Scenario

The scarcity of health resources continues to negatively affect communities across the country. Deciding how to allocate scarce resources creates significant ethical challenges for local policymakers and other stakeholders within the community.

You represent a local non-profit community health organization in Chicago. Your organization is compiling data to conduct a needs assessment in order to determine the feasibility of a new community-based mobile health clinic. You have been asked to review the most recent strategic plan for the city of Chicago.

The mobile clinic would offer free preventive care, urgent care, and chronic disease management services to vulnerable citizens of Chicago, who may not otherwise have the financial resources to access quality healthcare services. Your executive summary will be used in the development of a needs assessment for the project.

Your targeted population is an urban, low income community disenfranchised by current health reform policies, high unemployment, a shortage of primary care physicians, and divisive partisan attitudes regarding entitlement programs. The goal of the community-based clinic is to work collaboratively with local health facilities to reduce costs, improve access, and to enhance the quality of care for underserved communities.

Instructions

Review the community health needs assessment linked here that was conducted by the Health Impact Collaborative of Cook County:

POST-South-Report.pdf

Pages 37 – 49 of the report highlight challenges facing the city with respect to costs, access, and quality of care issues. Write an executive summary addressing the following questions:

What are some of socio-economic factors that affect access to care based on the findings in the report?

What are the critical focus areas identified in the report?

Based on the report’s content, how might the use of a mobile health clinic address the critical focus areas?

What are some of the potential barriers to success for a mobile health clinic?

Health Impact Collaborative of Cook County

Community Health Needs Assessment South Region

healthimpactcc.org/reports2016

June 2016

» Advocate Children’s Hospital » Advocate Christ Medical Center » Advocate South Suburban Hospital » Advocate Trinity Hospital » Chicago Department of Public Health » Cook County Department of Public Health » Illinois Public Health Institute

Participating hospitals and health departments:

» Mercy Hospital and Medical Center » Provident Hospital – Cook County Health and

Hospital System » Roseland Community Hospital » Park Forest Health Department » South Shore Hospital » Stickney Public Health District

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Table of Contents Table of Contents ……………………………………………………………………………………………………………. 1

Executive Summary – South Region ………………………………………………………………………………… 4

Community description for the South region of the Health Impact Collaborative of ………….. 5

Collaborative structure …………………………………………………………………………………………………………. 5

Stakeholder engagement ……………………………………………………………………………………………………. 5

Mission, vision, and values …………………………………………………………………………………………………….. 6

Assessment framework and methodology …………………………………………………………………………… 7

Significant health needs ……………………………………………………………………………………………………….. 8

Key assessment findings ……………………………………………………………………………………………………….. 9

Introduction …………………………………………………………………………………………………………………… 13

Collaborative Infrastructure for Community Health Needs Assessment (CHNA) in Chicago and Cook County ……………………………………………………………………………………………………………….. 13

Community and stakeholder engagement ……………………………………………………………………….. 15

Formation of the South Stakeholder Advisory Team …………………………………………………………… 17

South Leadership Team ………………………………………………………………………………………………………. 18

Steering Committee ……………………………………………………………………………………………………………. 18

Mission, vision, and values …………………………………………………………………………………………………… 19

Collaborative CHNA – Assessment Model and Process ………………………………………………… 20

Community Description for the South Region ……………………………………………………………….. 21

Overview of Collaborative Assessment Methodology ………………………………………………….. 25

Methods – Forces of Change Assessment (FOCA) and Local Public Health System Assessment (LPHSA) …………………………………………………………………………………………………………….. 25

Methods – Community Health Status Assessment ………………………………………………………………. 26

Methods – Community Themes and Strengths Assessment ………………………………………………… 28

Community Survey – methods and description of respondents in South region ……………… 29

Focus Groups – methods and description of participants in South region ………………………. 30

Prioritization process, significant health needs, and Collaborative focus areas …………… 32

Health Equity and Social, Economic, and Structural Determinants of Health ………………. 37

Health inequities …………………………………………………………………………………………………………………. 37

Economic inequities ……………………………………………………………………………………………………………. 39

Education inequities ……………………………………………………………………………………………………………. 39

Inequities in the built environment ………………………………………………………………………………………. 39

Inequities in community safety and violence ……………………………………………………………………… 39

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Structural racism …………………………………………………………………………………………………………………. 40

The importance of upstream approaches …………………………………………………………………………. 40

Key Findings: Social, Economic, and Structural Determinants of Health ………………………. 41

Social Vulnerability Index and Child Opportunity Index ……………………………………………………… 41

Social Vulnerability Index …………………………………………………………………………………………………. 41

Childhood Opportunity Index ………………………………………………………………………………………….. 42

Poverty, Economic, and Education Inequity ………………………………………………………………………. 43

Poverty …………………………………………………………………………………………………………………………….. 43

Unemployment………………………………………………………………………………………………………………… 47

Education ………………………………………………………………………………………………………………………… 49

Built environment: Housing, infrastructure, transportation, safety, and food access—Social, economic, and structural determinants of health ……………………………………………………………… 52

Housing and Transportation …………………………………………………………………………………………….. 52

Food access and food security……………………………………………………………………………………….. 53

Environmental concerns ………………………………………………………………………………………………….. 53

Safety and Violence—Social, economic, and structural determinants of health ………………. 56

Structural racism and systems-level policy change—Social, economic, and structural determinants of health ……………………………………………………………………………………………………….. 57

Health Impacts—Social, economic, and structural determinants of health ………………………. 58

Key Findings: Mental Health and Substance Use ………………………………………………………….. 61

Overview …………………………………………………………………………………………………………………………….. 61

Scope of the issue – Mental health and substance use ……………………………………………………… 63

Mental health ………………………………………………………………………………………………………………….. 63

Substance use …………………………………………………………………………………………………………………. 66

Youth substance use ……………………………………………………………………………………………………….. 67

Community input on mental health and substance use …………………………………………………. 72

Key Findings: Chronic Disease……………………………………………………………………………………….. 73

Overview …………………………………………………………………………………………………………………………….. 73

Mortality related to chronic disease …………………………………………………………………………………… 75

Obesity and diabetes …………………………………………………………………………………………………………. 77

Asthma ……………………………………………………………………………………………………………………………….. 78

Health behaviors …………………………………………………………………………………………………………………. 79

Persons living with HIV/AIDS ………………………………………………………………………………………………… 80

Community input on chronic disease prevention ………………………………………………………………. 81

Key Findings: Access to Care and Community Resources ……………………………………………. 82

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Overview …………………………………………………………………………………………………………………………….. 82

Insurance coverage …………………………………………………………………………………………………………… 84

Self-reported use of preventative care ………………………………………………………………………………. 84

Provider availability …………………………………………………………………………………………………………….. 85

Prenatal care ……………………………………………………………………………………………………………………… 87

Cultural competency and cultural humility ………………………………………………………………………… 87

Conclusion – Reflections on Collaborative CHNA ………………………………………………………… 88

*Appendices are included as a separate document

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Executive Summary – South Region The Health Impact Collaborative of Cook County is a partnership of hospitals, health departments, and community organizations working to assess community health needs and assets, and to implement a shared plan to maximize health equity and wellness in Chicago and Cook County. The Health Impact Collaborative was developed so that participating organizations can efficiently share resources and work together on Community Health Needs Assessment (CHNA) and implementation planning to address community health needs – activities that every nonprofit hospital is now required to conduct under the Affordable Care Act (ACA). Currently, 26 hospitals, seven health departments, and nearly 100 community organizations across Chicago and Cook County are partners in the Health Impact Collaborative. The Illinois Public Health Institute (IPHI) is serving as the process facilitator and backbone organization for the collaborative CHNA and implementation planning processes. A CHNA summarizes the health needs and issues facing the communities that hospitals, health departments, and community organizations serve. Implementation plans and strategies serve as a roadmap for how the community health issues identified in the CHNA are addressed. Given the large geography and population of Cook County, the Collaborative partners decided to conduct three regional CHNAs. Each of the three regions, North, Central, and South, include both Chicago community areas and suburban municipalities. IPHI and the Collaborative partners are working together to design a shared leadership model and collaborative infrastructure to support community-engaged planning, partnerships, and strategic alignment of implementation, which will facilitate more effective and sustainable community health improvement in the future.

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Community description for the South region of the Health Impact Collaborative of Cook County This CHNA report is for the South region of the Health Impact Collaborative of Cook County. As of the 2010 census, the South region had 2,081,036 residents which represents a 5% decrease in total population from the year 2000. Non-Hispanic whites and non-Hispanic blacks experienced the largest population decreases. Between 2000 and 2010 the non- Hispanic white population decreased by 163,693 residents and the non-Hispanic black population decreased by 65,704 residents. Despite an overall population decrease in the South region from 2000 to 2010, the Hispanic/Latino and Asian populations increased by 86,747 and 15,846 residents, respectively, during the same time period. Children and adolescents represent more than a quarter (26%) of the population in the South region. The majority of the population is between ages 18 and 64 and approximately 12% of the population is older adults aged 65 and over. Overall, the South region is extremely diverse and several priority groups were identified during the assessment process. Collaborative structure Six nonprofit hospitals, one public hospital, four health departments, and approximately 30 stakeholders partnered on the CHNA for the South region. The participating hospitals are Advocate Christ Medical Center and Children’s Hospital, Advocate South Suburban Hospital, Advocate Trinity Hospital, Mercy Hospital and Medical Center, Provident Hospital of Cook County, and Roseland Community Hospital. Health departments are key partners in leading the Health Impact Collaborative and conducting the CHNA. The participating health departments in the South region are Chicago Department of Public Health, Cook County Department of Public Health, Park Forest Health Department, and Stickney Health Department. The leadership structure of the Health Impact Collaborative includes a Steering Committee, Regional Leadership Teams, and Stakeholder Advisory Teams. Collectively, the hospitals and health departments serve as the Regional Leadership Team. Stakeholder engagement The Health Impact Collaborative of Cook County is focused on community-engaged assessment, planning, and implementation. Stakeholders and community partners have been involved in multiple ways throughout this assessment process, both in terms of community input data and as decision-making partners. To ensure meaningful ongoing

Priority populations identified during the assessment process include: • Children and youth • Diverse racial and ethnic communities • Homeless individuals and families • Incarcerated and formerly incarcerated • Immigrants and refugees, particularly

undocumented immigrants • Individuals living with mental health

conditions • LGBQIA and transgender individuals • Older adults and caregivers • People living with disabilities • Unemployed • Uninsured and underinsured • Veterans and former military

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involvement, each region’s Stakeholder Advisory Team has met monthly during the assessment phase to provide input at every stage and to engage in consensus-based decision making. Additional opportunities for stakeholder engagement during assessment have included participation in hospitals’ community advisory groups, community input through surveys and focus groups, and there will be many additional opportunities for engagement as action planning begins in the summer of 2016. The Stakeholder Advisory Team members bring diverse perspectives and expertise, and represent populations affected by health inequities including diverse racial and ethnic groups, immigrants and refugees, older adults, youth, homeless individuals, unemployed, uninsured, and veterans. Mission, vision, and values IPHI facilitated a three-month process that involved the participating hospitals, health departments, and diverse community stakeholders to develop a collaborative-wide mission, vision, and values to guide the CHNA and implementation work. The mission, vision, and values have been at the forefront of all discussion and decision making for assessment and will continue to guide action planning and implementation.

Mission: The Health Impact Collaborative of Cook County will work collaboratively with communities to assess community health needs and assets and implement a shared plan to maximize health equity and wellness. Vision: Improved health equity, wellness, and quality of life across Chicago and Cook County

Values: 1) We believe the highest level of health for all people can only be achieved through the

pursuit of social justice and elimination of health disparities and inequities. 2) We value having a shared vision and goals with alignment of strategies to achieve

greater collective impact while addressing the unique needs of our individual communities.

3) Honoring the diversity of our communities, we value and will strive to include all voices through meaningful community engagement and participatory action.

4) We are committed to emphasizing assets and strengths and ensuring a process that identifies and builds on existing community capacity and resources.

5) We are committed to data-driven decision making through implementation of evidence-based practices, measurement and evaluation, and using findings to inform resource allocation and quality improvement.

6) We are committed to building trust and transparency through fostering an atmosphere of open dialogue, compromise, and decision making.

7) We are committed to high quality work to achieve the greatest impact possible.

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Assessment framework and methodology The Collaborative used the MAPP Assessment framework. The MAPP framework promotes a system focus, emphasizing the importance of community engagement, partnership development, shared resources, shared values, and the dynamic interplay of factors and forces within the public health system. The four MAPP assessments are:

• Community Health Status Assessment (CHSA)

• Community Themes and Strengths Assessment (CTSA)

• Forces of Change Assessment (FOCA)

• Local Public Health System Assessment (LPHSA) The Health Impact Collaborative of Cook County chose this community-driven assessment model to ensure that the assessment and identification of priority health issues was informed by the direct participation of stakeholders and community residents. The four MAPP assessments were conducted in partnership with Collaborative members and the results were analyzed and discussed in monthly Stakeholder Advisory Team meetings. Community Health Status Assessment (CHSA). IPHI worked with the Chicago Department of Public Health and Cook County Department of Public Health to develop the Community Health Status Assessment. This Health Impact Collaborative CHNA process provided an opportunity to look at data across Chicago and suburban jurisdictions and to share data across health departments in new ways. The Collaborative partners selected approximately 60 indicators across seven major categories for the Community Health Status Assessment.1 In keeping with the mission, vision, and values of the Collaborative, equity was a focus of the Community Health Status Assessment. Community Themes and Strengths Assessment (CTSA). The Community Themes and Strengths Assessment included both focus groups and community resident surveys. Approximately 5,200 surveys were collected from community residents through targeted outreach to communities affected by health disparities across the city and county between October 2015 and January 2016. About 2,250 of the surveys were collected from residents in the South region. The survey was disseminated in four languages and was available in paper and online formats. Between October 2015 and March 2016, IPHI conducted eight focus groups in the South region. Focus group participants were recruited from populations that are typically underrepresented in community health assessments including diverse racial and ethno-cultural groups; immigrants; limited English speakers; families with children; older adults; lesbian, gay, bisexual, queer, intersex, and asexual (LGBQIA) individuals; transgender individuals; formerly incarcerated adults; individuals living with mental illness; and veterans and former military. 1 The seven data indicator categories—demographics, socioeconomic factors, health behaviors, physical environment, healthcare and clinical care, mental health, and health outcomes—were adapted from the County Health Rankings model.

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Forces of Change Assessment (FOCA) and Local Public Health System Assessment (LPHSA). The Chicago and Cook County Departments of Public Health each conducted a Forces of Change Assessment and a Local Public Health System Assessment in 2015, so the Collaborative was able to leverage and build off of that data. IPHI facilitated interactive discussions at the August and October 2015 Stakeholder Advisory Team meetings to reflect on the findings, gather input on new or additional information, and prioritize key findings impacting the region. Significant health needs Stakeholder Advisory Teams in collaboration with hospitals and health departments prioritized the strategic issues that arose during the CHNA. The guiding principles and criteria for the selection of priority issues were rooted in data-driven decision making and based on the Collaborative’s mission, vision, and values. In addition, partners were encouraged to prioritize issues that will require a collaborative approach in order to make an impact. Very similar priority issues rose to the top through consensus decision making in the South, Central, and North regions of Chicago and Cook County.

Based on community stakeholder and resident input throughout the assessment process, the Collaborative’s Steering Committee made the decision to establish Social, Economic and Structural Determinants of Health as a collaborative-wide priority. Regional and collaborative-wide planning will start in summer 2016 based on alignment of hospital-specific priorities.

Through collaborative prioritization processes involving hospitals, health departments, and Stakeholder Advisory Teams, the Health Impact Collaborative of Cook County identified four focus areas as significant health needs:

• Improving social, economic, and structural determinants of health while reducing social and economic inequities. *

• Improving mental health and decreasing substance abuse. • Preventing and reducing chronic disease, with a focus on risk factors –

nutrition, physical activity, and tobacco. • Increasing access to care and community resources.

* All hospitals within the Collaborative will include the first focus area – Improving social, economic, and structural determinants of health – as a priority in their CHNA and implementation plan. Each hospital will also select at least one of the other focus areas as a priority.

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Key assessment findings

1. Improving social, economic, and structural determinants of health while reducing social and economic inequities.

The social and structural determinants of health such as poverty, unequal access to healthcare, lack of education, structural racism, and environmental conditions, are underlying root causes of health inequities.2 Additionally, social determinants of health often vary by geography, gender, sexual orientation, age, race, disability, and ethnicity.2 The strong connections between social, economic, and environmental factors and health are apparent in Chicago and suburban Cook County, with health inequities being even more pronounced than most of the national trends. Figure 1.1. Summary of key assessment findings related to the social, economic, and structural determinants of health

2 Centers for Disease Control and Prevention. (2013). CDC Health Disparities and Inequalities Report. Morbidity and Mortality Weekly Report, 62(3)

Social, Economic, and Structural Determinants of Health Poverty and economic equity. African Americans, Hispanic/Latinos, and Asians have higher rates of poverty than non-Hispanic whites and lower annual household incomes. More than half (54%) of children and adolescents in the South region live at or below the 200% Federal Poverty Level. In Chicago and suburban Cook County, residents in communities with high economic hardship have life spans that are five years shorter on average compared to other areas of the county. Unemployment. The unemployment rate in the South region from 2009 to 2013 was 17% compared to 9.2% overall in the U.S. African American/blacks in Chicago and suburban Cook County have an unemployment rate that is three times higher (22.5%) than the rate for whites (7.5%) and Asians (7.1%). Education. The rate of poverty is higher among those without a high school education, and those without a high school education are more likely to develop chronic illnesses. The overall high school graduation rates in the South region (83%) are only slightly lower than the state and national averages of 85% and 84%, respectively. However, the high school graduation rates for the South region (83%) are substantially lower than those in neighboring DuPage (94%) and Will (91%) counties. Housing and transportation. Many residents indicated poor housing conditions in the South region and a lack of quality affordable housing that leads to cost-burdened households, crowded housing, and homelessness. There are inequities in access to public transportation options and transportation services for multiple communities in the city and suburbs of the South region. Environmental concerns. Climate change, poor air quality, changes in water quality, radon, and lead exposure are environmental factors that were identified as having the potential to affect the health of residents in the South region. The South region is particularly vulnerable to natural and manmade disasters and disease outbreaks due to its areas of high economic hardship and low economic opportunity. In addition, vacant or foreclosed housing has contributed to the long-term economic decline and divestment in the South region and has caused a noticeable increase in crime. Safety and Violence. Firearm-related and homicide mortality are highest among Hispanic/Latinos and African American/blacks in the South region. Police violence, gang activity, drug use/drug trafficking, intimate partner violence, child abuse, and robbery were some of the safety concerns identified by residents in the South region. The South and Central regions of the collaborative are disproportionately affected by trauma, safety issues, and community violence.

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Disparities related to socioeconomic status, built environment, safety and violence, policies, and structural racism were identified in the South region as being key drivers of community health and individual health outcomes. 2. Improving mental health and decreasing substance abuse.

Mental health and substance use arose as key issues in each of the four assessment processes in the South region. Community mental health issues are exacerbated by long- standing inadequate funding as well as recent cuts to social services, healthcare, and public health. The World Health Organization (WHO) emphasizes the need for a network of community-based mental health services.3 The WHO has found that the closure of mental health hospitals and facilities is often not accompanied by the development of community- based services and this leads to a service vacuum.3 In addition, research indicates that better integration of behavioral health services, including substance use treatment into the healthcare continuum, can have a positive impact on overall health outcomes.4 Figure 1.2. Summary of key assessment findings related to mental health and substance use

Mental Health and Substance Use Community-based …

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