochelle) Health Care Resources .....................................95 iii Abstract Costly non-urgent emergency department visits in the US are influenced by neighborhood-level factors, including socioeconomic disparities, convenience, and lack of access to primary care and community services. Two demographically similar ZIP codes with significantly different emergency department visit rates were studied to determine which local neighborhood contextual factors contribute to this difference. Systematic social observation was performed to collect data on the neighborhoods’ physical environments, bus routes, primary care services, and safety. In addition, data for both ZIP codes were analyzed to obtain neighborhood characteristics, local history, sociology, geography, healthcare services, and social services resources. Findings indicate that residents in one ZIP code faced a number of social-environmental challenges and access barriers to healthcare services, which may result in a higher emergency department visit rate. These challenges include (a) having an emergency department as the focal point of medical care without nearby alternative care sites; (b) a weak local economy; (c) an inadequate local public transportation system with expensive alternative transit options; (d) poor neighborhood conditions and poor housing conditions; (e) an unsafe neighborhood; (f) high level of income disparity within the ZIP code; and (g) a lack of adequate primary care services. Suggested solutions for this ZIP code include the adoption of co-located primary care-emergency department services, implementation of telemedicine systems, better coordination of primary care services, improved community outreach, and increased local advocacy for new bus stops, safer neighborhoods, and economic opportunities. iv Tables Table 1. Priority Neighborhoods–Neighborhood Selection Based on Income, Race/Ethnicity, Education Attained, and Emergency Department Visit Rate per 1,000 ................................................................................................................................... 19 Table 2. Summary of Methodological Approaches to Assessing Neighborhoods ............ 21 Table 3. Summary of Data Sources and Data Variables ................................................... 27 Table 4. Emergency Department Visits Data (2014) ........................................................ 30 Table 5.Comparison of Population, Income, Employment, Commuting to Work, and Crime Data for ZIPs 12550 and 10801 ..................................................................... 32 Table 6. Primary Care Practice Medical Groups in Newburgh (ZIP 12550), NY ............ 34 Table 7. Primary Care Practice Medical Groups in New Rochelle (ZIP 10801), NY ...... 35 Table 8. Community-Based Organization Categories ...................................................... 37 Table 9. Healthcare Resources Categories ........................................................................ 38 Table 10. Neighborhood Characteristics Results at the ZIP code level ............................ 46 v Figures Figure 1. Hudson Valley Region Map – Median Household Income ................................65 Figure 2. Map of Primary Care Providers – ZIP 12550 - Newburgh ................................66 Figure 3. Map of Primary Care Providers – ZIP 10801 – New Rochelle ..........................67 Figure 4. Newburgh City – ZIP 12550 - Boarded-up building and houses several blocks from St. Luke’s Cornwall ..................................................................................................68 Figure 5. Newburgh City – ZIP 12550 - Dilapidated homes with trash accumulation, abandoned buildings near Broadway .............................................69 Figure 6. Newburgh City – ZIP 12550 - Local businesses and bus stop on Broadway. Bars and old signage in front of local businesses. Abandoned businesses and empty bus stop. ..............................................................................70 Figure 7. Map of Primary Care Providers – Newburgh City – ZIP 12550 ........................71 Figure 8. Primary care providers in Newburgh City and New Rochelle ...........................72 Figure 9. New Rochelle – ZIP 10801 - Housing and nursing home across from Montefiore New Rochelle Hospital’s Emergency Department .............................73 Figure 10. New Rochelle – Residential and housing projects in ZIP 10801 .....................74 Figure 11. New Rochelle – ZIP 10801 - Local businesses and bus stop ...........................75 1 Chapter 1: Introduction to the Study Background There is general acceptance of two main groups of determinants influencing individual health outcomes: medical or clinical determinants of health; and non-medical or social determinants of health, including neighborhood contextual factors. Poor health outcomes because of a lack of understanding and inadequate investments in social determinants of health can have a costly effect in the long term, with consequences like excessive, costly, preventable, and non-urgent Emergency Department (ED) visits. The purpose of this dissertation study is to assess the influence of neighborhood contextual factors on health services utilization of ED visits in two ZIP codes in the Hudson Valley, NY region. The goal of the study is to identify and to gain a better understanding of how these neighborhood contextual factors may influence ED visit rates in the two neighborhoods. Neighborhood-level factors and health. The influence of neighborhood and socioeconomic factors on residents’ health has been studied for nearly 200 years. In 1826, Louis René Villermé (1782-1863) examined