2016-2019 Community Health Needs Assessment and ... · Whatcom Alliance for Health Advancement (WAHA): WAHA is an organization with a mission to connect people to health care and

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2016-2019

Community Health Needs Assessment and Implementation Plan

Adopted by Community Health Board: June 30, 2016

Community Health Needs Assessment | PeaceHealth St. Joseph Medical Center 1

Table of Contents

I. EXECUTIVE SUMMARY .......................................................................................................................... 2

II. OVERVIEW ............................................................................................................................................ 6

State, Regional and Community Partners ...................................................................................... 6

Community Health Framework ...................................................................................................... 8

III. 2013 CHNA REVIEW .............................................................................................................................. 9

IV. WHATCOM COUNTY DEMOGRAPHIC AND SOCIOECONOMIC PROFILE ............................................. 12

V. KEY HEALTH INDICATORS .................................................................................................................... 15

Method ......................................................................................................................................... 15

Healthy, Active Living ................................................................................................................... 16

Child & Family Wellbeing ............................................................................................................. 21

Health Delivery Systems ............................................................................................................... 26

Equity ............................................................................................................................................ 31

VI. COMMUNITY CONVENING .................................................................................................................. 34

Method ......................................................................................................................................... 34

VII. IMPLEMENTATION PLAN .................................................................................................................... 40

Selected Strategies ....................................................................................................................... 40

Significant Health Needs Not Addressed by Implementation Plan .............................................. 42


I. EXECUTIVE SUMMARY

Overview

PeaceHealth St. Joseph Medical Center

PeaceHealth St. Joseph Medical Center (PeaceHealth St. Joseph) is one of ten hospitals within

PeaceHealth, an integrated, not-for-profit health system in the Pacific Northwest. Located in Bellingham,

Washington, the primary service area for PeaceHealth St. Joseph is Whatcom County, Washington.

Community Health Needs Assessment

PeaceHealth St. Joseph and partners conducted a Community Health Needs Assessment (CHNA), a

systematic process involving the community to understand community health needs in order to

prioritize, plan and outline solutions.

The 2016 CHNA was carried out with community input, including public health and nonprofit community

groups representing minority and low-income residents. Both primary and secondary data were

collected and incorporated. We also interviewed key informants and held a community forum in which

needs were affirmed and possible strategies to address the needs were identified.

Data and local perspectives are presented and analyzed using a four-pillar structure of community

health: 1) Healthy, Active Living; 2) Child & Family Wellbeing; 3) Integrated Health Delivery Systems

(including medical dental and behavioral health services); and 4) Equity.

PeaceHealth St. Joseph conducted this CHNA in conjunction with state, regional, and local community

health planning in Washington, the North Sound Region and Whatcom County.

2013 CHNA

The problem of health care access and lack of insurance coverage was identified in all PeaceHealth

communities in 2013 as a major need and was therefore chosen as a major focus area in our 2013 CHNA

implementation plans. PeaceHealth worked as part of the community coalitions that were formed

across the state for the purpose of helping people sign up for commercial health insurance and Apple

Health, i.e. Medicaid. By any measure these efforts were successful.

Summary of the 2016 Community Health Needs Assessment

Demographic and Secondary Data

Whatcom County has about 205,000 residents. 24% are children 0-19 years old, 65% are adults age 18-

64, and the remaining 14% are seniors age 65+. Bellingham is the largest city in the county representing

approximately 40% of the county’s population. Approximately 41% of Whatcom County residents are

either “Asset Limited, Income Constrained, Employed” or live below the poverty line. 8% of the

County’s population is Hispanic and 4% of the population is American Indian/Alaska Native.


Key health indicators were organized into the four community health pillars using primary data from

Robert Wood Johnson’s 2016 County Health Rankings and other state sources. Health outcomes gaps in

each area are summarized below.

HEALTHY, ACTIVE LIVING: Major issues identified include the abuse of opiates and excessive adult

drinking. The county ranks 3rd in negative effects from heroin abuse and 6th of 39 counties in negative

effects from prescription drug use.

CHILD & FAMILY WELLBEING: Adverse Childhood Experiences and low vaccination completion rates are

major concerns for Whatcom County. These factors put Whatcom County residents at greater risk of

poor health outcomes or greater risk of serious infections.

HEALTH DELIVERY: Data show that there are significant differences in uninsured rates by race/ethnicity,

and racial/ethnic differences in the quality of preventive care received by Medicare beneficiaries.

Addressing these inequities is important to the health of the community.

EQUITY: Affordable housing is a key component of financial wellbeing and stability, and forms the basis

of good health. A high percentage of cost-burdened housing in certain areas of Whatcom County

imperils the wellbeing of affected households and the community as a whole.

Community Engagement and Local Perspectives

PeaceHealth St. Joseph interviewed 10 key informants from organizations throughout the County

representing public health and health care for non-majority populations to identify health gaps and

possible health solutions.

The key informant interviews were conducted in advance of a convening that was held on May 19, 2016

wherein more than 60 community leaders from public health, health and social services, business,

schools, and government met to confirm, refine, and identify health needs/gaps and possible solutions.

The chart below summarizes the results of the community stakeholder meeting. It should be noted that

the lists of gaps and strategies represented in the table were generated in two separate set of group

processes at the meeting, i.e. the strategies were not necessarily identified as specific solutions to the

identified gaps.


Table 1. Results of the Community Stakeholder Meeting

Major Health Problems/Gaps Prioritized Evidence-Based Strategies

Healthy,

Active

Living

Adult alcohol use

Teen tobacco use

Food and beverage environments at

school and in the community

Elder isolation

Physical inactivity

Community Health Worker programs

School-based early intervention

School nutrition programs

Child &

Family

Wellbeing

Low immunization rates

Low graduation rates, particularly

among homeless and low-income

families

Maternal smoking during pregnancy

High cost of childcare

ACEs

Prenatal and early childhood home

visiting programs

Levy to support early childhood

services

‘ Early Pathways’/home-based

mental health

Health

Delivery

Systems

High rates of opiate abuse/pain management, e-cigarette use, DUI rates

Racial/ethnic disparities in health insurance

Unaffordable health care Lack of dental and behavioral health

care providers

Supported housing programs

Expand triage/crisis stabilization

Linking social services and medical

services

Equity

High poverty and low educational attainment concentrated around Bellingham and certain rural areas

Cost-burdened housing Underrepresentation of non-

majority persons at all levels of health and social service delivery systems

Limited economic opportunities Lack of affordable child care for

ALICE populations Transportation barriers

Expanded Housing First programs

School based health centers

Community Health Workers / patient

navigators


Implementation Plan

The Implementation Plan strategies summarized below were extrapolated from the data and from

community input. Our plan is comprehensive in the sense that there are strategies that impact the focus

areas within each of the community health pillars (and a number of strategies cross pillars). The display

of strategies is not intended to be a complete listing of all the activities that PeaceHealth will undertake

with its community partners to affect the health status of the community. Rather, it is a statement of

our community health priorities.

PeaceHealth St. Joseph CHNA 2016 Priorities

Ensure effective information exchange and care coordination for particular populations (e.g. PeaceHealth Medical Group patients with complex health and psychosocial conditions who are served by multiple organizations) through the PeaceHealth Transforming Clinical Practice Initiative (TCPI) and other community collaborations.

Increase participation in the PeaceHealth employee wellness program, particularly for caregivers at the lower end of the compensation scale.

As part of our ongoing efforts to create an inclusive organization that exercises cultural humility, recruit for and support a workforce that reflects the changing ethnic, racial and cultural diversity of the communities that we serve.

Advocate for and actively support the development of a comprehensive continuum of behavioral health services that includes access to crisis stabilization, transitional and long housing, substance abuse treatment services, and psychiatry that is available to children and seniors.

Work with local school districts, Head Start, and others to advocate for and support the wide-spread availability of early learning opportunities for all children.

Develop a Community Health Worker initiative that empowers individuals within specific communities to serve a liaison/linking/intermediary role between health/social services and the community to facilitate access and improve the quality and cultural competence of service delivery.

Advocate for and support policies and programs geared to promoting healthy nutrition, activity and lifestyles for youth aged 8-11, with a particular focus on lower income families.


“ ”

II. OVERVIEW

Founded by the Sisters of St. Joseph of Peace in 1890, PeaceHealth is a Catholic Healthcare Ministry

serving in the communities of Alaska, Washington and Oregon. Today, PeaceHealth is a 10 hospital

integrated not-for-profit health system that offers a full continuum of health and wellness services.

PeaceHealth’s mission is to carry on the healing mission of Jesus Christ by promoting personal and

community health, relieving pain and suffering, and treating each person in a loving and caring way. The

fulfillment of our Mission is our shared purpose. It drives all that we are and all that we do. We have

embraced the CHNA process as a means of engaging and partnering with the community in identifying

disparities and prioritizing health needs, and importantly, in aligning our work to address prioritized

needs.

Caring for those in our community is not new to PeaceHealth; it’s been in practice since the Sisters of St.

Joseph of Peace arrived in Fairhaven, Washington to serve the needs of the loggers, mill workers,

fishermen and their families more than 125 years ago. Even then, they knew that strong, healthy

communities benefit individuals and society, and that social and economic factors can make some

community members especially vulnerable. The Sisters believed they had a responsibility to care for

them, and that ultimately, healthier communities enable all of us to rise to a better life. This philosophy

inspires us today and guides us toward the future.

State, Regional and Community Partners

PeaceHealth’s 2016 CHNA process was undertaken in the context of other recent or concurrent planning

activities in the State, region and County related to community health:

The Washington State Health Improvement Plan (2014-2017 Creating a Culture of Health in

Washington) provides a statewide framework for health improvement efforts.

PeaceHealth St. Joseph Medical Center and Whatcom County Health Department in

collaboration with multiple community partners developed the Whatcom County Community

Health Improvement Plan for 2012-2016. The Health Department’s 2015 Community Health

Improvement Annual Report provides an update to this report and associated activities. The

annual report identifies three community priorities: improving access to health care and service

Wellness is something we nurture, something we build into our policies,

something we come together to create as public health professionals,

doctors, nurses, lawyers, transportation planners, neighborhood

advocates and PTAs, and others.

John Wiesman, DrPH, MPH Washington State Secretary of Health

http://www.doh.wa.gov/Portals/1/Documents/Pubs/822-034_SHIPreport.pdf

http://www.doh.wa.gov/Portals/1/Documents/Pubs/822-034_SHIPreport.pdf

http://www.whatcomcounty.us/DocumentCenter/Home/View/14543

http://www.whatcomcounty.us/DocumentCenter/Home/View/14543


delivery, enhancing family and child well-being (which includes ensuring that all children are

healthy and safe) and promoting healthy active living (this includes enhancing access to healthy

foods, particularly for low-income and isolated populations and limiting exposure to tobacco,

alcohol and other harmful substances, especially for youth).

The North Sound Accountable Community of Health (NS-ACH) includes representatives from

the five-county area that includes San Juan, Island, Skagit, Snohomish and Whatcom counties.

An Accountable Community of Health (ACH) is

a regional coalition consisting of leaders from

a variety of different sectors working together

to improve health in their region. As part of the

Healthier Washington Initiative, nine ACHs began

formally organizing across Washington in 2015.

They are intended to strengthen collaboration,

develop regional health improvement plans and

projects, and provide feedback to state agencies

about their regions’ health needs and priorities. The

Health Care Authority (HCA) is supporting ACH

development through guidance, technical assistance

(TA), and funding.

Whatcom Alliance for Health Advancement (WAHA): WAHA is an organization with a mission to

connect people to health care and facilitate transformation of the current system into one that

improves health, reduces cost and improves the experience of care for all. PeaceHealth is a

major sponsor of WAHA and anticipates working with WAHA to carry out a number of the

identified CHNA health improvement strategies.

Map 1. Accountable Community of Health Regions

Source: Washington Health Care Authority

http://whatcomalliance.org/

http://www.hca.wa.gov/hw/Pages/communities_of_health.aspx


Community Health Framework

Drawing from the CHNAs conducted by PeaceHealth hospitals in 2013, and after reviewing existing

community health improvement plans and collecting public data on health status and the social

determinants of health, a PeaceHealth Community Health Framework was developed. This four-pillar

framework, depicted below, was used to organize data and collect input from community stakeholders.

The subcategories, or “focus areas” were used as guideposts for considering community health

improvement strategies.

Figure 1. 2016 PeaceHealth Community Health Framework Pillars

Healthy,

Active Living

Child & Family

Wellbeing

Integrated Health

Delivery Systems Equity

Physical activity

Healthy Eating

Tobacco, alcohol

and other drug

prevention

Social engagement

Maternal-child

health

Adverse Childhood

Experiences (ACEs)

and family resiliency

Access to quality

and affordable

medical, behavioral

health and dental

services

Assistance for

people who are

homeless

Cultural humility

There are two terms that are used in the above table that perhaps need to be defined, and they are:

Adverse Childhood Experiences (or ACEs) are traumatic events that occur in childhood and

cause stress that changes a child’s brain development. Exposure to ACEs has been shown to

have a dose-response relationship with adverse health and social outcomes in adulthood,

including but not limited to depression, heart disease, COPD, risk for intimate partner violence,

and alcohol and drug abuse.

Cultural humility is a term used to describe a way of infusing multiculturalism into a workplace.

Replacing the idea of cultural competency, cultural humility is based on the idea of focusing on

self-reflection and lifelong learning.


III. 2013 CHNA REVIEW

During the 2012-2013 timeframe, the Whatcom County Health Department and PeaceHealth St. Joseph

conducted a comprehensive Community Health Assessment and, along with a wide array of community

partners, developed an equally comprehensive Community Health Improvement Plan (CHIP).

PeaceHealth contributed to this effort both as an organizational sponsor and a leader of the work

associated with the health care section of the plan. The PeaceHealth 2013 CHNA implementation plan

focused on health care delivery and associated issues. The table below summarizes the 2013-2016

PeaceHealth CHNA and includes available metrics which summarize measurable progress to date.

Table 2. 2013 CHNA Summary and Current Status

Objectives Strategies Outcomes

Baseline Current

Objective 1: Ensure access to essential health care services for all County residents

Increase Medicaid and Health Insurance (HIE) enrollment Increase Whatcom County primary care capacity at PHMG and at the Interfaith Community Health Center

Whatcom County adult un-insurance rate: 16%

Whatcom County health care provider ratios:*

PCP: 1,126:1

Dentists: 1,588:1

Whatcom County adult un-insurance rate: 9%

Whatcom County health care provider ratios:*

PCP: 1,140:1

Dentists: 1,400:1

Objective 2: Improve support for children, adults, and seniors with complex health needs

Develop community response to high-utilizing patients Integrate mental health care with primary medical care

Avoidable emergency room visits to PeaceHealth St. Joseph (defined as ‘low acuity’)

Medicaid: 20.2%

Commercial/Other: 18.9%

Avoidable emergency room visits to PeaceHealth St. Joseph (defined as ‘low acuity’)

Medicaid: 18..2%

Commercial/Other: 16.0%


Objectives Strategies Outcomes

Baseline Current

Objective 3: Provide welcoming, culturally aware health care for every patient

Institute ongoing dialogue with Tribal

Health leadership, social workers and

others within the Lummi and Nooksack

communities

Review organizational practices; institute cultural sensitivity training for PeaceHealth caregivers

Over the last three years PeaceHealth convened quarterly meetings with Tribal health leaders, area social service and health care providers and others that has resulted in greater trust and improved operational relationships.

Efforts to use the standard patient experience survey to track the experience of care for selected sub-populations were not successful.

Ongoing diversity training not instituted; planning underway for “cultural humility” pilot trainings.

*Data methods changed/can’t compare to prior years. Sources: Washington State Health Care Authority; Robert Wood Johnson

Foundation County Health Rankings; PeaceHealth Internal Data

As we move forward in adopting the 2016 CHNA, we reflect on lessons learned and accomplishments of

our process, goals, and implementation of the previous (2013) CHNA:

Lessons Learned

Begun in 2013, the WAHA Intensive Case Management (ICM) program consisted of case

managers working in a multi-disciplinary team across organizational boundaries to provide the

appropriate level of support for complex patients. The effort was supported in part by

PeaceHealth St Joseph and involved a local FQHC and representatives from the Criminal Justice,

Emergency Medical Services (EMS) and behavioral health sectors with the aim of coordinating

care management for the most difficult to serve patients.

Over the three year period, the program met with initial success, but had trouble scaling up to meet

demand and was eventually absorbed into the State Health Home program designed to provide

case management for a similar patient population. The lessons learned were that a lot can be

accomplished when local organizations work across organizational boundaries, but, in the end, the

question of cost in relation to outcome needs to be adequately addressed. The other lesson is that

health care reform in Washington State is calling for regional collaboration with Medicaid insurance

plans, and intensive case management for the Medicaid population needs to be implemented

collaboratively with the Medicaid Pans.


Accomplishments

The Hospital Community Connector program is a successful partnership between PeaceHealth St.

Joseph and the two area FQHCs, (Sea Mar CHC and Unity Care NW). Both organizations embed care

coordinators in the hospital emergency department and work with hospital caregivers to ensure

appropriate primary care follow-up and social service linkage, particularly for higher-risk patients.

Over the last three years, PeaceHealth St. Joseph has contributed more than $1.5 million and

ongoing technical assistance to support the activities of key nonprofit organizations providing

primary health care, child abuse prevention services, pediatric dentistry, behavioral health

services, nutrition and native food programming, services for people who are homeless and

health insurance assistance for lower income individuals, families and seniors.

The 2013 PeaceHealth CHNA identified the problem of health care access and lack of insurance

coverage as the one issue that we wanted to focus on across all of our communities.

PeaceHealth worked as part of the community coalition that was led by WAHA for the purpose

of helping people sign up for commercial health insurance and Apple Health, i.e. Medicaid. By

any measure these efforts were successful.

Between 2013 and 2014 there was a more than 41% increase in Medicaid enrollment.

Enrollment continued to increase in 2015 but not at the pace of the initial increase. Adult

enrollment rose nearly 63% from 2013 to 2015 and child enrollment rose 41% over the same

period. As a result, uninsured adults in Whatcom County decreased from 16% in 2013 to 9% in

2015.

Figure 2. Medicaid Enrollment and Percent Uninsured, Whatcom County

.

16%

9%

2013 2015

34876 36514

5151555929

2012 2013 2014 2015


Figure 3. Medicaid Enrollment by Adults and Children, Whatcom County

Source: Health Care Authority, State of Washington. Children are defined as under age 19.

IV. WHATCOM COUNTY DEMOGRAPHIC AND SOCIOECONOMIC PROFILE

Map 2, Whatcom County

PeaceHealth St. Joseph serves the North Sound region of Washington, with

Whatcom County being its primary service area and the focus of this CHNA1.

1 All data in this section is from the American Community Survey (US Census Bureau) unless otherwise noted.

15,063 15,942

20,836 22,480

19,813 20,572

30,679 33,449

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

2012 2013 2014 2015

Children Adults

Of Note:

The 2015 United Ways of the Pacific Northwest ALICE report summarizes the status of ALICE families—an acronym that stands for Asset Limited, Income Constrained, Employed. These are families that work hard and earn above the Federal Poverty Level (FPL), but do not earn enough to afford a basic household budget of housing, child care, food, transportation, and health care. Most do not qualify for Medicaid coverage.

In Whatcom County, 41% of all households are either in poverty or are ALICE households. This is greater than Washington State overall, wherein 32% of all households are either ALICE or in poverty.


Current Profile

Whatcom County has about 205,000 residents

11,413 (5%) are preschoolers age 5 or younger

38,321 (19%) are 5-19 years old

133,438 (65%) are adults age 18-64

29,345 (14%) are seniors age 65+

17,264 (8%) are Hispanic (stasis since 2010)

8,380 (4%) are American Indian/Alaska Native (growth of 32% since 2010)

Approximately 40% of Whatcom County residents live in Bellingham. In terms of the socioeconomic

determinants, Countywide:

91% of adults have a high school diploma

16% of individuals live below the FPL

41% of all households are either in poverty or cannot afford basic household expenses

652 people are homeless in Whatcom County, both sheltered and unsheltered (Homelessness in

Washington State,2015, Annual Report on the Homeless Grant Programs)

In the Bellingham, WA school district, 477 children in grades k-12 are reported from homeless

families (239) or doubled up (living with other families) (239). (http://www.k12.wa.us/HomelessEd/pubdocs/StatewideHomelessReportByDistrict2015.pdf

Table 3, Whatcom County, WA Sociodemographic Profile

City High school

diploma (%)

Individuals living

below the FPL (%)

Median

Household

Income

People over age 5

who are

linguistically

isolated

Bellingham 92.6% 23.2% $42,440 9.6%

Blaine 93.2% 9.7% $55,229 4.6%

Everson 74.4% 15.6% $51,735 14.2%

Ferndale 85.9% 16.0% $51,944 8.7%

Lynden 90.7% 8.6% $59,021 4.3%

Nooksack 93.3% 13.4% $65,368 2.1%

Sumas 85.6% 6.7% $55,526 5.3%

Whatcom County 91.0% 16.2% $53,025 4.7%

Washington State 90.2% 13.5% $60,294 7.8%


The Community Need Index (CNI), a tool created by Dignity Health, measures a community’s social and

economic health on five measures: income, cultural diversity, education level, unemployment and

health insurance, and housing. The CNI demonstrates that within Whatcom County, there are pockets

of higher and lower need:

Map 3, Whatcom County Community Need Index Map, 2015

Source: Dignity Health

Key Take-Aways

Nearly half of all Whatcom County residents are either below the FPL, or are ALICE households and live

above the poverty level but do not earn enough to afford a basic household budget of housing, child

care, food, transportation, and health care.

Within Whatcom County, there are pockets of high poverty and low educational attainment,

with highest need areas concentrated in and around Nooksack, Everson, Bellingham, and the

inland areas of the county.


V. KEY HEALTH INDICATORS

Method

Data for each of the four PeaceHealth pillars is detailed on the following pages. For each pillar, we

provide a description, how the community compares to other Washington counties, provide a profile of

the community, identify important indicators and provide key takeaways.

PeaceHealth selected the most currently available data from publically available sources. Data elements

were selected that align with the focus of the CHNA. The goal was to identify metrics that could be

consistently measured, monitored and benchmarked for all PeaceHealth communities throughout the

Pacific Northwest.

Data from the Robert Wood Johnson Foundation (RWJF) was used as a primary source. RWJF’s county

health rankings data compare counties within each state on more than 30 factors. Counties in each of

the 50 states are ranked according to summaries of a variety of health measures. Counties are ranked

relative to the health of other counties in the same state. RWJF calculates and ranks four summary

composite scores used in this report:

Overall Health Outcomes

Overall Health Delivery Factors

Health Factors – Health behaviors

Health Factors – Social and economic factors

This is a nationally recognized data set for measuring key social determinates of health. RWJF is

committed to continually measuring these metrics.

Data in this evaluation is also supplemented with sources from state and local agencies in Washington.

Unless otherwise noted all data cited in this section is from RWJF or the following sources:

Behavioral Risk Factor Surveillance System; Washington Healthy Youth Survey; Washington Department

of Health, Vital Statistics; US Census Bureau; The University of Washington’s Alcohol and Drug Abuse

Institute; WA Office of the Superintendent for Public Instruction; Feeding America; Enroll America;

Centers for Medicare & Medicaid Services; Community Commons and Whatcom County Health

Department WIC.

Next to each local indicator we've shown whether the local rate (percentage) is less than, greater than,

or equal to the state rate (percentage). With any indicator, there is a range of possible 'true' values

because data collection always entails some error. Often, percentages that appear different are rated as

'equal.' This is because, statistically speaking, there is a large chance that the 'true' value of the data at

the state and county level is equal, rather than different, due to error inherent in the data collection

process.


Healthy, Active Living: Whatcom County Health Indicators, 2016

What is Healthy, Active Living?

Healthy, Active Living is a key pillar of a healthy community. We envision a community where the

environment and resources of that community allow adults, teens, and children to be physically active,

to eat nutritious meals, to be free of the burdens of substance abuse and chronic disease, and to live

with an ample sense of wellbeing and connection to others.

How Does Whatcom County Compare to Other Counties?

Whatcom County is ranked 5 out of 39 Washington Counties for its food and physical activity environment, as well as the adult behavioral health indicators such as excessive drinking and smoking. This means we’re doing well compared to nearly 9 out of 10 counties in Washington.

Healthy, Active Living Profile:

Adults:

Adult obesity: 21% (<WA: 27%)

Adult physical inactivity: 16% (=WA: 18%)

Adult diabetes: 11% (=WA: 9%)

Youth:

10th graders who are obese: 12.4% (=WA: 11.2%)

10th graders reporting physical inactivity: 13.2% (=WA: 12.0%)

Environment:

Reasonable access to exercise opportunities: 87% of residents (=WA: 88%)

Food environment index: 2016: 7.2 (=WA: 7.5)

Substance abuse:

Opiate use:

o Whatcom County ranks 3rd of 39 counties in Washington for overall negative impacts

from heroin abuse

o Whatcom County ranks 6th of 39 counties in Washington for overall negative impacts

from prescription opiates

o Deaths attributed to any opiate: 8.2 per 100,000 population (=WA: 8.6 per 100,000

population)

o Publicly funded treatment admissions involving any opiate: 380.5 per 100,000

population (>WA: 176.3 per 100,000 population)

o Some of the highest rates of Buprenorphine prescription for Suboxone treatment for

opiate addiction in all of Washington counties

Adult excessive drinking: 22% (>WA: 19%)

Adult smoking: 14% (=WA: 15%)

10th graders smoking cigs in past 30 days: 8.7% (=WA: 7.9%)


Closer Look:

Growth in opiate abuse

Opiate abuse, including heroin and prescription opiates, has grown steadily in

the past fifteen years. Several measures, including the rate of Whatcom

crime lab results related to an opiate, the rate of residents treated for opiate

addiction and the rate of deaths attributed to any opiate, have increased

significantly in Whatcom County between 2002-2004 and 2011-2013. Opiate

use and abuse is a significant health and political issue in Whatcom County

that requires cross-sector collaboration in order to alleviate its negative

health and social consequences for our community.

Figure 4. Opiate use and abuse growth over time,

Washington State, 2002-2004 to 2011-2013

Of note:

Caregiver Wellness As the largest employer in the community, PeaceHealth is working to support Active Healthy living in its workforce by offering an employee wellness program. Workplace wellness programs are evidence-based strategies to improve physical fitness and risk factors. At PeaceHealth, we can make an impact on community wellness by improving our employees’ wellness, but there are differences based on income levels:

60.6% of eligible PeaceHealth St. Joseph employees participate in a wellness program 26.3% of eligible PeaceHealth St. Joseph employees earning $25,000 - $40,000 participate in a wellness program

Participation by Income Group


Figure 5. Increase in Opiate-related Deaths by county, Washington State, 2002-2004 to 2011-2013

Source: Univ. of WA Alcohol & Drug Abuse Institute, “Opioid Trends Across Washington State,” April 2015)

Excessive drinking among adults

Whatcom County adults report higher levels of excessive drinking (binge drinking, defined as four drinks

in a sitting for women and five drinks in a sitting for men, or drinking an average of two servings of

alcohol per day for men and one serving per day for women). Excessive drinking leads to injury and is

the third-leading cause of lifestyle-related death in the U.S.

Figure 6. Excessive drinking among adults, Washington State, results by county, 2016

(Figure source: Robert Wood Johnson County Health Rankings)

Additional Indicators with Trend Data

The Behavioral Risk Factor Surveillance System is used to measure chronic diseases and health behaviors

among a population of adults in all 50 states at the county level. The Washington Healthy Youth Survey

measures health risk behaviors and outcomes among 6th, 8th, 10th, and 12th graders in Washington

State. It should read: The Washington Department of Vital Statistics measures causes of death and

circumstances of prenatal outcomes and birth. The Robert Wood Johnson Foundation County Health

Rankings aggregates BRFSS, Vital Statistics, US Census, and business data to provide an overview of

measures that matter for health. The University of Washington’s Alcohol and Drug Abuse Institute


measures markers of opiate abuse over time in Washington counties, and the Whatcom County

Department of Health added important data on opiate abuse over time in Whatcom County.

Table 4 Healthy, Active Living: Whatcom County vs. Washington State, 2016

Better Equal Worse

Chronic Conditions

Adult diabetes ●

Heart disease death rate ●

Adult obesity ●

Risk behaviors

Adult physical inactivity ●

Adult excessive alcohol use ●

Adult smoking ●

Deaths due to any opiate ●

Suicide death rate ●

Environment

Grocery availability & food insecurity ●

Access to exercise opportunities ●


Table 5 Healthy, Active Living: Whatcom County 10th Graders,

Health Indicators vs. Washington State, 2014 and Trend Since 2010

Better Equal Worse Trend

Chronic Conditions

Obesity ● stasis

Depression ● stasis

Risk behaviors

Smoking cigarettes ● improving

Drinking alcohol ● improving

Using marijuana/hashish ● improving

Binge drinking ● improving

Eat 5+ fruits/vegetables per day* ● stasis

Consumed no sugar-sweetened beverages in past 7

days ● **

Reports no leisure-time physical activity for 60

min/day in past 7 days ● stasis

Reports ‘seriously considering suicide’ ● stasis

Environment

Bought sugar-sweetened beverages at school ● improving

*trend since 2012 **no trend data available due to methodology change

Key Take-Aways

Abuse of opiates has grown in Whatcom County since the early 2000s; Whatcom County crime

lab reports are more likely to have an opiate result than most other counties in the state, and

the rate of treatment for opiate addiction is higher than most other counties in the state.

Whatcom County ranks 3rd of 39 counties in negative effects from heroin abuse and 6th of 39

counties in negative effects from prescription drug use.

Whatcom County adults are more likely to drink to excess than adults in Washington state

overall, which imperils the health of the community.


Child & Family Wellbeing:

Whatcom County Health Indicators, 2016

What is Child & Family Wellbeing?

Child & Family Wellbeing is a key pillar of a healthy community. Circumstances in pregnancy through

early childhood are key predictors of health and wellbeing later in life. We envision a community where

all pregnant women and families with children are well-fed, safe, and equipped with resources and

knowledge to succeed in school, from kindergarten to high school graduation.


In social and economic factors, including the percentage of adults who have completed high school and

have some college education, as well as the percentage of babies born to single mothers, Whatcom

County is ranked 9th of 39 counties in Washington.

Child & Family Wellbeing Profile:

Percent of students who demonstrate expected skills in 6 of 6 domains: 51.5% (>WA: 39.5%)

Childhood food insecurity: 22.3% (=WA: 21.0%)

Graduation rate: 75.2% (=WA: 77.2%)

Maternal smoking in third trimester of pregnancy: 7.7% (=WA: 7.3%)

Low birth weight: 5% (<WA: 6%)

Prenatal care beginning in first trimester: 75% (=WA: 74.7%)

19-35-month olds up-to-date with vaccinations: 50% (<WA: 56%)

Teens up-to-date with vaccines: 28% (<WA: 34%)

WIC infants fully or partially breastfed: 44% (Whatcom County Health Dept WIC) (=WA: 41.3%)

Closer Look:

Readiness to Learn Inequities

In the Bellingham School District, as in Washington State, children from low-income families and

children with limited English are significantly less ready for kindergarten than their peers as measured

by skills in six domains of ability of average 5-year olds. These domains include social/emotional

functioning, physical functioning, language ability, and cognitive, literacy, and math abilities. These

kindergarten deficits are difficult to make up over time and can lead to lower levels of high school

completion and a host of vulnerabilities later in life.


Figure 7. Percentage of entering kindergarteners demonstrating

kindergarten-level skills in 6 of 6 domains, 2014-2015

Adverse Childhood Experiences (ACEs)

Adverse Childhood Experiences, or ACEs, are traumatic events that occur in childhood and cause stress

that changes a child’s brain development. Exposure to ACEs has been shown to have a dose-response

relationship with adverse health and social outcomes in adulthood, including but not limited to

depression, heart disease, COPD, risk for intimate partner violence, and alcohol and drug abuse.

Adverse Childhood Experiences include emotional, physical, or sexual abuse, emotional or physical

neglect, seeing intimate partner violence inflicted on one’s parent, having mental illness or substance

abuse in a household, enduring a parental separation or divorce, or having an incarcerated member of

the household.

Figure 8. Association between ACEs and Negative Outcomes

Source: Centers for Disease Control & Prevention, "Association between ACEs and negative outcomes"

Of Note:

49% of kindergarteners entering school are not ready for kindergarten in at least one domain in Whatcom County.

Nearly three quarters of teens in Whatcom County are not up-to-date with vaccinations.

Nearly a quarter of Whatcom County children lack access to adequate, nutritious food.

0%

10%

20%

30%

40%

50%

60%

All Low-income Limited English

Bellingham SD WA State

https://www.cdc.gov/violenceprevention/acestudy/about_ace.html


We can examine ACEs reported by adults in Washington and see that many Whatcom County adults are

bearing childhood traumas that put them at risk for poor health and social outcomes in adulthood.

Figure 9. Adverse Childhood Experiences reported by adults in Whatcom County and Washington State, 2011

Source: Washington State Behavioral Risk Factor Surveillance System

Child and teen vaccination rates

The percentage of toddlers and teens in Whatcom County that have completed the recommended

vaccine series is lower than Washington State overall. Lack of vaccination puts children and teens, as

well as immunocompromised people in Whatcom County like pregnant women, newborns, and the

elderly at risk of serious infectious diseases like pertussis and measles.

Figure 10. Rate of vaccine completion, toddlers and teens, 2014

Source: Washington State Department of Health

0%

10%

20%

30%

40%

50%

60%

70%

1+ ACEs 2+ ACEs 3+ ACEs 4+ACEs

Whatcom County Washington State

0%

10%

20%

30%

40%

50%

60%

19-35-month olds 13-17-year olds

Whatcom County WA State


Food insecurity is more complicated than simply going hungry; in fact, some families are food insecure

without being hungry because they are forced by their limited resources of time, money, and availability

to subsist on cheap convenience foods with little nutritional value. Low-income families that are food

insecure often live in a nexus of environmental factors that impede their ability to adopt healthy

lifestyles. According to the Food Research & Action Center, food insecure households tend to “lack

access to healthy, affordable foods,” be vulnerable to “cycles of food deprivation and overeating” due to

the instability of their financial and other resources, and are often at “greater exposure to marketing of

obesity-promoting products,” such as billboards and other advertisements.

Due to these and other environmental factors typical of the neighborhoods of low-income, food-

insecure families, childhood food insecurity has been shown by many studies to be related to

childhood overweight and obesity, in addition to children’s performance in school and social and

emotional development. Food insecurity is therefore a crucial, justice-oriented metric of childhood

wellbeing that affects their development and opportunities throughout the life course.

22% of all children in Whatcom County are food insecure, slightly higher than the rate in Washington.

Figure 11. Childhood food insecurity rate, all counties, Washington, 2013

Child & Family Wellbeing Data Sources:

The Washington Department of Vital Statistics measures causes of death and circumstances of

prenatally and birth. The Washington Department of Health measures vaccine rates and

conducts the BRFSS, which compiles rates of Averse Childhood Experiences. The Robert Wood

Johnson Foundation County Health Rankings aggregates BRFSS, Vital Statistics, US Census, and

business data to provide an overview of measures that matter for health. The Office of the

Superintendent for Public Instruction measures “Readiness to Learn” among entering

http://frac.org/pdf/frac_brief_understanding_the_connections.pdf


kindergarteners in Washington State in 6 domains: social-emotional, physical, language,

cognitive, literacy, and math. The USDA Women, Infant, and Children nutrition program

measures breastfeeding among its program recipients by individual WIC site—the numbers for

Whatcom County come from the Whatcom County Health Department WIC site. Low birth

weight is compiled in a seven-year period by RWJF County Health Rankings from WA State Vital

Statistics data (2007-2013). Childhood food insecurity is measured by the USDA and Feeding

America, and is characterized by a lack of consistent, sufficient, and varied nutrition.

Table 6. Child & Family Wellbeing: Whatcom County Health Indicators vs. Washington State, 2016

*Data aggregated from 2007-2013 *no trend data available

Key Take-Aways

Inequities in readiness for kindergarten make it harder for children of low-income families and

children with limited English skills to do well in school.

Over half of adults in Whatcom County endured in childhood at least one Adverse Childhood

Experience that puts them at greater risk of poor health outcomes, negative health behaviors,

and poor social outcomes.

Rates of vaccine completion are low in Whatcom County relative to the state and imperil the

health of the community; not only are children and teens affected, but vulnerable populations

like newborns, pregnant women, and the elderly are at increased risk for serious infectious

diseases when vaccine rates are low.

Low rates of low birth weight demonstrate exceptional health outcomes for newborns and

pregnant women and are an important source of health resilience.


Social Indicators

High school graduation rate ● stasis

Childhood food insecurity ● stasis

Entering kindergarteners demonstrating Readiness

to Learn in 6 of 6 domains* ● stasis

Health Indicators

Prenatal care in 1st tri. of pregnancy ● stasis

Maternal smoking in 3rd tri. of pregnancy ● stasis

Low birth weight* ● *

WIC infants partially or fully breastfed ● stasis

Toddlers up-to-date with vaccines ● **

Teenagers up-to-date with vaccines ● **


Health Delivery Systems:

Whatcom County Health Indicators, 2016

What are Health Delivery Systems?

Health Delivery Systems are a key pillar of a healthy community. Access to quality, affordable,

comprehensive care throughout the life course is an important facet of community wellness. We

envision a community where all people have access to quality, affordable preventive and acute care,

including mental health and dentistry, throughout the life course.


In health delivery factors including the ratio of physicians, dentists, and mental health providers to the

population, as well as certain measures of quality of care like the percentage of Medicare recipients that

receive mammograms and diabetic monitoring, Whatcom County ranks 17th out of 39 counties in

Washington—near the median score of Washington counties.

Health Delivery Systems Profile:

Ratio of residents to care providers:

o Primary care: 1,140:1 (=WA: 1,190:1)

o Dentists: 1,400:1 (>WA: 1,290:1)

o Mental health: 260:1 (<WA: 380:1)

Uninsured rate among adults below age 65: 8% (=WA: 8%)

10th graders who saw a doctor for a physical in the past year: 64.7% (=WA: 66.1%)

10th graders who saw a dentist for a checkup, exam, teeth cleaning, or other dental work:

78.8% of 10th graders in 2014 (=WA: 79.0%)

Closer Look:

Health Insurance Inequities

Though Whatcom County’s overall insurance rate is improving, there are inequities in health insurance

rate by race/ethnicity, with Hispanic/Latino adults being less likely to have insurance than other groups.

(Figure 12.)


Figure 12. Uninsured rate among adults <65 years, 2015

Preventive Hospital Stays

Preventable Hospital Stays (Figure 13) is the hospital discharge rate for ambulatory care-sensitive

conditions per 1,000 fee-for-service Medicare enrollees. Ambulatory care-sensitive conditions include:

convulsions, chronic obstructive pulmonary disease, bacterial pneumonia, asthma, congestive heart

failure, hypertension, angina, cellulitis, diabetes, gastroenteritis, kidney/urinary infection, and

dehydration. This measure is age-adjusted.

Hospitalization for diagnoses treatable in outpatient services suggests that the quality of care provided

in the outpatient setting was less than ideal. The measure may also represent a tendency to overuse

hospitals as a main source of care.

Lower numbers on this measure are the goal. Whatcom County ranks below the nation, but at the State

of Washington average. The data suggest that there are opportunities to better serve populations with

improved primary care delivery.

Of Note:

Whatcom County Medicare beneficiaries have a rate of 35 preventable hospital stays per 1,000 beneficiaries per year, equal to WA State (36 preventable hospital stays per 1,000 beneficiaries per year).

Racial/ethnic disparities in access to insurance and preventive care exist in Whatcom County.

0%

2%

4%

6%

8%

10%

12%

14%

All Black White Hispanic orLatino

Asian



Figure 13. Preventable Hospital Stays in Whatcom County

Preventive care inequities among Medicare beneficiaries

The preventive care received by Hispanic Medicare beneficiaries in Whatcom County is worse than the

preventive care received by White Medicare beneficiaries in Whatcom County.

High-quality preventive care, like seeing a primary care doctor frequently and monitoring one’s blood

sugar and blood pressure, can improve health outcomes. One way to look at possible differences in the

quality of care is to examine Medicare beneficiaries (people aged 65 years and older that have access to

government-sponsored health insurance) of different races and ethnicities, since they have the same

source of health insurance.

In order to understand if differences in quality of preventive care exist, we can look at a measure of the

overall quality of care of diabetes using a composite measurement called Prevention Quality Indicators

among Hispanic and White Medicare beneficiaries by county in Washington State. The data in the map

below show that Whatcom County has some of the state’s most glaring inequities in preventive care for

diabetes by race/ethnicity. White Medicare beneficiaries have 70 PQIs per 100,000 beneficiaries, while

Hispanic Medicare beneficiaries have 0 PQIs per 100,000 beneficiaries.

The preventive care received by Hispanic Medicare beneficiaries in Whatcom County is worse than the

preventive care received by White Medicare beneficiaries in Whatcom County. Greater access to quality

primary care among minority communities is an important strategy to mitigate these unequal health

outcomes.


Figure 14. Age-adjusted Prevention Quality Indicators for Diabetes, Medicare beneficiaries, 2014

Source: Center for Medicare & Medicaid Office of Minority Health, “Disparities Mapping Tool”

Emergency Room Use

Treating patients with low-acuity conditions in the emergency room is an issue because it is not the best

care setting for those conditions and it contributes to unnecessary overcrowding and increased cost.

Approximately 16.1% of emergency room visits to PeaceHealth St Joseph could be considered avoidable

given their low acuity. When viewed by payer, Medicare patients have the lowest rate of these visits,

representing nearly 6.5% of all Medicare emergency room encounters. Medicaid patients have the

highest rates, 18%. However, these rates have generally deceased since 2013.

Figure 15. Low-Acuity ED Visits by Payer, PeaceHealth St. Joseph, 2013-2015


Source: PeaceHealth Internal Data

Health Delivery Systems Data Sources:

The Washington Healthy Youth Survey measures health risk behaviors and outcomes among

6th, 8th, 10th, and 12th graders in Washington State, including health care access. The Robert

Wood Johnson Foundation County Health Rankings aggregates provider and US Census data to

provide an overview provider to resident ratios and overall clinical care relative measures. Enroll

America aggregates measures of insurance across all 50 states at the county and state level. The

Centers for Medicare & Medicaid Services Office of Minority Health Disparities Mapping Tool

shows measures of health inequities at the county level across the US for different health

delivery indicators.

Table 7. Health Delivery Systems: Whatcom County Health

Indicators vs. Washington State, 2016 and Local Trend since 2010


Primary Care Provider to resident ratio ● improving

Dentists to resident ratio ● improving

Mental Health Providers to resident ratio ● improving

Uninsured adults below age 65 ● improving

Saw a doctor for a physical in the past year (10th

graders) ● stasis

Saw a dentist for checkup, cleaning, or other work

in past year (10th graders) ● stasis

Key Take-Aways

Overall access to care in Whatcom County appears similar to Washington State as a whole

Significant disparities in uninsured rates and quality of preventive care received exist along

racial/ethnic gradients in Whatcom County.

About 15% of emergency room visits to PeaceHealth St Joseph, (18% for Medicaid visits) could

be considered avoidable given their low acuity.

Over a third of Whatcom County 10th graders did not have a physical in the past year, and

nearly a quarter did not see the dentist.


Equity: Whatcom County Health Indicators, 2016

What is Equity?

Equity is a key pillar of a healthy community. Health equity will be achieved when everyone is

given the opportunity to reach their full health potential. Affordable, safe housing, and employment

that allows sufficient resources to meet a household budget are important facets of equity.


In social and economic factors, including the percentage of children in poverty, violent crime, and

income inequality, Whatcom County is ranked 9th of 39 counties in Washington. This means that we’re

doing better than 3 out of 4 counties in Washington.

Equity Profile

Individuals living below the Federal poverty level: 16% (>WA: 13.5%)

Individuals in poverty or ALICE (Asset-Limited, Income Constrained, Employed): 41% (>WA: 32%)

Linguistic isolation: 4.7% (<WA: 7.8%)

Households with ‘severe housing problems,’ including cost-burdened housing: 22% (>WA: 18%)

Unemployment rate: 9% (=WA: 9%)

Veteran population: 9% (=WA: 11%)

Income inequality (ratio of income at the 80th percentile to income at the 20th percentile): 4.7 (=WA: 4.5)

Closer Look

Cost-burdened housing

Affordable housing is a key component of financial wellbeing and stability, and forms the basis of good

health. Whatcom County residents in nearly every area have high rates of high housing costs.

Figure 16. Percentage households where housing costs exceed

30% of household income, Whatcom County, 2010-2014

Source: Community Commons


High percentage of households struggling economically

Nearly half—41%--of Whatcom County residents either live in poverty or are

“Asset Limited, Income Constrained, Employed” (ALICE), meaning that they

are employed and make a wage above the poverty line but below the

threshold of a stable household budget for housing, food, transportation,

health care, and childcare.

Lack of economic resources imperils the health of these families and is a

significant detriment to their wellbeing.

Figure 17. Asset Limited, Income Constrained, Employed and Impoverished

Households, 2013

(Source: United Way of Whatcom County, “ALICE Report”)

Homelessness

Homelessness affects the health and wellbeing of 652 County residents. This population requires

linkages between health and social services to implement sustainable solutions to alleviate the burden

of homelessness. The count is a point in time enumeration that seeks to document the number of

people without a permanent, habitable place to call home. The data collected is critical to assessing

strategies and funding decisions by policymakers seeking to successfully meet the needs of homeless

individuals and families.

Equity Data Sources

The US Census measures the percentages of individuals living in poverty, in linguistic isolation, and

adults who are unemployed. The Robert Wood Johnson County Health Rankings provide estimates of

individuals who have ‘severe housing problems,’ meaning individuals who live with at least 1 of 4

conditions: overcrowding, high housing costs relative to income, or lack of kitchen or plumbing, as well

as a measure of income inequality at the county and state level, which is the ratio of household income

Of Note:

Changing demographics call for employers to monitor their workforce so that it reflects the composition and diversity of the community.

Increasing racial and ethnic diversity among licensed health professionals is particularly important because evidence indicates that among other benefits, it is associated with improved access for non-majority patient groups, increased patient satisfaction and an overall decrease in health care disparities.

.

0%

5%

10%

15%

20%

25%

30%

ALICE Households Households in Poverty


http://www.unitedwaywhatcom.org/sites/unitedwaywhatcom.oneeach.org/files/ALICE%20in%20Whatcom%20County.pdf


at the 80th percentile to income at the 20th percentile. Community Commons provides maps of census-

tract level data, including housing cost burden. The United Way of Whatcom County produced an in-

depth ALICE report that profiles the population of Whatcom that is above poverty but cannot afford a

household budget in Whatcom County.

Table 8. Social Equity: Whatcom County Health

Indicators vs. Washington State, 2016 and Local Trend since 2012


Individuals living below the poverty line ● stasis

ALICE Households ● **

Individuals over age 5 in linguistic isolation ● stasis

Households with ‘severe housing problems’ ● stasis*

Unemployment rate ● stasis

Income inequality ● **

*Baseline trend data aggregated from 2006-2010 **No trend data available

Key Take-Aways

Whatcom County does very poorly in measures of affordability—nearly half of Whatcom

residents cannot afford a basic household budget.

Levels of income inequality are similar to overall Washington State income inequality levels

A high percentage of cost-burdened housing in certain areas of Whatcom County imperils the

wellbeing of affected households and the community as a whole


VI. COMMUNITY CONVENING

Method

Key informant Interviews

PeaceHealth St. Joseph interviewed key informants from organizations throughout Whatcom County

representing perspectives from public health and medically underserved and vulnerable groups. The

interviews were conducted in advance of a community convening session that was held on May 19,

2016. The interviews were conducted to elicit perspectives on the health needs and gaps of the

community, to get feedback on the continuing relevance of the 2013 CHNA priorities and health

priorities found through the secondary data gathering of the 2016 CHNA, and to understand possible

solutions that local experts support.

Table 9. Organizations to which key informants belong, 2016 CHNA

Organization Population Served

Whatcom Community Foundation

All Whatcom County residents.

United Way of Whatcom County

All Whatcom County residents; particularly lower-income children and families, homeless, and immigrant and ethnic minority groups.

Chuckanut Health Foundation

All Whatcom County residents.

Sea Mar Community Health Center

All Whatcom County residents; particularly low-income children and families, homeless, and migrant and Spanish-speaking community.

Unity Care NW All Whatcom County residents; particularly low-income children and families, homeless and immigrant groups.

Whatcom County Health Department

All Whatcom County residents and people have mental illness and chemical dependency

Opportunity Council All Whatcom County residents; particularly low-income children and families, and people who are homeless

Whatcom Alliance for Health Advancement

All Whatcom County residents; particularly people are have lower incomes

Community Convening

The key informant interviews were conducted in preparation for a community convening session that

was held on May 19, 2016. More than 60 community leaders from local and regional public health,


health and social services, business, schools, and government were convened for approximately three

hours.

Community convening participants were led through a two-part process to identify gaps and needs and

then to rank community health improvement strategies that were organized into the community health

pillars. The process was designed to build on the considerable amount of time and effort that the

County Health Department, PeaceHealth and others have put into health assessments over the last

several years and to focus more on what we can actually do together to address the problems.

Following an update regarding secondary data and key informant perspectives for each of the

community health pillars, participants were asked to identify health and social needs /gaps, and strategy

opportunities. There was repetition and overlap between the key informant and group process input,

with the community convening participants adding infill to the key informant perspectives.


Gaps and opportunities

Table 10. Summary of health and social gaps/needs and strategy opportunities according to key

informants and community convening participants, by community health pillar, May 2016

Healthy, Active Living Child & Family Wellbeing

Needs/Gaps

Adult alcohol use

Teen tobacco use

Food and beverage

environments at school and

in the community

Elder isolation

Physical inactivity

Low immunization rates

Low graduation rates, particularly

among homeless and low-income

families

Maternal smoking during pregnancy

Unintended pregnancies

High cost of childcare

ACEs

Strategy

Opportunities

Community building and

collaboration to reduce

social isolation and

attachment to places

Address food insecurity and

healthy food availability

Reduce sugar-sweetened

beverage availability in

schools

Physical activity

Improve places to play and

be active, especially for

vulnerable populations

Community policies for

water fluoridation

Community Health Workers

Nontraditional prescriptions

for parks, healthy foods,

and other lifestyle changes

“Age in place” orientation

Community initiatives aimed at

providing new families useful

information, support, and ongoing care

Tax levy to support early childhood

services

Support child and families after ACEs

through evidence-based programs and

supports

Affordable child/infant care—

employer-sponsored childcare is a

solution

Additional supports for vulnerable

parents and children, including early

screening for developmental

disabilities

Family-friendly policies and

environments

North Sound ACH LARC project

Pregnancy supports

Education system

- Supports for bullying, depression

- Mentorship

- Change school start times

- Health literacy programs


Table 11. Summary of health and social gaps/needs and strategy opportunities according to key

informants and community convening participants, by community health pillar, May 2016

Health Delivery Systems Equity

Needs/ Gaps

High rates of opiate abuse/pain management, e-cigarette use, DUI rates

Racial/ethnic disparities in health insurance

Unaffordable health care; high deductible plans

Lack of dental and behavioral health care providers

High poverty and low educational attainment concentrated around Bellingham

Cost-burdened housing

Underrepresentation of non-majority persons at all levels of health and social service delivery systems

Poor economic opportunities

Lack of affordable child care for ALICE populations

Transportation barriers

Strategy

Opportunities

Access to health care:

More primary care and dental

providers that accept Medicaid and

Medicare; incentives for providers

Access to specialty care

Expanded practice for midlevel dental

care providers

Integration of medical care with:

Dental care

Mental health

Behavioral health

Mobile health services - rural

School-based health centers

Care coordination:

CHWs

Behavioral health/mental health and

chemical dependency

Chronic pain management

Heroin addiction treatment

Residential treatment services

Staff training on mental health crisis

response and rapid treatment

Suicide prevention/depression

management

Process:

Should focus on action

Include vulnerable populations

in planning and implementation

Should have a systemic

approach, including schools,

hospitals, and criminal justice

Economic barriers:

Living wage jobs

Vulnerable populations:

Housing affordability and infill

Culturally-appropriate care

Community Health Workers

Faith-based outreach

Improve affordability of quality

child care for ALICE and groups

in poverty

Bring care to the community

Homelessness:

Homeless one-stop center

Housing First policies


Strategies for Consideration in Implementation Plan

In the third part of the Community Convening, participants were provided with a packet of evidence-

based intervention strategies for each of the four community health pillars. Given their understanding

of community needs, participants were asked to collectively discuss strategies and then individually

select up to three evidence-based strategies within each pillar or write in a preferred strategy based on

the following criteria:

Magnitude of need

Organizational capacity in the community to address

Realistic to implement

Personal interest and passion

Table 12. Top evidence-based strategy solutions identified at the community convening

Strategy Needs Addressed

Healthy,

Active

Living

Community Health Worker

programs

Social isolation, chronic diseases, poor health

outcomes for undocumented/vulnerable groups,

transportation to health care appointments, chronic

disease management

School nutrition programs Chronic disease, access to healthy foods

School-based early intervention E-cigarette use, teen substance abuse

Child &

Family

Wellbeing

Prenatal and early childhood home

visiting programs

Care coordination for prenatal/postpartum

vulnerable mothers, infants, and children, maternal

smoking, ACEs

Levy to support early childhood

services

Affordable childcare, early developmental

screening, ACEs

‘Early Pathways’/home-based

mental health

Mental health services for families and children,

follow-up for high-risk mothers and children

Health

Delivery

Systems

Supported housing programs

Affordable housing, integration of primary care and

behavioral/dental/mental health care, care

coordination for vulnerable populations

Expand triage/crisis stabilization Improved mental health care, improved pain

management without opiates

Linking social services and medical

services Care coordination for vulnerable populations


Strategy Needs Addressed

Equity

School based health centers Access to health care for rural populations,

transportation barriers

Expanded Housing First programs

Care for the chronically mentally ill and homeless,

interface between criminal justice and health care

systems, affordable housing

Patient navigators

Poor access to social and health services for the

undocumented and isolated, chronic disease care

coordination and follow-up, transportation barriers


VII. IMPLEMENTATION PLAN

Selected Strategies

Adopted by our authorized body, the statement of strategies below will serve as the basis for a more

detailed CHNA implementation plan which will be published no later than November 30, 20162. The

Implementation Plan strategies summarized below were extrapolated from the data and from

community input. Our plan is comprehensive in the sense that there are strategies that impact the focus

areas within each of the community health pillars (and a number of strategies cross pillars); and the

display of strategies is not intended to be a complete listing of all of the activities that PeaceHealth will

undertake with its community partners to affect the health status of the community. Rather, it is a

statement of our community health priorities.

The PeaceHealth St. Joseph Board will approve an annual CHNA implementation plan that includes

tactics, timelines and metrics.

Table 13. 2016 PeaceHealth St. Joseph Implementation Plan Summary

Strategies Target population Potential partners

1. Ensure effective information exchange and care coordination for select populations (e.g. PHMG patients with complex health and psychosocial conditions who are served by multiple organizations) through the PeaceHealth Transforming Clinical Practice Initiative (TCPI) and other community

collaborations.

Children and adults

who receive

Medicaid and have

particularly complex

health psychosocial

conditions.

PeaceHealth Medical group

and the WAHA convened

Provider Council among other.

2. Increase participation in the PeaceHealth

employee wellness program, particularly for

caregivers at the lower end of the

compensation scale.

PeaceHealth

Caregivers

PeaceHealth HR; potential

partners could include union

representatives

2The final IRS regulations (published in the Federal Register on December 31, 2014) provide hospital facilities

with an additional four and a half months to adopt the implementation strategy, specifically requiring an

authorized body of the hospital facility to adopt an implementation strategy to meet the health needs identified

through a CHNA on or before the 15th day of the fifth month after the end of the taxable year in which the

hospital facility finishes conducting the CHNA.

http://www.gpo.gov/fdsys/pkg/FR-2014-12-31/html/2014-30525.htm


Strategies Target population Potential partners

3. As part of our ongoing efforts to create an inclusive organization that exercises cultural humility, recruit for and support a workforce that reflects the changing ethnic, racial and cultural diversity of the communities that we serve.

Hispanic, American

Indian, and other

non-majority

populations within

the County.

Workforce Development

Council; Community and

Technical colleges; Tribal

Health Centers and others

4. Advocate for and actively support the development of a comprehensive continuum of behavioral health services that includes access to crisis stabilization, transitional and long housing, substance abuse treatment services, and psychiatry that is available to children and seniors.

Children and adults

experiencing mental

health conditions

and/or substance

use disorders

Regional Behavioral Health

Organization (BHO); Compass

Health; Whatcom County

Health Department and

others

5. Work with local school districts, Head Start, and others to advocate for and support the wide-spread availability of early learning opportunities for all children.

Children between

the ages of 3 and 5

and their families,

particularly those

with lower incomes.

Head Start; area School

Districts; Whatcom Center for

Philanthropy and others

6. Develop a Community Health Worker

initiative that empowers individuals within

specific communities to serve a

liaison/linking/intermediary role between

health/social services and the community to

facilitate access and improve the quality and

cultural competence of service delivery.

Specific target

populations to be

determined

Whatcom Alliance for Health

Advancement; Chuckanut

Health Foundation and others

7. Advocate for and support policies and

programs geared to promoting healthy

nutrition, activity and lifestyles for youth

aged 8-11, with a particular focus on lower

income families.

Children between

the ages of 8-11 and

their families,

particularly those

with lower incomes.

YMCA, Bellingham Parks and

Rec, primary care physicians,

Whatcom Food Network and

others


Significant Health Needs Not Addressed by Implementation Plan

PeaceHealth St. Joseph has expertise in providing primary, specialty and tertiary care for Whatcom

County residents. We are able to address care access and coordination challenges for specific

populations, as well as employee wellness and cultural humility within our own organization. We look

forward to partnering with public health, local non-profit organizations and others to address the

broader issues of population and community health that are outlined in our CHNA.

The issues that we have prioritized with input from the community leverage our resources and expertise

and address significant community needs. In prioritizing some issues however, others are not directly

addressed. These include low graduation rates, immunization rates, the overall affordability of health

care and the effect of high deductible plans on lower income people not eligible for Medicaid; lack of

dental care, and poverty disparities.