mah community health needs assessment 2015 appendix

Community Health Needs Assessment

September 2015

Appendix

1. Advisory Group

2. Evaluation of Mount Auburn Hospital’s 2012 Implementation Plan

3. Quantitative Data-Mass CHIP

4. Mount Auburn Hospital Emergency Room Data

5. Tufts Health Plan Foundation Healthy Aging Data Report 2015

6. Youth Behavior Risk Surveys Summary

7. Data Collection Summary

8. Key Informant Interview Guide

9. Community Organization Relationship Grids

10. Group Conversation Guide

11. English Speakers of Other Language Staff Survey

12. Community Electronic Survey

13. Qualitative Data Summaries

14. Community Resources and Related MAH Community Benefit Programs

Appendix 1

Community Health Needs Assessment

Advisory Group

Name Organization

Ann Bruhn Caregroup Homecare

Christopher

Kowaleski Somerville Council on Aging

Deborah Rosati Watertown Department of Public Health

Mary DeCourcey Mount Auburn Hospital Community Health

Dida Obler Community Conversations-Sister to Sister

Elizabeth Seelman Cambridge Council on Aging

Kathy Howard Mount Auburn Hospital Director of Social Work

Jo White Springwell

Judy Fallows Healthy Waltham

Laura Kuman Wayside Youth Services

Mary Ann Dalton Somerville Cambridge Elder Services

Marybeth Duffy Waltham Council on Aging

Michelle Holdcome Food for Free

Michael O'Connell Mount Auburn Hospital VP

Stacey King Cambridge Department of Public Health

Susan Carp Arlington Council on Aging

Susan Pacheco Cambridge Council on Aging

Wil VanDinter Watertown Department of Public Health

Jayne Germano Mount Auburn Hospital Walk In Clinic

Karen Avery Mount Auburn Hospital Travel Clinic

Laura Beaton Mount Auburn Hospital Community Health

Richard Bail Community Physician

Appendix 2

Evaluation of Community Benefit Goals and Activities Outlined

In the Implementation Plan September 30th

2012

Throughout the 2012 and 2015 assessment processes, both MAH and engaged community members

recognized that the causes of community health needs are complex and challenging to articulate.

Equally challenging is choosing activities to address identified needs in meaningful ways and choosing

methods to evaluate the impact of those activities. To meet these challenges MAH developed an array

of Community Benefit Programs in 2012 and has aimed to monitor and evaluate those programs as part

of the 2015 assessment. This evaluation summary includes recommendations of whether or not to

continue the programs in the 2015 Implementation Plan. A summary of these recommendations can

also be found in the 2015 Assessment.

This review is organized into two sections- the ways MAH increased the health and wellbeing of

community members at the community level and at the individual level.

Evaluation of Community Level Activities

To implement evidenced based programming. The following chart is a summary of the evidenced based

programs that were offered. Staff was trained to lead these programs and outreach was conducted to

enroll community members. Program Title # of Leaders

Trained

# of

Classes

Number of

Participants

Evaluation Recommendation

to continue?

Matter of Balance Fall

Prevention

7 25 258 Very successful. Strong

community and clinical

interest.

Yes

Stanford Chronic

Disease Self-

Management

5 6 43 Difficult to enroll.

Participant’s feedback

positive.

Possibly

Stanford Diabetes Self-

Management

4 4 18 Difficult to enroll.

Participant’s feedback

positive.

Possibly

Powerful Tools for

Caregivers

3 3 21 Impression is that class

is very helpful however

it is difficult for

caregivers to get time

to attend. Tried

providing respite care

with minimal success.

No

Stanford Thriving and

Surviving

2 2 11 While this class

information is very

important, feedback

from participants is

that the material and

format doesn’t serve

the needs of the

community members.

No

Review of data reveals that:

• There was a 47% increase in the number of attendees who reported being able to find a way to

reduce falls.

• There was a 35% increase in the number of attendees who reported being able to protect

themselves if they fell.

• Participants who felt confident that they can do things other than just taking medication to reduce

how much their illness affects their everyday lives rose from 33% before the class to 60% after the

class.

• Participants who felt confident that they could control their diabetes so that it does not interfere

with the things they want to do rose from 47% before class to 73% after the class.

• Powerful Tools For Caregiver participant “I came to this class a child to a parent. Now I have

learned I am a parent to my parent. I had no tools before this class, now I have a toolbox. This

class gave me more emotional strength & self-esteem to take more control of the situation.”

• All of the Powerful Tools for Caregiver participants felt that they were a more confident caregiver

than they were before the class.

To promote health policies that supports the healthy choice being the easy choice Recommendation to continue: As they fit with the rest of the Implementation Plan.

• Mount Auburn Hospital funded 8 different grants for Food and Activity Living Policy. Enhancement

of established Food and Active Living Collation’s in Cambridge, Somerville and Waltham and creation

of two new coalitions; Live Well Watertown and Belmont Food Collaborative.

o Two new Food and Activity Councils-Live Well Watertown and the Belmont Food

Collaborative were funded.

o Three existing Food and Activity Councils-Shape Up Somerville, Healthy Waltham and the

Cambridge Food and Fitness were also funded.

o By May 2014 three Food and Activity Policy Councils had developed policy recommendations

for their respective cities or towns. o By May 2014 three Food and Activity Councils had built support and developed partnerships

among decision makers and community members to move recommendations forward.

• Along with other community organizations, supported a new social worker position in Watertown.

Recommendation to continue: Projects Completed

• Mount Auburn Hospital became a Tobacco Free Campus on November 1st, 2013.

• Mount Auburn Hospital worked with Arlington Public Schools to change programming aimed at

reducing smoking among students.

o By January 2013 a Tobacco Peer Leadership Programming module for middle school students

to increase positive health behaviors and decrease negative behaviors was developed.

o By January 2014 the program was expanded to the high school to promote health policies

that support the healthy choice is the easy choice

Partnership with CHNA 17 Mount Auburn Hospital has provided funding to community members

and community based organizations through Community Health Area (CHNA) 17. The RFPS for each

program were specifically crafted to meet the goals below-for example applicants were asked to

increase networking and sharing of resources as part of their project. A total of 75 grants and 23

scholarships were granted to address for areas identified in the assessment.

Youth Issues Obesity and Active Living

Adult Mental Health

Crime & Safety

Address youth mental

health, substance

abuse, access to care,

teen dating violence

and bullying.

Support new and

existing Food and

Activity Policy

Councils

Support Mental Health

First Aid Scholarships

and promoting mental

health well-being.

Support communities to

create, formalize or

enhance inter-community

collaborations to

promote safety and

prevent crime.

5 grants. $25,000 each

year. These grants

were renewed twice for

a total of 3 years.

3 grants. $15,000

each year. These

grants were

renewed once for a

total of 2 years of

funding.

Funded three levels of

scholarships; individual

(5), community (7) and

instructor (11).

Focus groups in each of

CHNA 17 towns.

9 one year grants of

$10,000 each

5 eighteen month

grants for $20,000

each.

5 one year grants for

$10,000 each

3 eighteen month grants.

$20,000 each.

In two other areas 58 grants were allocated. These RFPs were designed to achieve certain goals.

Mini-grants Capacity Building

To address health areas not prioritized, mini-

grants improve care and direct services, policy

and organizational change or address access

for particularly for vulnerable populations.

To help meet the day-to-day needs of community based

organizations and local departments of public health

and to enable these organizations to be better able to

fulfill their organizational mission and be better

positioned for future opportunities.

44 grants have been provided of up to $5,000

each to twenty seven different organizations

across the CHNA.

9 one year grants of $5,000 and 6 one year grant of

$5000 to each DPH in CHNA 17 were awarded. (DPH

RFP was noncompetitive)

In addition to addressing the individual health areas the CHNA recognizes the intersectionality between

these areas and has made intentional steps to not only fund innovative and evidence based projects

throughout the region, but moreover partner with and support organizations to implement the work.

Therefore, MAH staff conducted Communities of Learning for each program area. Participants met to

share successes and tackle challenges.

• Based on general membership surveys and grant reports, in 2012, 2103 and 2014 CHNA 17

members demonstrated:

o Increased awareness of larger health trends, knowledge of programs, services and initiatives,

networking and collaborations, and sharing of resources,

o Increased capacity to effectively administer and evaluate programs and services and

o Increased knowledge use and documentation of best practices

• Within their funding cycle, grantees funded by the CHNA developed, implemented and reported on

programs that:

o Were evidenced-based,

o Included the target population,

o Addressed the needs of vulnerable populations,

o Included intercommunity and interagency collaborations,

o Addressed the health indicators noted in the assessment,

o Built on existing community resources and

o Incorporated CHNA 17 member input

• In 2013 and 2014 CHNA 17 community members met in Communities of Learning and shared:

o Ideas and plans for evaluation, policy and programming.

o Challenges and successes in developing and implementing quality programs and

implementing policy changes.

• After three years (2012, 2013 and 2014) the CHNA 17 community demonstrated:

o Increased number of collaborations and partnerships

o Increased efficiency and effective utilization of resources

o Individual CHNA members incorporate increased knowledge and understanding into their

organization’s programs and services

o Increased knowledge and capacity among CHNA members and grantees

about the operational management of community based organizations.

• Additionally the CHNA 17 community:

o Documented best practice used in CHNA 17 communities

o Implemented and expanded cross community collaborations

Youth Services in CHNA 17

• By January 2013 all grantees demonstrated:

• Implementation of evidence-based youth programming.

• Involvement of youth in program planning and implementation.

• Youth leaders playing an pivotal role in programming and peer education

• By January 2014 all grantees demonstrated:

• Increase in availability of programs and services for youth in CHNA 17 communities

• Increase in the number of youth receiving education on issues such as violence, substance abuse,

bullying and mental health.

• By November 2014 all grantees will demonstrated:

• Increase in the number of youth served.

• Increased effectiveness of youth services and programs across violence, bullying, substance

abuse and mental health to reduce harmful behaviors in CHNA 17 communities.

Food and Activity Policy • By January 2013 three Food and Activity Councils had researched, assessed and identified

resources and areas of need in their communities; and will have shared this information with

their community.

• By January 2014 three Food and Activity Councils had developed policy recommendations.

• By January 2014 three Food and Activity Councils had built support and developed partnerships

among decision makers and community members to move recommendations forward.

Crime and Safety • By January 2014 six focus groups were conducted to better understand issues and concerns

about crime and safety. The forty six community members who participated included

community leaders, civic organizations, law enforcement officials, school personnel and others

other stakeholders.

• Results reported at community forum June 2013

• Created RPF based on feedback from focus groups which was released November 2013.

• 3 programs were funded that enhanced inter-community collaborations to promote safety and

prevent crime.

Capacity Building • Created an Organizational Capacity Building Grant Program in response to difficulties that nonprofit

organizations in our region have identified in meeting the day-to-day needs of their clients and/or

other community stakeholders. 9 programs funded.

• Support local DPH by offering non-competitive funding to build capacity to serve their city/town.

Grants awarded to Arlington, Belmont, Cambridge, Somerville, Waltham and Watertown.

Adult Mental Health • In March 2015 released RFP for aimed at changing community morns and understanding about

mental health/mental illness as well as to fill in gaps in service provision.

• 9 programs funded May 2015.

Mental Health First Aid Trainings

• By June 2015:

o 11 new instructors had been trained in MHFA.

o 10 group trainings had occurred.

• By September 2014 train all Arlington police staff were trained in MHFA.

• By January 2015 Watertown school staff was trained in MHFA.

MHFA participants answered how this training will affected their work?

• We serve a number of community members who present some mental health

challenges but are unable/unwilling to access mental health resources. The MHFA

scholarship has helped me be more confident in identifying and managing the

symptoms as they present themselves, and without fear refer people to mental health

services when necessary.

• I work in a clinic setting with the homeless population where there are significant

mental health issues. The training supports my interactions with our patients.

• It does help with the population we work with.

• This course was perfect my work as an outreach advocate, since almost all of our

clients struggle with alcoholism and/or addiction, as well as depression, anxiety, PTSD,

etc. I felt that the main benefit of the training was the emphasis on non-judgmental

listening... the idea of being present for a client vs. trying to "fix" the client.

• I feel that it will help me both recognize the signs of an individual in crisis and also that

it gave me the training to feel confident enough to help the individual and direct them

towards whatever help they may need for their individual problem.

• It will be helpful dealing with our clients as incidents arise

MHFA participants answered how they planned on using MHFA in their personal life?

• It has made me more sensitive to identifying depression in my friends

• I think the training applies to all areas of my life, as I believe that everybody struggles with

depression, anxiety, etc. at some point.

• I feel you never know when you may run into someone who needs help, and I now feel

confident that I can steer them in the right direction.

Sixty participants completed the following Opinions Survey pre and post the class. Increased knowledge

was demonstrated in most areas.

Summary of Programs in Partnership with CHNA 17

Program Area Recommendation to continue Youth As it fits with rest of Implementation Plan

Mental Health First Aid Yes

Mental Health Grants As it fits with rest of Implantation Plan

Crime and Safety As it fits with rest of Implementation Plan

Obesity and Active Living As it fits with rest of Implementation Plan

Capacity Building As it fits with rest of Implementation Plan

0% 20% 40% 60% 80% 100% 120%

It is not good idea to ask someone if they are feeling suicidal

in case you put the idea in their head.

Schizophrenia is one of the most common mental disorders.

If someone has a traumatic experience, it is best to make

them talk about it as soon as possible.

Males complete suicide four times more frequently than

females.

Antidepressant medications work right away.

It is best to get someone having a panic attack to breath into a

paper bag?

A first-aider can distinguish a panic attack from a heart attack.

Exercise can help relieve depressive and anxiety disorders.

People with psychosis usually come from dysfunctional

families.

It is best not to try to reason with people having delusions.

People who talk about suicide don't attempt suicide.

Psychosis is a lifelong illness.

People with psychosis are more at risk of being victims of

violent crime.

Smoking is much more common among people with mental

health problems.

People with mental health problems tent to have better

outcome if family isn't critical of them.

Post % Correct

Answers

Pre % Correct

Answers

Watertown Task Force Recommendation to continue: Yes

Facilitated health policies that support the healthy choice being the easy choice for Watertown

community members in need of social services by having a MAH social worker attend over 80 % of the

meetings.

Flu Clinics Recommendation to continue: Yes, if DPH requests.

• Staffed and provided supplies for urgent flu clinic in Belmont to meet high

demand of 2013 flu season

• Provided nurses to 9 flu clinics in Watertown in 2012 and 2013.

Emergency Preparedness Recommendation to continue: Yes

• Provided AEDs to two community organizations to increase their capacity to help community

members in cardiac arrest.

• Installed public monitors which will provide vital public information in the case of an emergency.

• Ebola training was provided to Cambridge Police, Fire and Professional Ambulance

• Collaborated with city and state emergency management programs to ensure preparedness of

hospital for emergencies

Overdose Prevention Work

Recommendation to continue: Yes.

• MAH staff attended OPEN (Overdoes Prevention and Education Network) meetings and facilitated

and printed 2012 Photovoice project.

• MAH provided startup funds for Learn to Cope™ support groups for families and friends of

community members struggling with addiction in Cambridge.

Improving Access for Deaf and Blind Community Member Recommendation to continue: Project completed

• Space created in the MAH lobby for community members to access American Sign Language via vide

remote relay and aids to assist low vision patients.

Cambridge Informal Caregivers of Elders Need Assessment Recommendation to continue: Project completed.

• By June 2012 MAH convened a working group of agencies that supported Cambridge Caregivers.

• By January 2013 MAH in collaboration with local partners conducted an assessment to document

needs and barriers expressed by Cambridge caregivers and clinicians who care for Cambridge

caregivers.

o Sixteen caregivers completed the Informal Caregiver Survey. Forty-three providers

responded to the Provider Survey on SurveyMonkey™, six agencies conducted self-

assessment of Caregiver Support.

o An example of the type of results that were shared broadly with community organizations

follows. Caregivers reported the types of care they provided to include supervision, personal

care, homemaking, home maintenance, medication support, transportation, errands,

doctor’s appointment, meals, emotional support, financial support, and financial

management. (Items in bold and in the chart red, reflect support that more than 75% of

caregivers provide.)

� The findings were shared with the MAH geriatric team who decided to incorporate social work

into the intake process to assess need for caregiver support.

Community Health Network Area Support During the last three years MAH provided more

than 5,000 hours of technical assistance and coordination to these CHNAs. In 2013 the statewide

system of Regional Centers for Healthy Communities disbanded. MAH continued to support these 5

CHNAs with an aim to make transition plans for each of the CHNAS. The grid below identifies the

current status and recommendations to continue support of each CHNA.

CHNA Total Hours

Provided

Current Status Recommendation

to continue?

7 700 Assisted CHNA to find local support. No


17 2503 Significant support provided. Yes

18 219 CHNA has not needed significant support. No


Lyme Disease Community Education

Recommendation to continue: Yes

• Increased awareness about prevention and early detection of Lyme disease.

• Provided health literate materials to local schools, departments of public health

• Created and disseminated local cable TV program-reached 40,000

• Disseminated information thru Facebook

• Created and disseminated 5,000 pamphlets about Lyme Disease.

• Translated educational pamphlet into Spanish.

Cambridge Community Policing Collaboration Recommendation to continue: Yes

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

What kind of care do you provide?What kind of care do you provide?What kind of care do you provide?What kind of care do you provide?

• 10 MAH staff participated in strategy meeting with

Cambridge Community Policing staff

• 3 MAH staff participated in Cambridge Community Policing

stakeholders forum

• 3 MAH staff participated in Cambridge Police Department

brainstorming session about Overdoses

Facilitate connections to health care-the Barron

Center for Men’s Health Recommendation to continue: No, demand has decreased with

the ACO.

• 64 clinics have been held allowing for 358 visits for

underserved me.

• 83% referrals from CRCHC

• 90% required interpretation and navigation services

• 70% patients had Health Safety Net for insurance

Facilitate connections to health insurance Recommendation to continue: Yes

• Two Mount Auburn Hospital Financial Counselors work onsite at Joseph M. Smith Community Health

Center. They have provided over 10,000 encounters.

• Nine financial Counselors were trained as certified application counselors (CAC)

• 2 MAH financial counselors have been trained to enroll community members in SNAP at the same

time they enroll them in health insurance. 72 SNAP enrollments completed.

Mind Body Program for Cancer Patients Recommendation to continue: Yes

• Two eight week sessions completed.

Listen and Learn, Bridge to Healthcare and Health Education for Homeless MAH provided

health education in the community where members work, play and learn. By providing these session in

locations comfortable to community members MAH has been successful in reaching community

members who might not travel to the hospital for a presentation. Over 1,000 community member

participated in education and training events. Seventy four percent of which were to underserved

audiences. Topics included Screening Guidelines and Early Detection of Cancer; Healthy Eating and

Active Living; Lyme disease and Seasonal Flu; Diabetes, Stroke, Heart Health, High Blood Pressure, and

Understanding the US Healthcare System.

Community members reported increasing knowledge; they knew more after the presentation than

before.

0

10

20

30

40

50

60

70

Number of Presentations

Community Education Populations

Reached

General

Homeless

Immigrants

Elders

0.00%

50.00%

100.00%

FY

20

13

FY

20

14

FY

20

15

Barron Center Patient Insurance

Private

Insurance

Medicare

Medicaid/mass

health

HSN

Nearly 50% of attendees stated they wanted to improve their health based on what they learned. Some

examples were:

• I will ask my doctor at my next appt for a breast exam.

• To continue my self-exams to make sure I don’t. Get another lump. Catch it early. Get my medical records.

• I will exercise and walk more. I will practice eating healthy.

• Use sunscreen to prevent skin cancer

• Use insect repellent to prevent Lyme

• Going to use sunscreen more to prevent the skin cancer for my family

• check my breast one time month and talk with my doctor about my breast

• I eat more fruit and vegetables, I do more exercise

• I will walk and eat more vegetables

• Quite smoking, do exercise, be active

• 9 inch plate with 4 types of portions

• About "us" immigrants before we came to the U.S. we don't have high blood pressure and now we adapted to the culture.

Smoking Cessation Recommendation to continue: Yes

• 12 free classes were held. 165 community members attended.

• 84% had a plan to quit smoking

• Attendees shared what they found most helpful about the class:

• To talk to others and our instructor with helpful information.

• The other people in the class and how they tried to quit.

• Positive support

• Support/understanding

• Interaction/sharing thoughts

• The group discussions

• The information I received

• Keeping track of how many cigarettes I had each day

• Talking learning about nicotine

• Facts from instructor

• Non-judgmental

• Listening to others

Bereavement Support Group


• 9 eight week group sessions served 102 community members.

0

500

1000

1500

BEFORE this session AFTER this session

How much did you know about________________________How much did you know about________________________How much did you know about________________________How much did you know about________________________

A greatdeal

• 100% of those who completed evaluations felt supported by the facilitator.

• 75% of those who completed evaluations felt supported by other participants.

• 58% of attendees indicated that they had learned "a great deal" of why they feel the way they do and

because of that their hope and confidence improved

Support for Community Members with Cancer


• Hosted 10 Look Good Feel Better sessions for community members

• Hosted 2 Mind Body 8 week sessions for community members.

• 2 MAH staff trained to lead “Cancer Surviving and Thriving” program

• Two Cancer Surviving and Thriving 6 week programs held

• Convened MAH clinicians and community members to explore ways to improve education and

support cancer survivors.

• 80 people attended first Survivor’s Day June 7th 2015

Postnatal Support Group Recommendation to continue: Yes

• Over 1,000 women attended postpartum sessions aimed at improving hope, empowerment and/or

confidence in new parents.

In-kind space for local Alcohol Recovery Programs Recommendation to continue: Yes

• Handicapped accessible space for meetings AA and SMART recovery meetings.

Elder Cardiovascular Health


� Provided 172 blood pressure clinics to underserved elders to increase understanding of prevention

and early detection of stroke, and cardiovascular disease.

• All community members received their blood pressure screening on a form which they can bring to

their primary care physician. Eleven percent had readings in the Stage I hypertension range.

Addressing Hunger

Recommendation to continue? Yes

• To facilitate connection to services, MAH Financial Counselors to enrolled 72 community members in

SNAP.

• Conducted 5 food drives

Lack of Transportation


• Facilitated connection to health care by providing transportation when it is a barrier to medical care

Safe Beds and Rooming In Recommendation to continue? Yes

• Provided shelter for woman and their dependents who are victims of domestic violence until safe

placement can be arranged.

• Allowed elders who are unable to stay at home because their caregiver has been admitted to the

hospital to stay in the hospital until appropriate accommodations can be made.

Personal Emergency Response Systems Recommendation to continue? Yes

• Provided personal emergency response services at a reduced cost to over 1000 elderly or disabled

adults annually.

Waltham Breast Feeding Continuing Care Recommendation to continue? Yes, episodically if needed

• WIC, MAH and CRCHC worked together to identify new materials, new information and new

methods to support breast feeding in underserved women in Waltham.

Prenatal Care for Underserved Women Recommendation to continue? Yes

• By August 2013 had piloted and implemented Group Prenatal Care at Joseph M. Smith Community

Health Center.

• 4 sessions have been held reaching over 50 women.

• Provided Immigrant Women Doulas to act as labor coaches for 150 births

o To better understand current systems look for opportunities for improvement in baseline rate of

pregnant women who enter prenatal care after gestational week (Baseline 18.9%)

� MAH staff attended CRCHC front desk meeting January 2015

� Flow Chart of the steps in the process of immigrant women entering the system and

getting to first prenatal appointment created

� CRCHC providers encourage to contact MAH staff directly to facilitate connection

• Enhanced Electronic Health Record allows for referrals to peripheral departments for immigrant

woman

� Two gestational patients were seen and followed by a diabetic educator

� Eight post-partum patients were seen by behavioral health.

� All patients in their third semester had documentation of a contraceptive plan or that

they choose not to utilize contraception.

o MAH Community Health educated six CRCHC Community Outreach workers Collaborated

about Men’s Health

Collaboration with CRCHC Outreach


• Supported CRCHC Community Health Center Celebrations

• Conducted Food Drive in 2014

• Provided Education to Community Health Outreach Staff about Colorectal Cancer, Prostate

Cancer, Testicular Cancer, Benign Prostate Hyperplasia

• Created Flipbook about Colorectal Cancer for outreach workers.

Appendix 3

Mass CHIP Data

The following information is from the 2010 census.

910.2

11.7

14.7 15.7 15.512.8 13.8

02468

1012141618

%

Age 65 and older

2.63.4

4.9

8.6

10.3 9.9

6.62 6.9

0

2

4

6

8

10

12

%

% Speak a language other than English

The following information is from the 2010 American Community Survey

5 year estimates.

9

6

12.1

4

2.63.7

6.23

0.080

2

4

6

8

10

12

14

%% Speak a language other than English -

Spanish or Spanish Creole

7.00%

5.00%

3.10% 3.00% 2.90%2.50%

3.92%

9.5%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

%

Households with Food Stamp/SNAP benefits in the past 12

months (ACS 2010 5-Year Estimates)

14.70% 15.00%

11.50%

6.40%

4.90% 4.90%

9.57%10.7%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

%All people with whose income in the past 12 months is below

the poverty level (ACS 2010 5-Year Estimates)

61731 64865 6634674081

82771

95197

7416565,981

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

$

Median household income in the past 12 months (in 2010

inflation-adjusted dollars) (ACS 2010 5-Year Estimates)

Quintiles

• The following are reported in quintiles.

• A number of "1" means the community has one of the lowest percentages of people

reporting a health condition, risk factor, or protective factor.

• A "5"means that your community has one of the highest percentages of people with that

health condition, risk factor, or protective factor.

• All data using quintiles were calculated using the Behavioral Risk Factor Surveillance System

(BRFSS).

5

1

3

2 2

1

0

1

2

3

4

5

6

Somerville Cambridge Waltham Watertown Arlington Belmont

QUINTILES: Three years average prevalence of current

smoker among adults in MA (CY2008 - 2010)

5 5 5

4

1

4

0

1

2

3

4

5

6


QUINTILES: Three years average prevalence of asthma

among adults in MA (CY2008 - 2010)

1 1 12

1

3

0

1

2

3

4

5


QUINTILES: Three years average prevalence of diabetes

among adults in MA (CY2008-2010)

3

2 2 2 2

1

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5


QUINTILES: Substance Abuse Treatment Rates 2013

5 5 5

4

1

2

0

1

2

3

4

5

6


QUINTILE: Five years average prevalence of 5+ drinks at

least once in the past month among adults in MA

(CY2007-2011)

1 1 12

1

3

0

1

2

3

4

5


QUINTILES: Three years average prevalence of

diabetes among adults in MA (CY2008-2010)

3

2 2 2 2

10

1

2

3

4

5


QUINTILES: Substance Abuse Treatment Rates 2013

5 5 5

4

1

2

0

1

2

3

4

5

6


QUINTILE: Five years average prevalence of 5+ drinks

at least once in the past month among adults in MA

(CY2007-2011)

2

5

2 2

4

5

0

1

2

3

4

5

6


QUINTILES: Three years average prevalence of adult eating 5 or

more fruits and vegetables in MA (CY2005, 2007, 2009)

1 1 12

1 10

1

2

3

4

5


QUINTILES: Three years average prevalence of hypertension

among adults in MA (CY2005, 2007, 2009)

4

1

3

4

2

10

1

2

3

4

5


QUINTILES: Three years average prevalence of obesity among

adults in MA (CY2008 - 2010)

4

1

4 4 4

1

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5


QUINTILES: Five years average prevalence of lack of physical

activity among adults in MA (CY2001, 2003, 2005, 2007, 2009)

5 5

3

4

3

4

0

1

2

3

4

5

6


QUINTILES: Three years average prevalence of symptoms of

depression in past two weeks by PHQ-8 among adults in MA

(CY2006, 2008, 2010)

5

4 4

2

4

2

0

1

2

3

4

5

6


QUINTILES: Five years average prevalence of poor mental

health (>15 days poor mental health) among adults in MA (CY

2007, 2008, 2009, 2010, 2011)

2

5

4

5

4

2

0

1

2

3

4

5

6


QUINTILES: Three years average prevalence of good physical

health (<15 days poor mental health) among adults in MA

(CY2008, 2009, 2010)

187.51201.02

113.91 106.69

272.38

127.57

168.18192.25

0

50

100

150

200

250

300

Respiratory: Asthma - Hospitalizations

(ages 0-19): Age Specific Rate Per 100000

588.98524.02

482.77

615.02

494.48461.67

527.82

820.48

0

100

200

300

400

500

600

700

800

900

Respiratory: Asthma - ED Visits (ages 0-19):

Age Specific Rate Per 100000

110.1205

84.70486

181.3176170.5162

208.3687

102.3323

142.89336

200.5458

0

50

100

150

200

250

Myocardial Infarction Hospitalizations in MA

(crude rate per 100,000) FY2010

245.4492

177.6176

344.7272 338.9655 340.0124318.3672

294.1899

376.5379

0

100

200

300

400

Coronary Heart Disease Hospitalizations in MA

(crude rate per 100,000) FY2008-2010

165.8441 174.3344

236.7202

288.3274 278.6325

234.5116 229.7283667

266.4987

0

100

200

300

Stroke Hospitalizations in MA


278.5331468

201.9107029226.5030567

296.6212335259.8574674

169.8410773

238.8777807

401.0098

0

100

200

300

400

500

COPD Hospitalization (crude rate per 100,000) 2008-2010

278.5331468

201.9107029226.5030567

296.6212335259.8574674

169.8410773

238.8777807

401.0098

0

100

200

300

400

500

COPD Hospitalization (crude rate per 100,000) 2008-2010

95.4845068786.8501296482.46470511

76.2441903

91.8059316

57.96163748

81.80185017

158.34

0

50

100

150

200

Asthma Hospitalization (crude rate per 100,000) 2008-2010

310.4601274.7983

359.2774

502.2477 494.2699

345.3716381.0708333

426.4286

0

100

200

300

400

500

600

Cancer Hospitalizations in MA


0200400600800

100012001400160018002000

Cardiovascular Disease Hospitalizations in MA


0200400600800

100012001400160018002000

Cardiovascular Disease Hospitalizations in MA


275.9645

177.2892

307.2326

421.6401

314.9759 328.3162304.2364167

334.7396

0

50

100

150

200

250

300

350

400

450

Congestive Heart Failure Hospitalizations in MA


971.1829 948.4975

1111.41

768.873707.4843

541.5085

841.4927 873.8178

0

200

400

600

800

1000

1200

Mental Health Hospitalizations in MA


Appendix 4 Mount Auburn Emergency Room Top 20 Diagnosis as of October 2014

0

1000

2000

3000

4000

5000

6000

7000

8000

2012 2013 2014 (10

months data)

MAH ED

Pneumonia

Open Wound of Hand

Contusions Face/Scalp/Neck

Cellulititus of Leg

Acute URI

Calculus of Kidney

Vomiting Alone

Lumbago

Open Wound of Forehead

Depressive Disorder

Sprain of Neck

Syncope and Collapse

Backache

Dizziness and Giddiness

Pain in Limb

Urinary Tract Infection

Lower Leg Unjury

Headache

Alcohol Abuse

Chest Pain

Head Injury

Open Wound of Finger

Abdominal Pain

Appendix 5

Tufts Health Plan Foundation Healthy Aging Data Report

WELLNESS and PREVENTION Arlington Belmont Cambridge Somerville Waltham Watertown MAH Towns State

% with self-reported fair or poor health

status 12.90% 16.00% 14.50% 14.50% 16.00% 16.00% 14.98% 20.70%

% with 15+ physically unhealthy days

last month 9.60% 12.30% 10.50% 10.50% 12.30% 12.30% 11.25% 14.00%

% with physical exam/check-up in past

year 87.90% 90.10% 89.10% 89.10% 90.10% 90.10% 89.40% 90.20%

% flu shot past year 76.70% 75.40% 68.90% 68.90% 75.40% 75.40% 73.45% 67.80%

% pneumonia vaccine 63.50% 61.20% 62.30% 62.30% 61.20% 61.20% 61.95% 60.80%

% shingles vaccine 18.00% 21.80% 26.00% 26.00% 21.80% 21.80% 22.57% 14.90%

% cholesterol screening 97.10% 97.50% 98.80% 98.80% 97.50% 97.50% 97.87% 95.80%

% mammogram within last 2 years

(women) 93.70% 88.30% 85.30% 85.30% 88.30% 88.30% 88.20% 85.40%

% colorectal cancer screening 68.20% 74.00% 69.30% 69.30% 74.00% 74.00% 71.47% 65.60%

CHRONIC DISEASE Arlington Belmont Cambridge Somerville Waltham Watertown MAH Towns State

% with Alzheimer’s disease or related

dementias 14.10% 13.90% 13.90% 14.50% 13.90% 15.30% 14.27% 14.40%

% with diabetes 27.10% 22.40% 24.90% 34.90% 31.10% 29.40% 28.30% 32.10%

% with stroke 11.10% 11.30% 10.70% 11.30% 11.80% 12.10% 11.38% 12.60%

% with chronic obstructive pulmonary

disease 19.50% 16.50% 16.60% 23.90% 22.30% 21.70% 20.08% 23.30%

% with asthma 9.10% 8.80% 10.60% 10.00% 11.20% 9.40% 9.85% 11.80%

% with hypertension 75.60% 70.90% 66.60% 76.60% 75.70% 74.90% 73.38% 77.50%

HEALTHY AGING INDICATORS Arlington Belmont Cambridge Somerville Waltham Watertown MAH Town State

% ever had a heart attack 5.00% 3.40% 3.50% 4.90% 4.90% 5.70% 4.57% 5.00%

% with ischemic heart disease 43.90% 42.00% 38.60% 46.80% 45.50% 46.30% 43.85% 44.10%

% with congestive heart failure 23.40% 21.60% 20.70% 28.80% 24.20% 25.20% 23.98% 24.80%

% with atrial fibrillation 16.40% 15.10% 14.20% 15.40% 15.30% 15.90% 15.38% 16.10%

% with osteoarthritis/rheumatoid arthritis 49.30% 48.90% 46.90% 46.90% 50.10% 50.00% 48.68% 50.20%

% with osteoporosis 23.50% 22.80% 20.30% 21.90% 21.80% 21.80% 22.02% 21.70%

% with glaucoma 27.80% 25.90% 25.50% 25.60% 26.20% 25.50% 26.08% 25.10%

% with cataract 64.90% 65.50% 62.40% 60.40% 65.30% 67.30% 64.30% 65.70%

% women with breast cancer 11.80% 12.40% 11.20% 9.70% 10.80% 12.10% 11.33% 10.30%

% with colon cancer 3.40% 3.90% 2.80% 3.60% 3.10% 3.30% 3.35% 3.30%

% men with prostate cancer 13.30% 12.50% 15.20% 12.30% 14.20% 16.20% 13.95% 14.60%

% with lung cancer 1.90% 2.30% 1.90% 1.80% 2.10% 1.70% 1.95% 2.10%

% with hypothyroidism 17.00% 15.60% 15.00% 16.00% 16.60% 16.10% 16.05% 17.20%

% with anemia 48.30% 49.10% 48.50% 51.40% 52.30% 54.80% 50.73% 48.70%

% with benign prostatic hyperplasia 38.60% 41.30% 36.90% 34.70% 43.80% 42.80% 39.68% 40.90%

% with chronic kidney disease 19.80% 16.70% 18.90% 23.80% 20.30% 21.90% 20.23% 22.20%

Summary chronic disease measures Arlington Belmont Cambridge Somerville Waltham Watertown MAH Towns State

% with 4+ chronic conditions 57.70% 55.00% 52.00% 61.00% 60.30% 61.00% 57.83% 61.50%

% with 0 chronic conditions 8.30% 8.90% 11.60% 9.70% 9.00% 9.00% 9.42% 7.80%

ACCESS TO CARE Medicare

(65+ population) Arlington Belmont Cambridge Somerville Waltham Watertown MAH Towns State

% Medicare managed care enrollees 21.90% 20.30% 21.00% 27.00% 20.60% 24.90% 22.62% 21.20%

% dually eligible for Medicare and

Medicaid 8.50% 6.40% 19.20% 23.50% 13.60% 15.50% 14.45% 15.90%

% with a regular doctor 96.10% 97.10% 97.80% 97.80% 97.10% 97.10% 97.17% 96.20%

% did not see doctor when needed due

to cost 4.30% 1.40% 3.70% 3.70% 1.40% 1.40% 2.65% 3.70%

# of primary care providers

(within 5 miles) 584 970 4,564 4,555 529 909 2,019 11,897

# of hospitals (within 5 miles) 3 2 11 9 1 2 5 69

# of nursing homes (within 5 miles) 18 18 20 22 13 22 19 418

# of home health agencies (in same

town) 41 33 51 49 53 39 44 210

SERVICE UTILIZATION Arlington Belmont Cambridge Somerville Waltham Watertown MAH Towns State

Physician visits per year * 7.10 7.50 7.00 6.70 7.30 7.10 7.12 7.6

Emergency room visits/1000 persons

65+ years per year 578 548 598 735 607 637 617 646

Part D monthly prescription fills per

person per year 50.20 45.30 50.60 57.00 50.60 50.00 50.62 52.7

Home health visits per year 4.00 3.20 3.40 4.80 4.10 5.70 4.20 4.2

Durable medical equipment claims per

year 1.50 1.40 1.80 2.30 1.80 1.90 1.78 2.1

Inpatient hospital stays/1000 persons

65+ years per year 347 310 300 396 337 384 346 354

Inpatient hospital readmissions (as % of

admissions) * 19.50% 17.20% 15.90% 18.20% 18.00% 20.40% 18.20% 17.80%

Skilled nursing facility stays/1000

persons 65+ years per year 111 89 97 104 109 124 106 117

WELLNESS and PREVENTION Arlington Belmont Cambridge Somerville Waltham Watertown MAH Towns State

% any physical activity within last month 79.20% 77.90% 78.40% 78.40% 77.90% 77.90% 78.28% 72.40%

% injured in a fall within last 3 months 4.80% 6.30% 3.90% 3.90% 6.30% 6.30% 5.25% 5.10%

% ever had hip fracture 4.40% 4.20% 3.80% 4.20% 4.40% 4.30% 4.22% 3.90%

NUTRITION/DIET Arlington Belmont Cambridge Somerville Waltham Watertown MAH Towns State

% with 5 or more servings of fruit or

vegetables per day 32.90% 32.70% 27.60% 27.60% 32.70% 32.70% 31.03% 24.90%

% obese 21.00% 15.80% 19.30% 19.30% 15.80% 15.80% 17.83% 22.60%

% high cholesterol 68.40% 68.20% 62.20% 68.40% 72.20% 71.50% 68.48% 73.60%

% current smokers 4.60% 3.30% 5.50% 5.50% 3.30% 3.30% 4.25% 9.10%

% excessive drinking 10.40% 10.20% 14.10% 14.10% 10.20% 10.20% 11.53% 9.20%

WALKABILITY OF COMMUNITY Arlington Belmont Cambridge Somerville Waltham Watertown MAH Towns State

Walkability score (0-100) 91 72 89 91 98 80 87 52.6

Walker's Paradise Very Walkable Very walkable Walker's Paradise Walker's Paradise Very walkable

MENTAL HEALTH Arlington Belmont Cambridge Somerville Waltham Watertown MAH Average State

% with 15+ days poor mental

health last month 5.90% 6.70% 2.60% 2.60% 6.70% 6.70% 5.20% 6.70%

% satisfied with life 96.80% 95.80% 95.80% 95.80% 95.80% 95.80% 95.97% 95.80%

% receiving adequate emotional

support 83.00% 81.30% 77.40% 77.40% 81.30% 81.30% 80.28% 80.70%

% ever diagnosed with

depression 28.10% 28.10% 32.40% 31.50% 27.70% 31.60% 29.90% 28.60%

Appendix 6

YRBS TOPIC SELECTION PROCESS:

Part of the Mount Auburn Community Health Needs Assessment is monitoring their community benefit area’s adolescent population. Every year each town in Mount Auburn’s community benefit area performs a survey called the Youth Risk Behavioral Survey (YRBS). The YRBS is based off of a survey initially developed by the Center for Disease Control and Prevention, however slight modifications of survey questions occurred at each town. While these tailored questions are meaningful for individual town analysis, it resulted in several inconsistencies. Additionally every two years, the state of Massachusetts performs a similar survey, in order to aggregate statewide averages. The variation in methodology between towns, and the state makes the process of comparative examination more challenging. Once it was determined that all six of the towns in the Mount Auburn Hospital Community Benefit area had YRBS surveys in the past 3 years, the approach to determine which parts of the YRBS survey to focus on was a two part process. First a scan of major topics included in each survey was performed. After all of the major topics were listed, individual surveys were crossed referenced. When the town’s survey included the overarching topic, it received a score of 1. If the overarching topic was not included in the survey, it received a score of zero. Topics were then organized according to score. Because this analysis was focused on finding common themes across the Mount Auburn Hospital community benefit area a priority was to review topics with this lens. Assigning a score of 1 for each town (n=6) and 1 for the state meant that seven was the highest possible score for a topic. Topics which received a score less than 7 were eliminated from the potential selection process. In total 7 topics were immediately eliminated from the selection process and 10 topics remained, see chart below for breakdown:

Topics Included in 2nd round selection process:

Score > 7

Topics Eliminated from 2nd round selection

process: Score < 7

Alcohol Use Personal safety

Tobacco Use HIV & AIDS education

Marijuana Use Substance abuse during school

Other Illicit Drug Use Helping resources & Social Supports

Physical Education and Physical Activity Protective Factors

Dietary Behaviors Disabilities and Other Health Conditions

Weight and Weight Control Gambling

Violence Related Behaviors/ Experiences

Suicidality/ Mental Health

Sexual Behaviors and Sexual Education

YRBS TOPIC SCORES:

Overarching

Topic YRBS Subsection State Arlington Belmont Cambridge Somerville Waltham Watertown

MAH

Community

Benefit Area

Average Score

Having exercised or

participated in physical

activity for at least 20 minutes;

3x in the week prior to the

survey

44% 55% 71% 47% 40% 61% 45% 53%

2 or more hours on school

night in front of a TV screen25% 42% 12% 74% 30% 24% 36%

taken diet pills/ powders/

liquids/ without a doctors

advice

3% 3% 3% 4% 5% 6% 7% 5%

vomited / used laxative 4% 5% 4% 3% 5% 5% 7% 5%

not eaten/ fasted 10% 6% 6% 6% 10% 12% 9% 8%

Identify themselves as

overweight 29% 26% 33% 30% 30%

Trying to loose weight 45% 42% 40% 48% 46% 43% 44%

lifetime cocaine 4% 5% 3% 2% 2% 8% 10% 5%

lifetime ecstasy 5% 3% 3% 2% 6% 3%

lifetime prescription

medication13% 10% 15% 7% 17% 12%

lifetime heroin 1% 3% 1% 0% 6% 3%

current alcohol use (defined as

at least 1 drink, 30 days prior

to the survey)

36% 30% 35% 35% 21% 44% 36% 33%

current binge drinking

(defined as 5 or more drinks in

a row, 30 days prior to the

survey)

19% 16% 23% 19% 11% 26% 22% 19%

lifetime alcohol use 63% 58% 57% 50% 69% 55% 58%

current marijuana use 25% 16% 21% 30% 19% 23% 27% 23%

lifetime marijuana use 41% 32% 46% 33% 43% 37% 38%

current cigarette use 11% 7% 8% 9% 8% 20% 15% 11%

lifetime cigarette use 32% 20% 22% 29% 29% 40% 32% 29%

Experienced depression in the

previous 12 months 22% 21% 31% 21% 24%

attempted non-suicidal self

injury during the past year14% 17% 12% 16% 15%

seriously considered suicide 12% 12% 11% 8% 13% 13% 13% 12%

made a suicide plan 11% 11% 10% 7% 12% 13% 10% 11%

attempted suicide 6% 7% 8% 2% 6% 15% 11% 8%

Physical

Activity,

Dietary

Behaviors,

Weight

Control

Drug Use

Mental

Health and

Suicide

Appendix 7

Organization Town(s) KII SurveysGroup

Discussion

Vulnerable

Populations?

Joseph M. Smith Community Health Center,

Outreach Manager

Waltham,

Allston X X X

MAH Social Work Director X X X

MAH Homecare Director X X

MAH Q&S, Director Clinical Data X

MAH Case Management Director X X

MAH Immediate past, Chair Dept. of Medicine X

MAH Chair, Quality and Safety X

Director, Waltham Family School Waltham X X

Somerville Center for Adult Learning Somerville X X X

Cambridge Learning Center Cambridge X X X

Project Literacy Watertown X X X

Assistant Director, VNA of Easter MA Somerville X X

MAH Case Managers X X

Community Wide Event Arlington X

Community Wide Event Waltham X

Community Wide Event Watertown X

Community Wide Event Somerville X

Community Wide Event Belmont X

MAH Oncology Staff X

Assistant Director, Council on Aging Somerville X X X

Director, Department of Public Health Arlington X

Director, Department of Public Health Belmont X

Director, Department of Public Health Cambridge X

Director, Department of Public Health Waltham X

Interium Director, Department of Public Health Watertown X

Interim Director, Department of Public Health Somerville X

Director Council on Aging Arlington X X

Springwell, Director Health Partnerships

Watertown,

Belmont,

Waltham X X

Massachusetts Alliance of Portuguese Speakers

Director Prevention and Screening Services

Cambridge,

Somerville X X

Director Council on Aging Belmont X X

Director Council on Aging Cambridge X X

Director Council on Aging Watertown X X

Director Council on Aging Waltham X X

Somerville Cambridge Elder Services, Executive

Director Somerville X X

American Cancer Society, Community Engagement All Towns X

Men's Health League Coordinator Cambridge X X

Watertown Together Watertown X X

Waltham High School Waltham X

CASPAR-Womans Homeless Shelter Cambridge X X

Data Collection Summary

Appendix 8

Key Informant Interview Thank you for taking the time to talk with me today. I am the Director of Community Health here at Mount Auburn Hospital. As part of our goal to engage the community in this process I am meeting with key stakeholders such as yourself to learn from you about community health and community needs. This interview should take about one hour. I’m going to ask you some questions to get your ideas and opinions what you see as priority areas to improve the health of the community Mount Auburn Hospital serves. Please let me know if you need me to repeat or clarify anything. What you have to share is very important. Please be candid with your responses, it is very important to us to hear both your positive and negative opinions. This interview has been approved by our Institutional Review Board as a Quality Improvement project. Your individual answers will be kept confidential and I won’t include any identifying information in the data or in the final report. Results will be reported for all interview respondents as a whole—we won’t produce reports on individual respondents. Your participation in this interview is totally voluntary. If you don’t want to answer any questions, just let me know. I’ll also be taking notes while we talk. Do you have any questions about the interview process before I get started with my questions?

1. How would you describe the town or population you serve?

If someone was thinking about serving this population what would you say are some of the biggest

strengths, the best or most positive things about it? What do you do? What are you most proud

of? How do you most impact the health of the community for the better?

2. What are some of the biggest problem or concerns for the population you serve?

What worries you the most? What doesn’t work well? (Probe Health, economic, social, safety…..) (If

applicable, in your opinion, what, if any challenges, does the population you serve have in trying to

get health care? Probe for barriers like insurance, appointment times; wait for appointment,

language, translation, transportation…)

3. From this list of health indicators please choose the top 3 health concerns in the population

you serve? (list as many as possible)

4. Substance Abuse

• Tobacco • Access To services

• Crime • Mental Health • Obesity and Active Living • Homelessness/Affordable Housing • Domestic Violence • Poverty/limited financial resources • Nutrition/Access to Food • Sexual Health • Transportation

• Others_________________

5. Now we are going to talk about a few of the health issues you mentioned in #2 (select top 3-5

health concerns from above).

a. Tell me more; what specifically concerns you about X?

b. How do you know that this is a problem (or, why do you believe that this is a problem?)

c. What, if any, evidence or information relates to X area? (probe for any kind of data, i.e.

annual reports, reason for calling, tracking tools, Facebook data, etc.)

d. Am I able to see that data? Can it be shared with the public?

e. What, if any, additional data do you think would be helpful that isn’t currently being

collected or looked at?

6. What do you think would make X better? (list-there may be more than one thing. Focus on the

top three) (add probes for policies, programs, collaboration, etc.)

a. Is anyone working on what would make X better?

b. What would be your vision relating to X (what is the best possible scenario)? Probe-

What that would look like? Who would be involved?

c. What are some barriers to realizing this vision/making X better?

7. Do you work with Mount Auburn Hospital or another hospital/health care organization to

address X?

8. If not already mentioned, where do you think your organization is uniquely positioned to

partner with other community organizations to address topic X?

****repeat questions 3-7 for each of the health topics****

9. Others we have interviewed have described wanting to find out what each organization offers

community members. Is there a comprehensive list of everything that your organization does?

Who has the list?

10. Earlier we discussed what clinical organizations you may work with regarding some of the

health topics we discussed. I would like to take a few minutes to review any current

connections to Mount Auburn

11. Population Health is a relatively new term being used in many arenas. I'd like to get your

opinions about the concept of population health. What do you think is meant by the term?

a. How would you describe it in your own words?

b. What are the most critical components of population health?

c. How, if at all, does population health relate to your role?

12. Based on what we have discussed what would be your priority topic(s) and/or content areas

for the next steps in the Community Health Needs Assessment?

13. Is there anything you think I should have asked, or anything else that you’d like to share?

14. Please answer the following question with up to three different answers:

If the organization I represent could work closer with _____________________ we would be able

to improve the health of the community members we serve.

1) 2) 3)

15. Please fill in the blank with something other than money or funding. If I had

__________________. It would enable me to better serve me community/population?

1) 2) 3)

Appendix 9

Community Organization Relationship Grids

OrganizationContact (including

town(s) served)

Type of

organization (local,

state, regional,

national)

Do you already work

with this

organization?

What the organization is doing

that’s working well?

What could be improved

upon?

Fill Out During Key Informant Interview

Health care

OrganizationContact Topics discussed

What the organization is doing

that’s working well?What could be improved upon?

Fill Out During Key Informant Interview

Appendix 10

Group Conversation Guide

Hi, my name is _______________ and I am a nurse with Mount Auburn Hospital. Thank you for taking the time to speak with us today. We’re here to learn from you today. We want to hear your opinions. There is no right or wrong answer. We want to know your opinions both positive and negative. We are going to take notes. Mount Auburn Hospital is talking to many people to learn more about the community. After all of the groups are done, we will write a summary report of the general opinions that have come up. In that report, we might provide some general information on what we discussed tonight, but I will not include any names or identifying information. I won’t say “Sue said……” What you say is strictly confidential. In the report, nothing you say here will be connected to your name. Now, first let’s spend a little time getting to know one another. Let’s go around the table and introduce ourselves. Please tell me: 1) Your first name; 2) what city or town you live in;

1. How would you describe your community? Where you live? Work? Go to School?

2. If someone was thinking about XX what would you say are some of the biggest strengths,

the best or most positive things about it? What is good?

3. What are some of your biggest problem or concerns in your community? (Probe Health,

economic, social, safety…..)

4. What are the more pressing health concerns in your community?

5. Now we are going to talk about a few of the health issues you mentioned (select top

health concerns from above and repeat the questions below for each).

• What would make XXXX better?

• Is anyone working on XXX?

• What do you think should be done? Probe- What that would look like? Who would

be involved?

6. Is there anything else you want to tell us?

7. Is there anything else we should have asked?

Thank you very much.

Appendix 11

ESOL Provider Survey

Thank you for taking the time to answer these questions. At Mount Auburn Hospital we are hoping to learn more about the students you

serve in order to improve our Community Health Programming. Your individual answers will be kept confidential and we won’t include

any identifying information in the data or in the final report. Results will be reported for all interview respondents as a whole—we won’t

produce reports on individual respondents.

Your participation in this survey is totally voluntary. If you don’t want to answer any questions, just leave them blank.

1. What towns does your organization serve? Check all that apply

Cambridge

Arlington

Belmont

Watertown

Waltham

Somerville

Other (please specify)

2. What, if any, new populations are utilizing your services?

3. Please list the top three health issues you believe affect your students.

1)

2)

3)

4. Please describe the three most common barriers to health care you believe your students may

experience.

1)

2)

3)

5. In your opinion your students have access to the following health screenings?

Yes No I don't know

Breast Cancer-

Mammograms

Colorectal Cancer-

Colonoscopy

Cervical Cancer-Pap

Smear

Prostate Cancer- PSA

testing

Cholesterol

Blood Sugar

Blood Pressure by a

doctor or nurse

6. In your opinion, what health topics are the students most interested in learning about? Please check all

that apply.

Cancer

Heart Disease

Stroke

Diabetes

Sexuality Transmitted Diseases

HIV


7. How do your students get their health information?

Doctor/Nurse

Friend

Family

At this ESOL program

Community Health Workers


8. Please list any resources that you know about that help your student’s access health care.

9. Please share any thoughts you may have about how to improve the health and/or well-being of your

students.

1

Appendix 12

Community Benefit General SurveyCommunity Benefit General Survey

Thank you for taking this survey. You answers will help us better serve our communities. All your responses are anonymous.

* 1. Where do you live?

Arlington

Belmont


Cambridge

Somerville

Waltham

Watertown

* 2. From the list below please pick the top 5 health concerns for you AND/OR your friends, family.

First Choice Second Choice Third Choice Forth Choice Fifth Choice

Alcohol Abuse

Drug Abuse

Being Overweight or

Obese

Getting Breast Cancer

Screening

Getting Colorectal

Cancer Screening

Getting Skin Cancer

Screening

Getting Lung Cancer

Screening

Getting Cervical Cancer

Screening

Getting Prostate Cancer

Screening

Cancer Treatment

Preventing Cancer

Asthma

Other Lung Disease like

Emphysema, COPD

Cost of Medical, Dental

or Mental health care

2

First Choice Second Choice Third Choice Forth Choice Fifth Choice

Dental and Oral Health

Diabetes

Domestic Violence

Heart Disease

Mental Health (like

Depression, Anxiety,

Stress, Bipolar Disorder)

Sexually Transmitted

Infections (Like

HIV/AIDS, Chlamydia)

Suicide

Teenage Pregnancy

Tobacco Use

* 3. In the past two years have you or a family member had difficulty accessing...

Yes No Have not needed service

Medical Care?

Surgical Care?

Dental Care?

Mental Health Care?

Emergency Care?

4. If you answered yes to any of the above please explain:

3

* 5. Please think about the AVAILABILITY of these health or medical services in your area. How satisfied or

dissatisfied are you with the availability of the following services?

Not at all

satisfied Slightly satisfied

Moderately

satisfied Very satisfied

Extremely

satisfied N/A

Health or medical

services for children

under age 18

Health or medical

services for adults ages

18 to 65

Health or medical

services for elders ages

65 and over

* 6. Please think about the AVAILABILITY of these medical specialists services in your area. How satisfied or


Not at all


Moderately


Extremely

satisfied N/A

Medical specialists for

children under age 18


adults age 18 to 65


elders ages 65 and over

* 7. Please think about the AVAILABILITY of these surgical services in your area. How satisfied or


Not at all


Moderately


Extremely

satisfied N/A

Surgical specialists for

children under age 18


adults age 18 to 65


elders ages 65 and over

4

* 8. Please think about the AVAILABILITY of these counseling or mental health services in your area. How

satisfied or dissatisfied are you with the availability of the following services?

Not at all


Moderately


Extremely

satisfied N/A

Counseling or mental

health services for

children up to age 18


health services for adults

ages 18 to 65


health services for elders

over age 65

* 9. Please think about the AVAILABILITY of dental or oral health services in your area. How satisfied or


Not at all


Moderately


Extremely

satisfied N/A

Dental or oral health

services for children up

to age 18


services for adults ages

18 to 65


services for elders over

age 65

* 10. Please think about the AVAILABILITY of these services in your area. How satisfied or dissatisfied are

you with the availability of the following services?

Not at all


Moderately


Extremely

satisfied N/A

Maternity Services

Birth Control or Sexual

Health Services

Alcohol or Drug

Treatment Services

5

* 11. How important to you are the topics below?

Not at all important

Somewhat

important

Moderately

important Very important Extremely important

Interpreters during

health appointments

Public transportation to

health appointments

On street parking for

health appointments

Low cost parking for

health appointments

Health appointments

after 5p

Weekend health

appointments

* 12. Are you interested in a program to?

For myself For someone I know

For myself AND someone

I know Not interested

Help quit smoking

Lose weight

Exercise more

Reduce stress

Manage a chronic

disease

6

* 13. Are you interested in the following?

Not interested at all For myself For someone I know

1 to 2 hour educational

session about health

topics

6 week self-

management class for

chronic diseases

6 week self-

management class for

diabetes

6 week class for

caregivers of elders

8 week class to help

prevent falling

1 to 2 hour educational

session on caring for

aging parents

14. Please list any health related programs you would be interested in seeing offered?

* 15. Do you have one person you think of as your personal doctor or health care provider?

Yes No

7

16. If you answered yes above where do you receive your primary health care?

Mount Auburn Hospital

Cambridge Health Alliance

Lahey Clinic

Harvard Vanguard Medical Associates

Joseph M. Smith Community Health Center

Winchester Hospital

Massachusetts General Hospital

Brigham and Women's Hospital

Beth Israel Deaconess Medical Center


* 17. Have you gone to the Emergency Department in the last year?

Yes No

18. If yes, where have you gone to the Emergency Department? Please check all that apply.

Mount Auburn Hospital

Cambridge Health Alliance

Lahey Clinic

Harvard Vanguard Medical Associates

Winchester Hospital

Massachusetts General Hospital

Brigham and Women's Hospital

Beth Israel Deaconess Medical Center


* 19. Was there a time in the past 12 months when you needed to see a doctor, nurse or other health care

provider but were not able to see one?

Yes No

8

20. If yes, why were you unable to see a doctor, nurse or other health care provider? Please check all that

apply.

Copay or other cost too high

Could not get appointment

Language barriers

Transpiration Issues

Insurance issues


21. Please let us know how you think Mount Auburn Hospital could help you or your family improve your

health?

22. Please share anything else you would like to tell us about your health, the health of your family or your

community?

Thank you for your thoughtful responses. The next few questions will help us understand you a little better.

9

* 23. What is your gender?

Male

Female


Transgender

Transsexual

Prefer not to answer

* 24. Which of the following would you say is your race? Check all that apply.

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White


* 25. Are you Hispanic or Latinos?

Yes No

* 26. What is your age group?

Younger than18

18-20

21-24

25-44

45-64

65-80

81 and over

* 27. What is the highest grade or year of school you completed?

Never attended school

Up to grade 8

Some high school

Grade 12 or GED

Some college

Completed college

Completed Masters or post college degree

1

Appendix 13

Qualitative Data Highlights

Community Paper Survey

What is the one thing you would like to

improve about your health?

Arthritis

Asthma/Breathing

Balance

High Blood pressure

Diabetes

Heart

Obesity and Active Living

Pain management

Sleep

Stress Management

Stop smoking

What Would Make Your Town A Better Place?

Active Living

Traffic

Crime & Safety

Public Transportation

Taxes

Schools

Community Events

Affordable Housing

3

0

20

40

60

80

100

120

140

160

Electronic Community Survey

Top 5 Health Concerns N=291

4

Chronic

Disease

15%

Obesity and

Active Living

46%Stop Smoking

11%

Gain Weight

4%

Improve

Mental Health

8%

Increase

Engergy

4%

See a

dentist

4%See a

podiatrist

4%

Sleep

Better

4%

CASPAR For WomanWhat do you want to improve about your

health?

5

Appendix 14

Current Community Resources and

Mount Auburn Hospital Community Benefit Programs

An overview of some current resources addressing the concern was generated during key informant

interviews, group conversations, advisory group meetings, the World Café. This is not intended to be

a complete resources list for each health concern but a living document outlining information

garnered during the assessment process.

Current MAH community benefit related programming is listed for each health concern along with a

recommendation whether or not to continue the program from the evaluation of the program. This

will be helpful during the implementation planning process.

I. Obesity and Inactive Living

A. Overview of some of the current resources addressing the concern:

1. Healthy Eating

• Somerville has healthy meals for the summer-free breakfast and lunch

• Somerville Farmer’s Market at Senior Center

• Many Farmer’s Markets take EBT coupons

• Watertown and Waltham have individual, school and low-income housing gardens.

• Somerville is integrating culturally appropriate food at farmers markets so immigrant

population can access it

• Watertown and Cambridge have school and city policies to promote healthier foods in

vending machines with healthy options.

• Waltham schools have USDA grant to introduce fruit and veggies during school snacks.

• The Food Project builds raised beds and distribution of produce

• Health Waltham conducts cooking classes and cooking demos

• Farmers Markets at schools for families

• Somerville Food Security Coalition

• Many companies have workplace wellness

• Cooking for One program is run at Belmont Senior Center

• Mobile Farmers Markets in many towns

• Boston Area Gleaner delivers to local food pantries

• Waltham- Vouchers for Community Fields Farms

• Watertown Boys and Girls Club healthy eating programs

• WIC is a great resource has recently revamped their education

• Head Start emphasis on eating and involving parents

• Food pantries working with local churches

• Meal cooking by local churches

• Bentley and Brandis giving up meal points for program called “Be Our Guest”

6

• Bentley and Brandis students cook at the Community Day Center Waltham

B. Active Living

• Cambridge- bike workshop series to encourage families and seniors to learn to ride bikes,

host bike rides and bike safety. Also expanding bike lanes and infrastructure and markings

Interest in Cambridge to connect homeless population with Hub way

• Waltham working on Complete Street Initiatives

• Waltham and Belmont have Walking School Bus

• Cambridge has a program with healthy markets-encourages walks with owners

• Boston Sports Club doesn’t require membership to use showers to bike/run to work/

• Grants for youth at Wayside include physical education, integrate the 2.

• House authorities who are working : no smoking, walking groups

• Watertown Pep grant explores options for how to be active

• City Sprouts in Cambridge-gardening and food prep

• Some schools keep physical education

• Fitness Buddies, Men’s Health League Cambridge

• Waltham-parent volunteers-run before school exercise

• Many walk to school programs

• Apps to help with health like Fitbit to increase awareness of activity and eating however are

costly only some have access

• Supermarket tours at CRCHC: how to shop on a budget, unit price, perimeter=best, labels etc.

Each participant receives $10 to create a meal

• Cambridge has workshops in different languages about how to be active with kids

C. Organizations working on addressing Obesity and Inactive Living

• Boston Area Gleaners

• Lovin Spoonful’s, food rescue project

• Food for Free

• Healthy Waltham

• Shape Up Somerville

• Live Well Watertown

• Cambridge Food and Fitness Council

• City Sprouts, Cambridge

• Belmont Food Collaborative-Be Well Belmont

D. Current MAH programming related to Obesity and Inactive Living

Current MAH Programming Recommendation to continue?

SNAP Enrollment Yes

Food Drives Yes

Food and Activity Policy Councils Consider during prioritization

7

II. Poor Self-Management of Chronic Disease


• Evidenced Based Programs (in particular Stanford Chronic Disease Self-Management,

Diabetes Self-Management, Healthy Living) provided by Springwell, Somerville Cambridge

Elder Services, Councils on Aging

• Matter of Balance Fall Prevention Programs

• Health coaches example-Compass Program, Medicare population Accountable Care

Organizations

• CRCHC is doing group visits-patients see all providers at one visit

• Facing Cancer Together Program

• Cambridge and Arlington have trained community members who work in-barbershop, hair

salons

• Mobile Health Apps

• Complex Care Nurse Managers- with some health plans, health organizations

• Somerville Cambridge Elder Services Transitions In Care Program

• YMCA-Diabetes prevention programs

• Cambridge-Men’s Health League Fitness Buddies

B. Current MAH programming related to Poor Self-Management of Chronic Disease


Matter of Balance Fall Prevention Yes

Watertown Task Force Consider during prioritization

Bereavement Support Yes

Cancer Support Yes

Lyme Disease Education Program Yes

Facilitation to Health Insurance Yes

Listen and Learn, Bridge to HealthCare

Community Education

Yes

Healthcare for Homeless Yes

Smoking Cessation Yes

Elderly Cardiovascular Health Yes

Addressing Transportation Yes

Personal Emergency Response Systems Yes

Stanford Chronic Disease Self-Management Consider during prioritization


Stanford Diabetes Self-Management Consider during prioritization

Powerful Tools for Caregivers Consider during prioritization

Stanford Thriving and Surviving No, current program has not met

needs of community members.

Mind Body for Cancer Patients Yes

Barron Center for Men’s Health Clinic Consider during prioritization

Transportation Yes

8

III. Mental Health Issues


• McLean’s Hospital including Waverly Place

• Mount Auburn Hospital

• Cambridge Health Alliance

• Edinburg Center

• Advocates

• Cambridge Community Policing

• Arlington Community Policing

• Somerville Community Policing

• Somerville Department of Public Health

• Cambridge Department of Public Health

• Mental Health First Aid Training, many organizations have participated

• Integrating behavioral physical health being done at some locations

• National Alliance on Mental Illness local chapter

• During May, Mental Health Month, media and social media information about mental health

• Arlington and Watertown have resource guides

• Cambridge working on resource guide for families

• Harvard University Students are collaborating with “Youth on Fire”

• Watertown Hoarding Task Force and program on Hoarding

• Paine Senior Services

• VINFEN

• New Guidance Center

• North Charles Mental Health

• Arlington Youth Counseling Center

B. Current MAH programming related to Mental Illness


Mental Health First Aid Yes

Safe Beds and Rooming In Yes

Mind Body Yes

Watertown Social Work Support Consider during prioritization

Support Groups- Cancer, Bereavement Yes

Collaborative Efforts between Se and

Community Organizations

Yes

Support for Family to Family Yes

9

IV. Substance Abuse


• Arlington, Belmont, Cambridge, Somerville, Waltham and Watertown police departments and

departments of public health.

• Mount Auburn Hospital and Cambridge Health Alliance

• AIDS Action Committee-Needle Exchange- Narcan training

• OPEN Cambridge

• Learn To Cope™

• Massachusetts Department of Public Health

• Bureau of Substance Abuse, MA

• Homeless Coalition

• Bay Cove

• Teen Empowerment Somerville

• Drug Free Communities grants

o Somerville Cares About Prevention

o Cambridge Prevention Coalition

o Watertown Youth Coalition/Wayside Youth and Family Support Network

o Waltham Partnership for Youth

B. Current MAH programming related to Substance Abuse

Current MAH Programming Recommendation to

continue?

Tobacco Cessation Yes

In Kind Space for AA and SMART

Recovery

Yes

Overdose Prevention Work Yes

Cambridge Community Policing Yes

V. Access to care

A. Resources to address access to care include:

• Joseph M. Smith Community Health Center

• Cambridge Health Alliance

• Mount Auburn Hospital

• Door 2 Door Transportation

• The RIDE (MBTA)

• Busy Bee Transportation

• Springwell Senior Medical Escort Program

• The Sanborn Foundation, Arlington

10

• Independent Transportation Network

• Local cab companies at discounted rates

B. Current MAH programming related to Access to Health Care Services


continue?

Financial Counselor Enrollment Yes

Transportation Yes

Doula Support Yes

Pregnancy Group Support Yes

Maternal Child Health Task Force Yes

Financial Counselors on site at

CRCHC

Yes

VI. Broad Public Health Concerns

A. Resources to address broad public health concerns include:

• Local Departments of Public Health

• State and Federal Departments of Public Health

• District Attorney’s Office

B. Current MAH programming related to Broad Public Health Concerns


continue?

Emergency Preparedness Yes

Flu Clinic Support Yes, as needed

Safe Kids, Safe Babies Yes

Cristo Rey Workforce Development Yes

mah community health needs assessment 2015 appendix

Documents