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«MONTEFIORE MEDICAL CENTER COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION STRATEGY Montefiore Medical Center Community Health Needs Assessment ...»

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MONTEFIORE MEDICAL CENTER

COMMUNITY HEALTH NEEDS ASSESSMENT

AND IMPLEMENTATION STRATEGY

Montefiore Medical Center

Community Health Needs Assessment and Implementation Strategy 2013

TABLE OF CONTENTS Page

1. Executive Summary 4

COMMUNITY HEALTH NEEDS ASSESSMENT 9

2. Introduction/This Is Montefiore 9 a. Montefiore’s Mission and Strategy 9 b. Enhancing Community Access to Health Insurance 11

3. Definition and Description of the Community/Service Area 12 a. The Population of the Bronx 14 b. Health Disparities 15 c. Medically Underserved Communities 16

4. Assessment of Community Health Need 16 a. Description of Process and Methods 16 i. Data Sources 16 ii. Collaborations/Partnerships 20

1. Partners/Organizations 22 a. Names of organizations 22 b. Summary of Input Provided from Primary 26 Data Sources c. Which medically underserved, low income 28 or minority populations represented

5. Identification of Community Health Needs 29 a. Secondary Data Analysis 29 b. Primary Data Analysis 82 i. Focus Group 83

1. Process 83

2. Methods 83

3. Demographics 84

4. Results 90 ii. Community Forum 109

1. Purpose/Process 109

2. Methods 109

3. Demographics 110

4. Results 114 iii. Online Survey 118

1. Process 1

–  –  –

Executive Summary 1.

The Community Health Needs Assessment Requirement The Affordable Care Act requires hospitals to assess and address the health needs of the communities they serve. This Community Health Needs Assessment meets the first component of these requirements, providing a report of the process, methods and results of a comprehensive assessment of the needs of the community served by Montefiore Medical Center. The second component, which will be developed over the next few months, will encompass the Implementation Strategy, which will further discuss the significant health needs of the community, describe the programs and strategies to address these significant health needs, and delineate the metrics to be used to evaluate the impact of these strategies.

Montefiore Medical Center’s Community Commitment Montefiore is a leader in community health and has a long history of developing innovative approaches to care and tailoring programs to best serve the changing needs of its community.

These include, but are not limited to the following: Community Service Plan, Community Services Strategy, Accountable Care Organization, Patient-Centered Medical Home, Disease Management Programs, and Community Outreach. The integration of these innovative approaches serves Montefiore well in its services to its community.

Montefiore embraces its social responsibility and defines its role broadly, promoting wellness in addition to treating disease and addressing needs ranging far beyond medical care. We extend this responsibility to the care of our employees and medical staff, many of whom live in the surrounding community.

The population Montefiore serves is one of the most diverse in the nation. Montefiore has been an incubator for programs that improve patients’ access to culturally appropriate services, and its progressive financial aid policy and robust entitlement enrollment program support access to care for those in need. Historically, Montefiore has viewed community service and community health improvement as a delivery system challenge, reaching out to serve the under-resourced.

Services to the community are an explicit and essential component of Montefiore’s mission and one of its most valued traditions. The medical center has a long history of reaching beyond the walls of its hospitals to identify and meet the needs of its community and has been a national leader in organizing and expanding community-based services. Our commitment to the community has required a multifaceted, continually evolving response, in which the unique capacities of the academic medical center are mobilized to improve the lives of the people and the communities we serve -- not just medically, but socially, economically and environmentally, wherever and whenever our resources can make a difference.

For much of our history, community service at Montefiore has been a vital grassroots movement. When pressing needs arose that lay beyond the purview of traditional health care, physicians, nurses, social workers, staff and community partners have stepped in to address them. These programs tackle a remarkable range of health problems in the Bronx; from the epidemics of diabetes and obesity to high rates of teen pregnancy. They come in an equally impressive range of sizes; from an online guide to hundreds of social services to complex federally-funded agencies with hundreds of staff. With the understanding that the practice of medicine is a service to the community, we have defined community service to include those efforts at preventing disease, enhancing wellbeing and enacting social change that go beyond traditional health care and its fee-for-service reimbursement system.

Montefiore participates in a variety of organized partnerships and collaboratives, working with other providers in the Bronx, the New York City Department of Health and Mental Hygiene, community-based organizations in the Bronx and members of the community in planning and developing initiatives aimed at improving the health of the people of the Bronx.





Definition and Description of the Community Montefiore has identified the Bronx as its primary service area. More than 85% of Montefiore’s hospitals’ discharges are residents of the Bronx, and it is within this geographic area that Montefiore has distributed the vast majority of its community-based primary care and specialty ambulatory services.

The Bronx has been an epicenter of the asthma, HIV, and drug epidemics and also has excess mortality rates from heart disease, stroke, and diabetes compared to city-wide and national averages. As the Bronx mortality rates remain significantly high, the number of physicians in the Bronx continues to dwindle.

Bronx County is New York City’s first borough to have a majority of people of color and it is the only borough with a Latino majority. The Bronx is also the youngest county in New York State with 39.2% children and one of only five U.S. counties with more than 30% single family households. Furthermore, with the Bronx has qualified as a Whole County Health Professions Shortage Area (HPSA) by HRSA, since 2008, as almost half (45%) of our population is currently living in a geographic area that is a documented federally designated HPSA.

Assessment of Community Health Needs The process to identify the needs of the community involved the collection of secondary and primary data.

Multiple conversations and meetings were convened internally and with external partners, and a thorough review of the data was conducted, all of which will frame the development of the Implementation Strategy. In this Community Health Needs Assessment, these collaborations and partnerships are described.

Multiple data sources were used to support the identification and selection of the priority items which were identified, selected, and reviewed with the partners. A listing and brief summary of the data sources used to complete the secondary data analysis that were used to identify the issues of concern beyond experience and direct observation are included in this report.

The collection of primary data from a representative sample of the Bronx residents was an important element of the development of the Community Health Needs Assessment. The Bronx is an ethnically diverse borough with a population of 1.37 million that despite economic and environmental improvements since the 1970’s continues to include numerous groups with difficulties such as low health literacy, limited income, English proficiency, and lack of insurance or insurance knowledge. To capture the voices of various sectors of Bronx community residents and workers from various perspectives, a mixed-methods approach to data collection consisting of online surveys, focus groups and participation in directed community forums were used.

Montefiore contracted with the Bronx Health Link, a not for profit 501c3 organization in the Bronx, to facilitate the implementation of the primary data collection process for the Community Health Needs Assessment within the Bronx and to assist in the facilitation of these community level connections.

Using data collected through Montefiore, the District Public Health Office and other sources, the impact on the community’s health by the interventions implemented can be measured and analyzed. As the borough with the smallest non-Hispanic White population in New York City, focusing on disparities is inherent in everything that Montefiore accomplishes. The priority areas selected and each of the planned interventions focus on specific priority populations and address the ethnic and cultural disparity defined in the indicators for the population served by Montefiore.

Collaborations/Partnerships Through collaborations with large stakeholder partner groups and awareness of the status of Bronx County, as the county with the lowest ranking health status in New York State (62 out of 62), as reported in the 2013 County Health Rankings from the Robert Wood Johnson Foundation, stakeholder groups have agreed on the significant health issues impacting the community. The significant areas are among the identified areas for which both the data and Montefiore have determined a community need.

Montefiore collaborated with the New York City Department of Health as a part of identifying the Take Care New York 2016 Priorities and identifying the points of alignment between the New York State priorities, the New York City Goals and the needs identified through the Community Health Needs Assessment process. In reviewing the full list of items from New York State and New York City, it was very clear that many of their targeted areas, such as Healthy Eating: Active Living, Tobacco Free Living, and Children and Youth agenda items were areas that there was inter-organizational synergy.

In addition to this collaboration with the New York City Department of Health and Mental Hygiene that Montefiore had used to gain input, Montefiore worked closely with its communities and ensured that community participation occurred by working with a variety of community advisory boards (CABs). Montefiore participates in a variety of organized partnerships and collaboratives, working with other providers in the Bronx, and we worked extensively with representatives of the affected communities through these CABs to identify health care needs and determine the appropriate configuration of services. Beyond the formal structure that Montefiore established to gain input from the communities it serves, the medical center participates in a variety of organized partnerships and collaboratives, working with other providers in the Bronx, the NYCDOHMH, community-based organizations in the Bronx and members of the community in planning and developing initiatives aimed at improving the health of the people of the Bronx. Montefiore has developed additional approaches to the assessment of community needs and health priorities and to the establishment of partnerships with community organizations.

In addition, Montefiore developed a community level approach involving relevant organizations, which are in the specific community and are interested in the particular health issues being addressed. This provides for a closer alignment between the community level goals of Montefiore and the organizational goals of the community organizations. This approach is the Collective Action to Transform Community Health (CATCH) Program, which is a community level coalition bringing together aspects of the community that may have a significant impact on community health.

The report provides information on the individuals, groups and organizations that are participating in the focused Implementation Plan activities that evolve out of the CHNA process.

As the CHNA process was conducted simultaneously with the New York State Community Service Plan (CSP) review, there is strong alignment between the areas of focus in this report and the areas presented in the CSP. Montefiore will continue to work with its partners on existing program initiatives.

Prioritization of Community Health Needs The primary and secondary data collection process illuminated four major categories of health needs that were both important across the populations surveyed and reflected in the data as

critical. The four areas identified are:

(1) Improve Overall Health Status and Reduce Health Disparities, (2) Prevention of Chronic Disease, (3) Prevent HIV/STD’s Vaccine Preventable Diseases and Healthcare Associated Infections, and (4) Promotion of Healthy Women Infants and Children.

Measures and Identified Resources to Meet Identified Needs Internal Resources and Measures Montefiore is a leader in community health and has a long history of developing innovative approaches to care and tailoring programs to best serve the changing needs of its community.

These include, but are not limited to the following: Community Service Plan, Community Services Strategy, Accountable Care Organization, Patient-Centered Medical Home, Disease Management Programs, and Community Outreach. The integration of these innovative approaches serves Montefiore well in its services to its community.

Montefiore has a vast portfolio of programs and services that address a majority of the significant community health needs identified in the Community Health Needs Assessment.

The breadth and depth of the programs and services vary, but each address a need identified in the community.

Across the identified significant priority areas, numerous indicators with associated metrics are described which will be utilized to demonstrate improvements needed to provide evidence of the impact of Montefiore’s efforts in addressing the health needs of its community.



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