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Heartland  Health  Center,  Inc.    

2015  Community  Health  Assessment                                                                                                                                                                              

 

Heartland Health Center has established the mission to “serve low-income and/or uninsured individuals with access to affordable primary care, through a coordinated community-wide effort”.  

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Introduction  

It  is  the  mission  of  Heartland  Health  Center  to  “serve  low-­‐income  and/or  uninsured  individuals  with  access  to  affordable  primary  care,  through  a  coordinated  community-­‐wide  effort”.  As  a  Federally  Qualified  Health  Center  (FQHC),  the  center  is  required  to  assess  the  health  needs  of  the  patients  and  communities  that  are  served.      Located  in  Grand  Island  Nebraska,  Heartland  Health  Center  was  established  for  the  residents  of  Hall  County  and  the  surrounding  area  in  Nebraska.  The  Center  became  operational  February  24,  2014  as  the  seventh  Federally  Qualified  Health  Center  in  the  state  of  Nebraska.    Heartland  Health  Center  serves  low  income  and  unserved  populations  in  the  service  area.  Heartland  Health  Center  is  the  only  FQHC  in  the  area,  the  closest  FQHC’s  are  located  at  a  70  mile  distance  to  the  east  in  Platte  County  and  314  miles  to  the  west  in  Scotts  Bluff  County.      The  communities  served  by  Heartland  Health  Center  are  agriculturally  based,  Grand  Island  the  largest  community  is  a  retail  center  for  the  geographical  area.    The  largest  employers  in  the  area  are  JBS  Swift  and  Company,  which  employs  2,590  people,  JBS  is  a  meat  packing  plant  which  provides  unskilled  work  opportunities  for  a  growing  number  of  migrant  workers  and  Chief  Industries  which  manufactures  construction  materials  and  employs  1641.    The  local  hospital  is  the  third  largest  employer  in  the  area  with  1,300  staff.      The  average  per  capita  income  level  in  Hall  County  in  2013  ($22,330)  is  lower  than  the  state  average  of  $26,899,  and  the  US  national  average  of  $  28,155  (US  Census  Bureau  State  Quick  Facts).  The  majority  of  employers  in  the  area  are  agriculture  or  industrial  employers.    Poverty  level  in  Grand  Island  is  15%,  and  for  Hall  County  13.7%  above  the  state  averages  of  12.8%.    Nebraska  did  not  choose  to  implement  expanded  Medicaid  services.  The  US  census  Bureau  reports  12.9%  of  Nebraskans  don’t  have  medical  coverage  and  based  on  findings  of  the  Kaiser  foundation  approximately  14%  of  those  fall  into  the  coverage  gap  making  them  ineligible  for  state  Medicaid  assistance  and  having  an  income  too  low  to  allow  them  to  cover  the  cost  of  premiums.    In  addition,  12%  of  the  uninsured  population  are  ineligible  for  coverage  due  to  their  undocumented  immigration  status.    This  group  will  likely  remain  uninsured  due  to  this  status  but  still  require  medical  care.    Given  the  poverty  rates  in  the  centers  service  area  and  the  number  of  individuals  who  do  not  qualify  for  coverage  the  center  will  likely  continue  to  experience  an  above  average  number  of  patients  who  are  uninsured.    

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The  tables  below  were  obtained  from  the  Kaiser  foundation”  January  2014  Fact  Sheet:  How  Will  the  Uninsured  in  Nebraska  Fare  under  the  Affordable  Care  Act?  “These  tables  demonstrate  the  coverage  gaps  for  the  Nebraska  population.    

         

 

 

Heartland  Health  Center’s  current  patient  population  is  identified  through  the  health  centers  electronic  records  system  which  tracks  information  based  on  UDS  reporting  measures.    Reports  indicate  that  79%  of  the  patients  served  by  Heartland  Health  Center  reside  in  Hall  County  with  the  majority  of  those  living  in  Grand  Island,  the  surrounding  counties  comprise  the  remaining  21%  of  the  centers  patient  base  with  Buffalo  County  having  the  next  highest  percentage  at  6%.      The  center  has  a  59%  sliding  fee  patient  base  meaning  that  the  household’s  annual  income  would  meet  the  Federal  Poverty  requirements  required  for  the  discounted  center  fees,  

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additionally  the  center  patient  population  has  a  78%  uninsured  rate.    Approximately  35%  of  the  patient  population  being  served  is  done  so  in  a  language  other  than  English  which  is  significantly  higher  than  the  city,  county,  state  and  national  averages.    Of  those  served  in  a  language  other  than  English  34%  identify  Spanish  as  their  primary  language.  

The  assessment  includes  clinic,  city,  county,  state,  and  national  data  with  regard  to  population  demographics,  socioeconomic  data,  priority  health  needs  by  county,  and  health  behaviors  risk  data.    Data  was  collected  from  the  following  reports:  

                                                                                                                                                                                                                               

Federal  State  and  County  data  identified  in  the  US  Quick  Facts  census  for  2013  is  as  follows:                                                                

Area   Population   Minority   Language  other  than  English  spoken  at  home  

Poverty     Median  Household  income  

Female  

National   316,128,839   34.4%   20.7%   15.4%   $53,046   50.8%  Nebraska   1,868,516   19%   10.5%   12.8%   $51,672   50.2%  Hall  County   60,720   30.0%   19.6%   13.7%   $48,712   49.8%  Buffalo  County   47,893   11.8%   7.1%   13.6%   $50,963   50.4%  Hamilton   9,112   4.3%   2.5%   10.1%   $56,065   49.9%  Adams   31,610   12.1%   7.1%   12.78%   $49,440   49.9%  Merrick   7,802   7%   3.1%   12.6%   $50,859   50.2%  Dawson   24,207   38.6%   32.5%   14.8%   $46,078   49.1%    Information  gathered  from  area  stake  holders  addressing  community  health  needs  shows  the  following  as  priorities  for  the  Heartland  Health  Centers  service  area.      

Agency   Central  District  Health  Department  (GI)  

South  Heartland  District  Health  Department  (Hastings)  

Mary  Lanning  Hospital    (Hastings)  

AMCH  Hospital    (Aurora)  

SFMC  Hospital  (GI)  

 ! HHC  UDS  2014  UDS  reporting  data  ! 2014  County  Health  Rankings  &  Roadmaps  ! USA  Quick  Facts  2013  estimated  data        ! Kaiser  Foundation  2014  reports  ! US  Census  Bureau  American  fact  finder  ! Healthy  People  2020  ! CDHD  2014  Community  Health  Assessment  ! SHDHD  2012-­‐2013  Community  Health  

Improvement  plan  ! SFMC  2012  Community  Health  Needs  

Assessment          ! Mary  Lanning  Healthcare    2012  Community  

Health  Needs  Assessment  ! Nebraska  Rural  Health  Association  2011  

Community  Health  Assessment  Collaborative  ! Aurora  Memorial  Community  Hospital  

Community  Health  Needs  Assessment  2013    

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Five  out  of  five:              Obesity                                                                        Cancer  Four  out  of  Five:          Access  to  Health  Care                                                                        MH/Substance  abuse  Three  out  of  five:        Diabetes    

Methodology  and  Processes:    

Heartland  Health  Center  (HHC)  is  a  newly  established  Federally  Qualified  Health  Center  and  is  required  to  complete  a  Health  Needs  Assessment  for  the  patient  population  it  serves  every  three  years.    The  information  gathered  for  this  document  will  be  used  to  guide  the  2015-­‐2018  strategic  plan  for  the  center  and  to  determine  services  to  be  offered  and  future  growth  planning.    

Community  information  was  compiled  from  key  stakeholder’s  community  health  information  plans,  data  in  the  clinics  Electronic  Health  Record  system,  patient  surveys  and  from  community  focus  group  work  done  in  collaboration  with  the  Central  District  Health  Department.    

The  following  documents  were  used  in  the  process  of  identifying  needs  and  composing  the  assessment:  

1. Local  District  Health  Departments  Community  Health  Assessments  include  information  for  Grand  Island  and  surrounding  area  where  the  majority  of  Heartland  Health  Center’s  patient  population  resides.    

2. Area  hospital  and  medical  facilities  Community  Health  Needs  assessments  were  utilized  to  cross  compare  area  needs  that  were  identified  by  the  health  department’s  assessments.    

current   2014   2013   2013   2013   2012  Priority            

1.   Access  to  health  care  

Obesity   Obesity   Cancer   Access  to  Health  Care  

2.   Violence   Cancer   Cancer   Obesity   Gang  Violence  3.   Obesity   Mental  Health   Mental  Health   Diabetes   Obesity  4.   Teen  Pregnancy   Substance  Abuse   Substance  Abuse     Teen  parenting  5.   Cancer   Access  to  health  

care  Access  to  Health  Care  

  Cancer  

6.   Substance  Abuse         Substance  Abuse  7.   Mental  health         Mental  Health  8.   Diabetes         Diabetes  9.   Hearth  Disease          

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3. 2014  County  Health  Rankings  &  Roadmaps,  USA  Quick  Facts  2013  estimated  data,  US  Census  Bureau  American  fact  finder,  Healthy  People  2020  were  used  to  assimilate  information  specific  to  the  HHC  service  area.    

4. Nebraska  Rural  Health  Association  2011  Community  Health  Assessment  Collaborative  was  used  for  base  data  regarding  rural  areas  of  Nebraska.    

5. Heartland  Health  Center  data  reporting  system.    6. The  2014  Kaiser  commission  on  Medicaid  and  Uninsured  reports  and  data.    

 Areas  of  Identified  Concern:    

Information  gathered  suggests  the  following  five  categories  as  areas  of  concern  for  patients  in  Heartland  Health  Center  service  area.    

Obesity:  In  five  out  of  five  of  the  community  health  information  plans  reviewed  obesity  was  named  in  the  top  three  topics  as  an  area  of  concern  for  the  communities.      The  Center  for  Disease  Control  and  Prevention  defines  Overweight  as  having  a  body  mass  index  (BMI)  of  25  or  higher  and  obesity  as  a  BMI  of  30  or  higher.  In  each  community  health  information  plan  obesity  was  rated  as  a  key  indicator  for  the  general  health  of  the  community  members.    In  the  U.S.  more  than  a  third  of  adults  (35.7%),  and  an  estimated  17%  of  children  and  adolescents  fall  into  the  obesity  range  for  weight.    Hall  county  and  the  surrounding  area  rates  of  obesity  are  reported  at  35.7%  with  71.7%  of  the  population  reporting  themselves  as  overweight.    The  health  conditions  related  to  Obesity  are  some  of  the  leading  causes  of  preventable  death  both  in  the  Hall  County  area  and  the  nation.  Individuals  identified  as  obese  are  at  higher  risk  of  developing  conditions  such  as:      

                                                                                                                                                                                                                                           Cancer:  Also  ranked  in  the  top  three  in  five  out  of  five  health  community  health  plans  was  cancer.    An  area  of  specific  study  for  Heartland  Health  Center  in  2014  has  been  the  low  follow  through  rates  for  early  screenings  and  detection  of  cancer.  The  center  has  worked  in  collaboration  with  the  Central  District  Health  Department  and  the  Nebraska  Department  of  Health  and  Human  Services  to  address  low  return  rates  for  Fecal  Occult  Blood  Testing  (FOBT)  and  low  rates  for  follow  through  with  PAP  smears  and  breast  exams  for  women.  Community  focus  groups  were  held  collaboratively  with  the  Central  District  Health  Department  to  assist  in  identifying  barriers  

Coronary  Heart  Disease                                                                                  Type  II  Diabetes  Cancer  (endometrial,  breast,  colon)  Dyslipidemia  (high  cholesterol)  Stroke  Liver  and  Gallbladder  Disease  Sleep  Apnea  and  Breathing  Issues  Osteoarthritis  Gynecological  Abnormalities    

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for  low  follow  through  on  cancer  screening  opportunities.    Information  gathered  from  focus  groups  indicate  a  need  for  more  formalized  training  for  providers.  For  consumers  who  participated  the  barriers  varied  from  having  no  health  insurance,  lack  of  time  to  have  the  screening  completed  and  the  perceived  complexity  of  using  the  screening  kits.    An  area  of  concern  for  providers  was  that  many  consumers  are  on  “survival”  mode  and  the  perception  is  that  “prevention”  is  not  on  the  consumer’s  radar.  The  key  take  away  on  this  topic  was  education  for  the  providers  and  the  consumers  on  the  importance  of  screening  and  early  detection  as  well  as  education  regarding  the  use  of  FOBT  and  availability  of  programs  such  as  Every  Woman  Matters.      Access  to  Health  Care:    Four  out  of  five  community  health  plans  identify  access  to  health  care  as  an  area  of  concern.    The  two  Health  Departments  and  the  two  larger  hospitals  serving  the  clinic  service  area  identified  access  to  health  care  as  a  priority  for  their  consumers.  Areas  identified  as  a  need  included  lack  insurance,  costs  and  financial  limitations,  transportation,  and  language  barriers.    Significant  health  behaviors  risk  factors  show  the  prevalence  of  uninsured  in  Nebraska  as  13%  and  Hall  county  exceeds  that  with  a  17%    uninsured  rate.    For  Heartland  Health  Center  the  current  patient  base  has  a  79%  uninsured  rate  with  21%  having  public  or  private  insurance  available.      The  center  offers  two  full  time  Outreach  and  Enrollment  workers  to  assist  with  applications  for  the  insurance  marketplace  as  well  as  assistance  in  accessing  state  and  local  assistance  programs.      Public  transportation  is  limited  in  the  Grand  Island  area  to  a  public  handy  bus  which  runs  weekdays.  The  use  of  this  mode  of  transportation  requires  24  hours’  notice  and  does  not  allow  for  patients  who  are  in  need  of  a  same  day  appointment.  In  addition  there  is  a  privately  owned  taxi  service  which  is  cost  prohibitive  to  patients.  To  address  this  barrier  to  health  care  Heartland  Health  Center  received  philanthropic  funding  to  assist  with  the  purchase  of  a  van  that  will  allow  patients  of  Heartland  Health  Center  access  to  transportation  to  assure  they  are  able  to  attend  appointments  as  needed.  The  center  will  implement  this  program  in  early  2015.  Language  barriers  were  also  identified  in  this  category.    Heartland  Health  Centers  currently  reports  approximately  35%  of  the  patient  base  as  being  better  served  in  a  language  other  than  English.  The  center  offers  bilingual  staff  for  Spanish  speaking  patients  and  utilizes  the  language  line  for  other  languages.      Approximately  99%  of  the  patients  identified  as  being  better  served  in  a  language  other  than  English  are  served  in  Spanish.    Less  than  one  percent  of  patient’s  primary  language  is  Sudanese  or  Arabic.      Mental  Health/Substance  abuse:      Mental  health  and  substance  abuse  were  identified  as  community  concerns  in  four  of  the  community  health  plans  data  collection.    The  Heartland  Health  Center  service  area  is  identified  as  a  shortage  area  for  mental  health  providers.    There  is  an  extreme  shortage  across  the  state  for  providers  who  are  able  to  provide  medication  management  for  psychiatric  medications.    For  the  severe  and  persistent  mentally  ill  this  creates  a  gap  in  client’s  abilities  to  get  appropriate  care.    

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For  patients  who  are  dealing  with  depression  or  anxiety,  the  availability  of  therapy  provided  at  reduced  rates  is  limited.  Mid  Plains  Behavioral  health  provides  counseling  and  medication  management  utilizing  a  sliding  fee  for  clients  who  qualify.    However  there  is  a  significant  wait  for  new  clients  to  be  seen,  which  can  cause  some  conflicts  for  the  clients.    Central  District  Health  Department  reports  a  ratio  of  4699:1  for  available  mental  health  providers  in  the  area.        Diabetes:      Approximately  9%  of  the  Central  District  Health  Department  population  report  Type  I  or  Type  II  diabetes  which  is  higher  than  the  state  reported  rate  of  8%.    Additional  information  gathered  from  local  health  assessments  indicate  that  11.8%  of  the  adult  Latino  population  in  Hall  County  carry  a  diagnosis  of  Type  I  or  Type  II  diabetes.    The  surrounding  counties  have  similar  measures  for  the  prevalence  of  diabetes  in  their  populations.    

Assessments  and  Priorities  for  Heartland  Health  Center:  

Access  to  Health  Care:    Heartland  Health  Center  reports  78%  of  its  patient  population  as  uninsured,  additionally  59%  of  those  who  use  services  at  the  center  meet  the  income  guidelines  for  discounted  services.    Heartland  Health  Center  uses  a  voucher  system  to  assist  with  transportation  for  the  community  handy  bus  and  taxi  services  when  the  handy  bus  is  not  available.  Heartland  Health  Center  recently  received  philanthropic  funding  to  assist  with  the  purchase  of  a  van  to  provide  transportation  for  patients  in  2015.  The  Center  will  be  revising  and  implementing  the  changes  for  the      transportation  program  in  early  2015.      Roughly  35%  of  Heartland  Health  Center’s  patient  base  are  reported  to  be  better  served  in  a  language  other  than  English.    Spanish  has  the  highest  need  for  interpretation,  with  99%  of  those  requiring  interpretation  services  speaking  Spanish,  additionally  approximately  1%  are  reported  to  speak  Arabic  or  Sudanese  as  their  primary  language.    The  center  employs  multiple  Spanish/English  bilingual  staff  to  assure  services  are  provided  in  the  appropriate  language.  The  center  also  uses  the  language  line  for  patients  who  speak  languages  other  than  English  or  Spanish.    The  center  will  monitor  for  increased  needs  related  to  language  and  take  appropriate  steps  to  address  those  needs.      Dental  Services:  Dental  services  will  be  added  to  the  Heartland  Health  Center  in  the  first  half  of  2015.  Although  this  was  not  an  area  of  need  identified  in  the  review  of  community  health  needs,  it  has  been  identified  by  the  centers  board  of  directors  and  patient  population  as  a  needed  service  for  the  Heartland  Health  Center.  In  the  Grand  Island  area  the  Third  City  Community  Clinic  is  the  only  provider  of  dental  care  to  those  without  a  means  to  pay  for  such  services  up  front.  The  Third  City  Community  Clinic  is  able  to  offer  dental  services  very  sporadically  due  to  limited  provider  availability.  They  do  offer  some  preventative  care  with  a  part  time  dental  hygienist  to  those  individuals  who  qualify  to  receive  services  at  their  clinic.    

9    

Reports  from  the  local  Veterans  Administration  Center  indicate  that  in  the  past  year  dental  services  has  been  a  need  for  local  veterans.  It  was  estimated  that  139  veterans  were  transported  by  bus  to  Lincoln  about  95  miles  away  to  receive  the  most  basic  dental  care.  The  availability  of  resources  to  provide  both  primary  and  preventative  dental  care  to  low  income,  uninsured  and  underserved  populations  is  minimal  at  best.  Many  simply  go  without  care  since  most  dental  providers  in  the  area  require  the  full  payment  amount  up  front  if  no  insurance  is  available.  Additionally  any  services  provided  for  emergencies  also  requires  full  payment  prior  to  the  patient  being  seen  whether  the  patient  has  insurance  or  not.      Most  dental  providers  in  the  area  limit  the  number  of  patients  they  will  accept  who  have  public  insurances  such  as  Medicaid  and  Medicare.    They  report  poor  reimbursement  rates  as  the  reason  for  this  practice.    Some  patients  reported  in  the  past  traveling  to  the  nearest  FQHC  a  distance  of  70  miles  for  dental  care.  In  general  patients  indicate  that  dental  service  as  part  of  the  Center  will  be  highly  utilized.      As  part  of  the  process  of  determining  the  needs  of  those  served  by  Heartland  Health  Center  a  patient  survey  was  implemented  to  determine  the  need  for  dental  services  and  the  likeliness  that  patients  will  use  the  services  when  they  become  available.  A  five  point  Likert  scale  was  used  to  determine  the  need  for  dental  services  if  offered  at  the  center.    The  survey  was  completed  on  patients  being  seen  at  the  clinic  in  a  two  week  period.    Of  those  surveyed  53%  were  completed  in  English  and  47%  in  Spanish.    91%  said  they  were  likely  or  very  likely  to  uses  dental  services,  6  %  did  not  answer  and  18  %  responded  that  they  would  be  unlikely  to  use  dental  services.        Mental  Health/Substance  abuse:  Based  on  data  collected  through  the  clinic  reporting  system  a  small  number  of  clients  have  a  substance  use  or  abuse  diagnosis.  The  clinic  has  a  more  significant  number  of  patients  having  a  diagnosis  of  depression,  anxiety,  and  other  mental  disorders  not  involving  substance  use.    Of  those  clients  in  the  center  having  a  mental  health  or  substance  abuse  diagnosis,  8%  where  diagnosed  with  substance  abuse  disorders  approximately  55%  of  these  were  related  to  tobacco  use.      The  most  identified  mental  health  issue  was  the  diagnosis  of  depression  which  comprise  58%  of  mental  health  diagnosis,  anxiety  disorders  and  other  mental  disorders  follow  with  roughly  22%  and  16%  of  the  mental  health  diagnoses.    Heartland  Health  Center’s  goal  for  the  2015  fiscal  year  is  to  bring  mental  health  services  in  house,  with  a  part-­‐time  Licensed  Mental  Health  Practitioner  or  a  Licensed  Clinical  Social  Worker.    This  will  allow  patients  to  opportunity  to  seek  counseling  services  in  the  center  and  encourage  more  integrated  care  for  the  patients.    As  part  of  the  process  of  determining  the  needs  of  those  served  by  Heartland  Health  Center  a  patient  survey  was  utilized  to  determine  the  need  for  mental  health/counseling  services  and  the  likeliness  that  patients  will  utilize  the  services  when  they  become  available.  A  five  point  Likert  scale  was  utilized  to  determine  the  likelihood  that  patients  would  utilize  behavioral  health  services  if  offered  at  the  center.  The  survey  was  completed  on  patients  being  seen  at  the  clinic  in  a  two  week  period.    Of  those  surveyed  53%  were  completed  in  English  and  47%  in  Spanish.    76%  said  they  were  likely  or  very  likely  to  uses  behavioral  health  services,  6  %  did  not  answer  and18  %  responded  that  they  would  be  unlikely  to  use  behavioral  health  services.    

10    

 Diabetes:    The  centers  reporting  system  indicates  that  of  the  most  utilized  diagnoses  given  at  the  center  diabetes  comprise  16%  for  the  overall  patient  population.    Of  these  individuals  50%  are  reported  to  have  an  HBA1c  of  <=9%  and  seek  regular  care  to  assist  in  their  awareness  and  control  of  their  disease.    Center  staff  continue  to  offer  education  on  the  importance  of  proper  care,  diet,  exercise  and  life  style  changes  to  empower  patients  to  take  control  of  their  health.      Obesity:  Heartland  Health  center  actively  seeks  to  educate  patients  on  the  importance  of  maintaining  a  proper  weight  for  their  overall  health.  The  center  reports  that  36.8  %  of  adult  patients  are  counseled  on  BMI  and  diet  and  82.3%  of  pediatric  patients  have  received  counseling  related  to  their  current  BMI.    Patients  identified  as  obese  are  at  higher  risk  for  the  following  health  conditions:        Coronary  Heart  Disease                                                                                  Type  II  Diabetes  Cancer  (endometrial,  breast,  colon)  Dyslipidemia  (high  cholesterol)  Stroke  Liver  and  Gallbladder  Disease  Sleep  Apnea  and  Breathing  Issues  Osteoarthritis  Gynecological  Abnormalities  Center  data  suggests  that  the  most  common  diagnosis  in  the  center  related  to  obesity  are  for  diabetes  at  16%  and  hypertension  at  20%.    Heartland  Health  Center  continues  to  utilize  patient  education  to  encourage  knowledge  and  awareness  of  obesity,  healthy  life  styles  and  proper  weight  management.          Cancer:  Heartland  Health  Center  has  a  low  rate  of  follow  through  related  to  cancer  screening  for  the  patients  it  serves.  Although  these  numbers  have  been  increasing,  the  center  has  taken  steps  to  increase  the  number  of  patient  who  participate  in  suggested  practices  for  cancer  screening.    The  center  reports  a  10.9  %  rate  for  colorectal  screening,  a  25.5%  rate  for  completed  cervical  and  breast  cancer  screening.    Through  collaborative  work  with  the  Nebraska  Department  of  Health  and  Human  services  and  the  Central  District  Health  Department,  Heartland  Health  Center  is  exploring  options  to  increase  awareness  and  follow  through  with  patients  for  cancer  screening.      Summary  of  Assessment  Priorities:    Heartland  Health  Center  will  continue  to  strive  to  meet  set  goals  for  meaningful  use  and  UDS  quality  measures.    Priorities  for  the  center  for  2015-­‐2018  will  be  focused  on  increasing  Cancer  screening  rates,  Dental  Services  and  Behavioral  Health  Care.  Dental  and  Behavioral  Health  services  will  be  put  in  place  in  late  spring  of  2015.