STEERING COMMITTEE MEETING FEBRUARY 24 2016 1 00

STEERING COMMITTEE MEETING FEBRUARY 24, 2016 1: 00 P. M. – 4: 00 P. M. QUIET WATERS PARK ANNAPOLIS, MARYLAND

Meeting Agenda Welcome and Introductions Update: Healthy Anne Arundel Month 2015 Community Health Needs Assessment Pamela Brown, Ph. D Strategic Planning Work Next Steps

UPDATE HEALTHY ANNE ARUNDEL MONTH APRIL 2016 CAROLYN RYAN CHAIR, HAAM PLANNING COMMITTEE

Healthy Anne Arundel Coalition History Founded in December 2011 First assessment and action plan in 2012 and 2013 Vision: Healthy County, Healthy People Mission: Working together as a community to promote the health and wellness of Anne Arundel County residents Guiding Principles: Utilize Existing Groups Flexibility Inclusive and Welcoming Embrace Change Transparent

Healthy Anne Arundel Coalition Organizational Structure Planning & Assessment Subcommittee Obesity Reduction & Prevention Subcommittee Co-Occurring Disorders Subcommittee Leadership Subcommittee Community Engagement Subcommittee Promotion & Publicity Subcommittee

Healthy Anne Arundel Coalition Community Health Improvement Process

Anne Arundel County Community Health Needs Assessment 2015 A collaboration between: • • Anne Arundel Medical Center Anne Arundel County Mental Health Agency Anne Arundel County Department of Health University of Maryland Baltimore Washington Medical Center Written and researched by Pamela M. Brown, Ph. D. and Bikash Singh

2015 Data Collection Summative Data • Update of Census Tables and American Community Survey, 1 year estimates • Refreshed data from public reports • 17 data sets related to family vulnerability and geography of need, 2015 • De-emphasis on race analyses • Extensive use of community networks for verification/link to qualitative data Formative Data • 10 Key Stakeholder interviews • 8 focus groups • 2013 Maryland Youth Risk Behavior Survey • 2014 Criminal Justice Coordinating Council Report • 2015 Housing Commission Report • 2014 Transportation Commission Report • 2014 AA County Mental Health Report

The State of the County Anne Arundel County population is 556, 348; a growth of 11. 2% since 2000 Senior population (over 65) increasing from 99, 086 (2013) to 140, 000 by 2030 The Hispanic population is now at 6. 4% or 34, 854 residents. There are 33, 352 residents (6. 3%) living below poverty, a slight dip from 2011 Anne Arundel County is one of most expensive places to live in the state The gap between rich and poor has widened since 2010. The majority of negative social/ health indicators polarized Northern and South All of our rivers are “impaired” under the Clean Water Act Anne Arundel was given an F by the American Lung Association for an average of 23 unhealthy, high ozone days every year between 2011 and 2013.

Quick Facts • Life expectancy has risen to an average of 79. 8 years • Cancer is leading cause of death in the county, followed by heart disease. • 21. 6% less primary care physicians and 8. 5% less dentists per 100 population compared to Maryland • A three-fold increase in the number of heroin-related deaths 2010 and 2014. • Demand for public mental health services has increased across all age groups biggest increase 0 -5 • Third highest number of prescription opioid-related deaths in Maryland • EDs have become the “catch-all”. There were 335 visits to the ED for every 1, 000 individuals in the county in 2014. • Overweight and obesity are still significant health issues

The Three Big Needs -unchanged since 2012 Affordable Housing The median price for a house is still rising and is higher than the state; $320, 000 in 2015 In 2013, Anne Arundel County homeowners spent 34. 3% and renters spent a staggering 49. 5% of their income on housing Child Care Child care ranks third among major household expenses at $21, 228 per year for a family with two children (20. 96% of median family income spent on child care) Transportation City of Annapolis offers a circular route and fixed route services County provides subsidy support for 3 bus routes (B, J and K) operating on one hour to ninety minute intervals

Top 7 Areas of Poverty, 2013 Selected Poverty Percentages by ZIP Code Anne Arundel County, 2013 ZIP Code 21225 21226 21077 21060 21061 20714 20751 Area Poverty Percentage Brooklyn 26. 5% Curtis Bay 16. 5% Harmans 16. 8% Glen Burnie (East) 11. 2% Glen Burnie (West) 10. 8% North Beach 9. 9% Deale 9. 2% Anne Arundel County 6. 3%

The Geography of Poverty

Access to Providers “We are barely keeping our noses above water and now we have five more things that we have to do and if we don’t do them, eventually we will have another problem. ” Primary Care Doctor Primary Care Physicians, Dentists and Mental Health Providers Anne Arundel County, Maryland AA County Total AA County Ratio Marylan d Ratio Top U. S. Counties Ratio Primary Care Physicians (2012) 385 1, 430: 1 1, 131: 1 1, 045: 1 Dentists (2013) 366 1, 518: 1 1, 392: 1 1, 377: 1 Mental Health Providers (2014) 774 718: 1 502: 1 386: 1

Health Care Access Medicaid Enrollment by Age, Sex, Race, Ethnicity Anne Arundel County, December 2014 In Maryland, under the ACA, persons whose income is up to 138% of the poverty level are eligible for Medicaid. The number of Medicaid enrollments increased from 68, 166 in January 2013 to 84, 616 in December 2014 There are still many primary care doctors who do not accept Medicare/Medicaid. Total Enrollment Medicaid Enrollment 84, 616 Age Under 18 years 18 to 64 years 65 years and over Sex Male Female Race and Ethnicity White, NH Black, NH Hispanic, Any Race Asian 37, 843 43, 040 3, 733 37, 186 47, 430 39, 793 (47%) 25, 193 (30%) 6, 349 (8%) 3, 829 (5%)

Health Professional Shortage Areas “They’re building places on the Eastern Shore but not in South County. You have to get someone to take you to AAMC. There are no taxis here. In other places they have those health clinics in Giant…. that would be very helpful in South County. ”

Leading Causes of Death, Anne Arundel County, 2013 N=4, 042 Cancer 1, 006 Heart Disease 892 CLRD* 207 Stroke 205 Unintentional Injuries 127 Influenza and Pneumonia 117 Diabetes 94 Alzheimer's 81 Septicemia 76 Suicide 58 0 200 400 Number of Deaths 600 800 1, 000

Cancer Rates Site Cancer Incidence Rates per 100, 000 by Site and Gender, Anne Arundel Compared to Maryland U. S. , 2007 -2011 Anne Arundel Maryland United States Breast (Female) 129. 3 127. 8 122. 8 Colorectal Male Female Lung/ Bronchus Male Female Melanoma Male Female Prostate Cervical All Sites 35. 7 39. 8 32. 1 68. 7 76. 5 63. 0 32. 4 43. 2 24. 0 151. 7 6. 6 479. 2 39. 3 45. 1 34. 8 59. 9 69. 9 52. 8 21. 0 27. 5 16. 5 148. 7 6. 7 451. 8 43. 3 50. 0 37. 8 64. 9 78. 6 54. 6 19. 7 25. 1 15. 9 142. 5 7. 8 467. 7

Disparities in Cancer Rates Cancer Incidence Rates by Race, Anne Arundel County, 2007 -2011 250 221. 6 Rate per 100, 000 200 150 100 130. 2 143. 7 118. 7 71. 5 54. 2 50 34. 7 43. 6 0 Lung and Bronchus Colorectal White Breast (Female) Black Prostate

Low Birth Weight Percentage of low birth weight babies is dropping slowly – 7. 9% average. Less than the state average of 8. 7% Low birth weight infants run the risk of developing health issues ranging from respiratory disorders to neurodevelopmental disabilities, especially those developmental issues related to school achievement.

Senior Population Trends Number of People Senior Citizen Population Estimates for Anne Arundel County 200000 150000 100000 50000 0 2013 2020 Year 2030 2040 The 65 and over population accounts for 40% of county hospital admissions and 46% of readmissions (admitted three times or more in a year. )

Senior Health Hospitalizations by Age Group Anne Arundel County, 2013 Issues for Seniors Falls Urinary tract infections (UTIs) Anxiety Dehydration Medication compliance Type 2 diabetes Obesity Lack mobility caused by joint issues. “I had a client with about 30 medications. She’s diabetic, has COPD and congestive heart failure. ” Age Group Number of Hospitalizations Rate per 1, 000 0 to 18 9, 371 74. 1 19 to 39 12, 584 76. 6 40 to 64 yrs. 18, 143 94. 3 Greater than 64 19, 435 267. 9

Health Needs Summary Health resource planning for geographic differences related to low income, poverty and health access, especially in North and South County Senior in-home care for non-emergency issues More primary care physicians and general surgeons, particularly in South County Improved access to adult dental care Improved care coordination to help people manage chronic conditions such as congestive heart failure and diabetes

Behavioral Health “Stress plays out on the health side of things in terms of mental illness and in terms of anxiety and depression. I think it is increased because with the anxiety piece you don’t have any down time, the more technologically advanced somebody’s life is the less free time they have. You can work 24/7 and you never get a break so I think that is a contributor to anxiety. ”

Public Mental Health 2012 -2014 Number of People Served by a Public Mental Health Service in Anne Arundel County, 2012 -2014 Early Childhood 0 -5 Child (6 -12) Adolescent (13 -17) Transitional (18 -21) Adult (22 to 64) Elderly (65 and over) TOTAL 2012 2013 Percent of Change (’ 12 -’ 13) 2014 Percent of Change (’ 13 -’ 14) 392 394 0. 5% 473 20. 1% 1, 821 1, 880 3. 2% 2, 152 14. 5% 1, 388 1, 476 6. 3% 1, 617 9. 6% 586 584 -0. 3% 610 4. 5% 5, 351 5, 762 7. 7% 6, 396 11. 0% 59 70 18. 6% 73 4. 3% 9, 597 10, 166 5. 9% 11, 321 11. 4%

Shortage of Mental Health Services 259 residential rehabilitation beds (for the chronic and persistent mentally ill). 24 crisis beds and only one in-patient psychiatric unit at UMBWMC with 14 beds, and it is often full. One Spanish-speaking psychiatrist for Hispanic uninsured population. Very few Spanish speaking mental health counselors. The county lacks psychiatrists and specialty therapists who have skill in trauma, veterans’ issues and geriatric psychiatry, especially for those residents with dementia. Demand for mental health services results in shortening care without proper follow-up/ step down from residential care. “Almost every Monday morning there will be 17 to 18 psychiatric patients in the emergency room waiting for placement. ”

Mental Health 0 -18 Years • 14. 5% increase in the use of public mental health services for children ages 6 to 12 • 9. 6% increase for children between ages 13 to 17 years of age Behavioral Risk Survey • 21. 9% of Anne Arundel County students had been bullied on school property • 27. 9% of students reported feeling so sad or hopeless almost every day for two weeks in a row that they stopped doing normal activities • 16. 9% of students seriously considered attempting suicide • 13% of students made a plan about how they would attempt suicide. 0 -5 Population • Very young children with serious mental health issues are presenting at pediatric emergency, in the Emergency Department and in primary care offices.

Substance Abuse “They look for someone they know who will buy them a six pack of beer. Then it’s ‘try this pill it’s called oxy’ – then they go on to heroin. We had heroin sales on our block. It’s right around the corner; it’s like Starbucks now. ” “We have kids who come into school high at 7 in the morning. There is no learning and it’s sad to watch. They are the kids that drop out and don’t get a job. ”

Tobacco Percent of Adults 18 Years and Older Who Are Current Smokers Anne Arundel, Maryland U. S. , 2011 -2013 25 Percent 20 15 10 5 0 U. S. Maryland Anne Arundel 2011 21. 1 19. 1 22. 9 2012 19. 2 16. 2 18. 1 2013 19 16. 4 18

Alcohol Number of Alcohol-Related Intoxication Deaths by Year, Anne Arundel County, 2010 -2014 30 25 22 Number of Deaths 21 20 18 15 15 10 10 5 0 2011 2012 2013 2014

Opioids Number of Prescription Opioid-Related Intoxication Deaths by County, Maryland, 2014 100 83 Number of Deaths 80 59 60 40 32 20 20 19 16 16 0 Baltimore City Baltimore County Anne Arundel Harford Montgomery Washington Prince George's

Heroin Number of Heroin-Related Intoxication Deaths by Year, Anne Arundel County, 2010 -2014 60 53 Number of Deaths 50 38 40 30 20 41 24 18 10 0 2011 2012 2013 2014

Behavioral Health Needs Summary More providers of psychiatric, counseling and substance abuse services, especially those who are Spanish speaking Residential mental health and substance abuse beds, especially for the adolescent population Care coordination for residents coming out of residential care and returning to the community. (Behavioral health providers and primary care. ) An increase in substance abuse providers across the continuum of care Mental health services for the early childhood population Integration of behavioral health care at the provider level Crisis beds for immediate response and to relieve the emergency departments School-based assessment of substance abuse

The Social Determinants of Health

Hospitalization Rates Related to Social Determinants “What is the biggest cause of asthma admissions in kids in Anne Arundel County in the summer? Is it that they don’t have air-conditioning, or that they didn’t take their medications? ”

Obesity – Good News and Bad News Percent of Overweight Adults (Body Mass Index of 25 to 29. 9) 18 Years and Older, Anne Arundel County and Maryland, 2011 -2013 Maryland Percent of Obese Adults (Body Mass Index of 30 or more) 18 Years and Older, 2011 -2013 Maryland Anne Arundel 36. 2 36. 7 36. 1 36. 2 30. 5 28. 3 27. 6 35. 9 32. 6 26. 9 2011 Anne Arundel 2012 2013 2011 28. 3 27 2012 2013 “We have a problem with diabetes but it seems as soon as things become sugar-free they are way more expensive. You can’t choose to change your lifestyle because eating healthy comes with a price…. when you don’t have money, you eat chicken and rice, ground beef, things that can go in the microwave, a lot of processed foods mainly - whatever is cheap and easy. ”

Food Deserts Approximately 69, 000 (12%) of Anne Arundel County residents live in an area categorized as a food desert. Food deserts are defined as urban neighborhoods and rural towns without ready access to fresh, healthy and affordable food.

Other Social issues Impacting Health Transportation Housing and Homelessness Domestic Violence and Sexual Abuse Lack of recreational and community facilities Hunger Technology

Needs Related to Social Determinants • Access to transportation, especially for low-income residents and seniors • Affordable housing. Lack of affordable housing is creating stress, and homelessness, for low-income families. • Access to recreational and social opportunities, especially for youth and the adult mentally ill • Primary care and behavioral health providers, which are especially lacking in South County. • Access to healthy food for low-income families • Healthy living conditions, including air conditioning • A Forensic Nurse Examiner Program to better serve domestic violence/sexual assault and abuse victims and to take pressure off emergency room personnel

Service Delivery Issues • Anne Arundel County residents made approximately 186, 124 ED visits to hospitals within Maryland. • There were 335 visits to the ED for every 1, 000 individuals in the county. Emergency Department Visits by Race and Ethnicity Anne Arundel County, 2013 Race/Ethnicity Number of ED Visits Rate per 1, 000 White, NH 98, 617 250. 3 Black, NH 48, 507 554. 0 Hispanic, Any Race 8, 552 223. 0 Asian, NH 1, 454 71. 7 186, 124 334. 9 Total

Geography of Emergency Room Visits “I would rather go to the hospital and have them see me right then instead of making an appointment with primary care and waiting a couple of days. I would go there because it is a lot closer than where my primary care is and it would be a lot quicker. It is on a bus route. ”

Other Service Issues Lack of communication and partnering between the various health and human services agencies, including emergency personnel Communication between agencies is made more awkward by the regulations for patient confidentiality Services are more fragmented because they occur in several different locations County health services overwhelmed by repeat patients. Drug users with frequent overdoses to those with chronic conditions like diabetes and the worried elderly with ongoing somatic issues. The two points of entry and discharge into EDs, hospitals and other systems are problematic Somatic care, mental health and substance use are too fragmented in the current system

Service Needs Summary Information sharing and coordination among agencies Comprehensive patient interviewing and case management at admission and discharge Home visiting and follow-up care Coordination and communication among care workers Further use and development of community health clinics One stop shops for health, behavioral health and social services “Discharge is not handing someone a piece of paper with multiple numbers. You need to make a plan. One can’t just give people a list of three clinics – they have to be coordinated by navigators. ”

Executive Summary The senior and Hispanic populations are growing rapidly The three big social needs; affordable housing, transportation and child care, impact everything The geography of poverty should be reflected in services Behavioral health needs are growing quickly, especially among the early childhood population Care coordination and communication among agencies and care workers is lacking Entry and discharge procedures in all systems need attention

The Good News Healthy Anne Arundel is increasing coordination among the public and private sectors The two county hospitals are partners and are increasing services related to behavioral health, care coordination and domestic violence The mental health agency has a state of the art crisis response system that is working closely with all health/behavioral health and human services systems The not for profit sector is increasing services – e. g. children’s center at Arundel Lodge The philanthropic community is planning, jointly, with the public and private sectors

Healthy Activity Break ANN HEISER-BUZZELLI

Strategic Planning

New Strategic Planning Process and Timeline Today, we will: Reaffirm our vision and mission Reaffirm/change/add priority areas Draft goals for each priority area By the April 27 th Steering Committee Meeting, we will: Convene subcommittees to refine goals, develop SMART objectives, and identify actions. Submit a draft action plan for each priority area to the steering committee By the June 22 nd Steering Committee Meeting, we will: Integrate feedback into action plans Compile action plans from different priority areas into one document Review the final draft to approve at June 22 nd meeting

Vision and Mission Vision Healthy County Healthy People Mission Working together as a community to promote the health and wellness of Anne Arundel County residents.

PRIORITY AREAS In your groups: Examine the two existing priority areas and discuss: Is this still a priority? Is it still relevant? Does it need to be revised? Please keep, revise, or delete as your group thinks its appropriate. Is there ONE other priority area that needs to be added?

What is a Goal? Goals are statements of the broad results you wish to achieve by the end of the your strategic planning period. They should be realistic and long-term Examples Reduce use of tobacco by youth Decrease the rates of cancer associated with smoking End childhood hunger X

What are our GOALS? In your priority area groups: You will have 25 minutes. Agree on 1 to 3 goal statements for your priority area What are you hoping to achieve by the end of the plan? Are your goal statements realistic? Are your goal statement measurable?

Housekeeping for Next Steps Please sign the subcommittee participation sheets and include your email address. An action plan template will be shared with subcommittee chairs. Chairs of each subcommittee will convene groups to flesh out objectives and activities. Chairs will share a draft version for discussion during the April 27 th steering committee meeting A final draft will be presented at the June 22 nd steering committee meeting

THANK YOU! NEXT MEETING APRIL 27, 2016 2: 00 P. M. – 4: 00 P. M. LOCATION? ?

Group Work In your groups Identify a scribe and a reporter Agree on three goals for the Improvement Focus Area