Community Health Needs Assessment

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Community Health Needs Assessment

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Introduction

Background and Purpose

Keck Hospital of USC is a private, nonprofit 411-bed acute care hospital staffed by the faculty at the Keck School of Medicine of the University of Southern California. On November 1, 2011 we introduced the Keck Medical Center of USC – a new name in world-class medicine encompassing Keck Hospital of USC (formerly USC University Hospital), USC Norris Cancer Hospital and 500 renowned faculty physi-cians from the Keck School of Medicine of USC.

Originally opened in 1991, the hospital offers some of the most sophisticated technology available. Among the hospital’s advanced services are neuro-interventional radiology, minimally invasive

cardiothoracic surgery, robotic surgery and interventional cardiology. Surgical specialties include organ transplantation and neurosurgery, as well as cardiothoracic, bariatric, esophageal, orthopedic, and plastic and reconstructive surgeries.

Keck Hospital of USC is home to these specialized services: • Heart, Lung and Vascular Services

• Weight Loss and Digestive Disorders • Orthopedics and Sports Medicine

• Transplant Programs – specializes in the treatment areas of: bone marrow, heart, kidney, liver and lung transplant

• Neuroscience and neurosurgery • Diabetes

• Cystic Fibrosis • Head and Neck • Ophthalmology

In addition to patient care, Keck Hospital of USC is a site for clinical research, supporting patients par-ticipating in cutting edge clinical trials. Keck Hospital of USC is also strongly committed to education. As a member of the USC family, we are a teaching hospital, training residents and fellows in graduate medical education. Keck Hospital of USC is also a highly regarded clinical rotation site for local nursing and allied health programs.

Keck Hospital of USC has undertaken a Community Health Needs Assessment (CHNA) as required by state and federal law. California Senate Bill 697 and the Patient Protection and Affordable Care Act and IRS section 501(r)(3) direct tax exempt hospitals to conduct a community health needs assessment and develop an Implementation Strategy every three years.

The Community Health Needs Assessment is a primary tool used by the hospital to determine its com-munity benefit plan, which outlines how it will give back to the comcom-munity in the form of health care and other community services to address unmet community health needs. This assessment incorporates components of primary data collection and secondary data analysis that focus on the health and social needs of the service area.

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Service Area

Keck Hospital of USC is located east of downtown Los Angeles on USC’s Health Sciences Campus at 1500 San Pablo Street, Los Angeles, California 90033. Keck Hospital of USC is located in the Boyle Heights neighborhood of Los Angeles in L.A. County Service Planning Area (SPA) 4. The hospital draws primarily adult patients regionally from Southern California, with a primary service area of Los Angeles County, California. Approximately 70% of the hospital’s patients originate from L.A. County.

Author

Melissa Biel of Biel Consulting conducted the Community Health Needs Assessment. Biel Consulting is an independent consulting firm that works with hospitals, clinics and community-based nonprofit organizations. Dr. Biel has over 10 years of experience conducting hospital Community Health Needs Assessments.

Organizations and Partners

As part of Keck Medical Center of USC, Keck Hospital of USC conducted the Community Health Needs Assessment in partnership with USC Norris Cancer Hospital. We acknowledge the organizations and agencies that contributed time and resources to assist with the conduct of the needs assessment.

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Boyle Heights Health Profile

Keck Hospital of USC is located in Boyle Heights, a community in East Los Angeles. Boyle Heights is one of fourteen communities in California that is participating in The California Endowment’s Building Healthy Communities initiative. Health information and community resources in Boyle Heights can be accessed here: www.calendow.org/communities/building-healthy-communities/

www.bhcconnect.org/boyle-heights

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Secondary Data Collection

Secondary data were collected from a variety of sources to present Los Angeles County demographics, social and economic factors, health access, mortality, birth characteristics, chronic disease, and health behaviors. Sources of data include the U.S. Census 2010 decennial census and American Community Survey, California Health Interview Survey, California Department of Public Health, California Employment Development Department, Los Angeles County Health Survey, Los Angeles Homeless Services Authority, Uniform Data Set, CDC National Health Statistics, National Cancer Institute, U.S. Department of

Education, and others. When pertinent, these data sets are presented in the context of California State. The report includes benchmark comparison data that measures Keck Hospital of USC community data findings with Healthy People 2020 objectives (Attachment 1). Healthy People 2020 objectives are a national initiative to improve the public’s health by providing measurable objectives and goals that are applicable at national, state, and local levels.

Primary Data Collection

Targeted interviews were used to gather information and opinions from persons who represent the broad interests of the community served by the hospital. Eighteen interviews were completed during February and March, 2013. For the interviews, community stakeholders identified by Keck Hospital of USC and Norris Cancer Hospital were contacted and asked to participate in the needs assessment. Interviewees included individuals who are leaders and representatives of medically underserved, low-income, minority and chronic disease populations, or regional, State or local health or other departments or agencies that have “current data or other information relevant to the health needs of the community served by the hospital facility.” A list of the stakeholder interview respondents, their titles, organizations and leadership roles are in Attachment 2.

Information Gaps

Information gaps that impact the ability to assess health needs were identified. Specifically, the results of the most recent 2011 Los Angeles County Health Survey (a population based telephone survey that provides information concerning the health of Los Angeles County residents) were not yet available during the conduct of this CHNA.

Health Care Facilities and Community Resources

Given the large number of organizations and agencies serving the area in Los Angeles County it is a challenge to compile a comprehensive list of community resources. Therefore, this Community Health Needs Assessment references the links to sources for health care facilities and community resources.

A list of hospitals and hospital systems is available through the Hospital Association of Southern California and can be found at: www.hasc.org/member-hospitals-systems

A list of community clinics is available at: www.ccalac.org. Additional resources can be accessed at:

• www.211la.org

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Based on the results of the primary and secondary data collection, health needs were identified. Each health need was confirmed by more than one indicator or data source (i.e., the health need was suggested by more than one source of secondary or primary data). In addition, the health needs were based on the size of the problem (number of people per 1,000, 10,000, or 100,000 persons); or the seriousness of the problem (impact at individual, family, and community levels). To determine size or seriousness of a problem, the health need indicators identified in the secondary data were measured against benchmark data, specifically California state rates or Healthy People 2020 objectives. Indicators related to the health needs that performed poorly against these benchmarks were considered to have met the size or seriousness criteria. Additionally, primary data sources were asked to identify community and health issues based on the perceived size or seriousness of a problem.

The identified health needs included:

Access to Care Healthy Eating/Physical Activity Alcohol and Tobacco use Minority Education

Chronic Diseases Overweight and Obesity Community Safety Preventive Care

Priority Health Needs

Priority setting is a required step in the community benefit planning process. The IRS regulations indicate that the Community Health Needs Assessment must provide a prioritized description of the community health needs identified through the CHNA, and include a description of the process and criteria used in prioritizing the health needs.

In April 2013, summary data on the identified health needs were presented to the hospital Leadership Team and the hospital’s Community Benefit Advisory Committee. They were asked to examine each health need as it related to the following priority factors:

• If left unaddressed, is the issue likely to become more serious?

• Does the issue offers potential for program intervention that can result in measurable impact?

• Does Keck Hospital of USC have acknowledged competencies and expertise to address the issue and the issue fits with the organizational mission?

The members of the Leadership Team and Community Benefit Advisory Committee were also asked to rank order the health needs given the scope of the problem and how the health need fit with the priority factors. The prioritized health needs to be addressed by the hospital and detailed in the Implementation Strategy are: Access to Care

Disease Prevention and Health Promotion, with a special focus on healthy eating, physical activity, and overweight/obesity issues

Chronic Disease Management

Health Sciences Education for Minority Students

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Population

At the time of the 2010 Census, the population for Los Angeles County was 9,818,605. From 2000 to 2010, population growth increased an estimated average of 3.1%. This was a slower rate of growth than experienced statewide.

Change in Total Population, 2000-2010

Los Angeles County California

Total Population 2000 9,519,338 33,871,648 Total Population 2010 9,818,605 37,253,956 Change in Population 2000-2010 3.1% 10.0% Source: U.S. Census Bureau, 2000 + 2010 Census

Children and youth (ages 0-17) make up 24.5% of the population; 33.1% are 18-39 years of age; 31.5% are 40-64; and 10.9% of the population are older adults, 65 years of age and older. The area has a higher percentage of adults, ages 18-39 than found in the State.

Population by Age

Number Percent Number Percent

Age 0-4 645,793 6.6% 2,531,333 6.8% Age 5-17 1,756,415 17.9% 6,763,707 18.2% Age 18-39 3,253,904 33.1% 11,814,407 31.7% Age 40-64 3,096,794 31.5% 11,897,995 31.9% Age 65+ 1,065,699 10.9% 4,246,514 11.4% Total 9,818,605 100.0 % 37,253,956 100.0 % Source: U.S. Bureau of the Census, 2010; Healthy City

Race/Ethnicity

The majority population race/ethnicity in the Service Area is Hispanic or Latino (47.7%). Whites make up 27.8% of the population. Asians comprise 13.5% of the population, and African Americans are 8.3% of the population. Native Americans, Hawaiians, and other races combined total 2.7% of the population. When com-pared to the state, the county has a larger percentage of Latinos, Asians, and African Americans, and a smaller percentage of Whites.

Population by Race and Ethnicity

Race/Ethnicity Los Angeles County California

Hispanic or Latino 47.7% 37.6%

White 27.8% 40.1%

Asian 13.5% 12.8%

Black or African American 8.3% 5.8% American Indian & Alaskan 0.2% 0.4% Native Hawaiian & Pacific Islander 0.3% 0.3%

Other or Multiple 2.2% 3.0%

Source: U.S. Bureau of the Census, 2010; Healthy City

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Citizenship

19.7% of the population in the county is not a U.S. citizen. This is a higher percentage than found in the state.

Not a Citizen 19.7% 14.9%

Source: U.S. Bureau of the Census, 2006-2010 American Community Survey

Language

In LA County, Spanish is spoken in 39.4% of the homes; this is higher than the number of Spanish speaking households in the state (28.5%). 39.4% of the residents speak English only, and 10.7% speak an Asian lan-guage.

Language Spoken at Home for the Population 5 Years and Over

Geographic Area English Only Spanish Asian Indo-European Other Los Angeles County 43.6% 39.4% 10.7% 5.3% 1.0%

California 57.0% 28.5% 9.4% 4.3% 0.8%

Linguistic Isolation

Linguistic isolation is the population over age 5 who speak English “less than very well.” In the county, 27% of the population is linguistically isolated, which is higher than in the state where 19.9% of the population is linguistically isolated.

Linguistic Isolation among Population 0ver 5 Years of Age Geographic Area Linguistic Isolation Los Angeles County 27.0%

California 19.9%

Family Size

The average family size in the Service Area is 3.65 persons, which is higher than in the state. Average Family Size

Geographic Area Family Size

Los Angeles County 3.65

California 3.50

Source: U.S. Bureau of the Census, American Community Survey, 2007-2011

Veteran Status

In the county, 5% of the population 18 years and older are veterans. This is lower than the percentage of vet-erans found in the state (7.6%).

Veteran Status 5.0% 7.6%

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Social and Economic Factors Ranking

The County Health Rankings rank counties according to health factors data. Social and economic indicators are examined as a contributor to the health of a county’s residents. California’s 58 counties are ranked according to social and economic factors with 1 being the county with the best factors to 58 for the county with the poorest factors. This ranking examines: high school graduation rates, unemployment, children in poverty, social support, and others. Los Angeles County is ranked in the bottom half of California counties for social and economic factors.

County Ranking (out of 58) Los Angeles County 36

Source: County Health Rankings, 2012

Poverty

Poverty thresholds are used for calculating all official poverty population statistics. They are updated each year by the Census Bureau. For 2012, the Federal Poverty Level for one person was $11,170 and for a family of four $23,050. The rate of poverty in the county is 15.7%, which is higher than in the state rate of 13.7%. Poverty in-creases markedly for the population at or below 200% of the FPL as over one-third of county residents (37.6%) exist at 200% of FPL.

Ratio of Income to Poverty Level

Geographic Area Below 100% Poverty Below 200% Poverty

Los Angeles County 15.7% 37.6%

California 13.7% 32.8%

Children in Poverty

Data on the percent of children in poverty paint a more concerning picture. In Los Angeles County, children suffer with higher rates of poverty than the general population. In the service area, 22.4% of children, under age 18 years, are living in poverty. Among families where there is a female head of household and children under 18 years old, 34.6% in the county live in poverty. This is higher than the state rate of 32.4%.

Poverty, Children under 18, Female Head of Household Families with Children under 18 Geographic Area Children in Poverty Female Head of Household (Under 18 Years) Families with Children in Poverty

Los Angeles County 22.4% 34.6%

California 19.1% 32.8%

Seniors in Poverty

In the county, 11.7% of seniors live in poverty, which is higher than the state rate of 9.1%. Geographic Area Seniors in Poverty

Los Angeles County 11.7%

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Public Program Participation

In LA County, 38.2% of residents are not able to afford food and 13.4% utilize food stamps. This indicates a considerable percentage of residents who may qualify for food stamps but do not access this resource. WIC benefits are more readily accessed in the County; 52.5% of qualified adults participate in the WIC program. Among qualified children, 60.1% access WIC. 5.9% of county residents are TANF/CalWorks recipients. Public Program Participation

Geographic Area Los Angeles County California Not Able to Afford Food (<200%FPL) 38.2% 40.4%

Food Stamp Recipients 13.4% 13.4%

WIC Usage among Qualified Adults 52.5% 46.4% WIC Usage among Qualified Children

(Ages 6 and Under) 60.1% 48.7%

TANF/CalWorks Recipients 5.9% 6.2%

Source: California Health Interview Survey, 2009

Free or Reduced Price Meals

The percentage of students eligible for the free or reduced price meal program is one indicator of socioeco-nomic status. Among all students in LA County schools, 65.3% are eligible for the free and reduced price meal program, indicating a high level of low-income families.

Free and Reduced Price Meals Eligibility

Geographic Area Number Percent

Los Angeles County 1,017,249 65.3%

California 3,465,446 56.7%

Source: California Department of Education, 2010-2011

Unemployment

Compared over three years, unemployment rates were lower in 2009, rising in 2010, and decreasing in 2011. In 2011 Los Angeles County had a 12.3% unemployment rate.

Unemployment Rates, Annual Average, 2009-2011

Geographic Area 2009 2010 2011

Los Angeles County 11.6% 12.6% 12.3%

California 11.3% 12.4% 11.7%

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Education

Of the population age 25 and over, 24.1% have less than a high school diploma. 21.4% of the population are high school graduates, which is consistent with state completion rates (21.5%).

Educational Attainment

Population age 25 and over 6,268,121 23,497,945

Less than 9th grade 13.9% 10.4%

9th to 12th grade, no diploma 10.2% 8.9%

High school graduate 21.4% 21.5%

Some college, no degree 18.8% 21.5%

Associate degree 6.8% 7.7%

Bachelor’s degree 19.0% 19.2%

Graduate or professional degree 9.9% 10.8% Source: U.S. Bureau of the Census, 2006-2010 American Community Survey

Educational attainment is considered a key driver of health status with low levels of education linked to poverty and poor health. In the county, 75.9% of the adult population, 25 years and older, have obtained a high school diploma or higher education. This is lower than the state rate of 80.7%.

High School Graduation or Higher Education Completion, Adults, 25 Years and Older Geographic Area High School Graduate or Higher

California 80.7%

Housing Units

There are over 3 million housing units in the county. 44.8% of the housing units are owner occupied and 49.2% are renter occupied. The percentage of renter occupied housing exceeds the rate found in the state (40.5%). Housing Units/Owners and Renters

Geographic Area Total Housing Units Owner Occupied Renter Occupied

Los Angeles County 3,445,076 44.8% 49.2%

California 13,680,081 51.4% 40.5%

Source: U.S. Bureau of the Census, 2010, Summary File 1

Median Household Income

The median household income in the county is $55,476.

Geographic Area Median Household Income Los Angeles County $55,476

California $60,883

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Homelessness

Every two years the Los Angeles Homeless Services Authority (LAHSA) conducts the Greater Los Angeles Homeless Count as a snapshot to determine how many people are homeless on a given day. For the 2011 homeless count, the county had an annualized estimate of 45,422 homeless individuals. 79% of the homeless are individuals, and 20% are homeless families, 1% were unaccompanied minors.

Los Angeles County

Total Homeless 45,422

Single Adults 79%

Family Members 20%

Unaccompanied Minors (under age 18) 1%

Source: Los Angeles Homeless Service Authority, 2011 Greater Los Angeles Homeless Count Reports

Among the homeless population, approximately one-fourth are chronically homeless (24%), 34% experience substance abuse and 33% suffer from mental illness. The county has 18% homeless veterans and 10% of the homeless were survivors of domestic violence.

Homeless Subpopulations

Los Angeles County Chronically Homeless 24%

Substance Abuse 34%

Mentally Ill 33%

Veterans 18% Survivors of Domestic Violence 10%

Source: Los Angeles Homeless Service Authority, 2011 Greater Los Angeles Homeless Count Reports

Crime and Violence

Violent crimes include homicide, rape and assault. Los Angeles County has a rate of 511.5 violent crimes per 100,000 persons in the service area. This is higher than the state rate of 440.1 violent crimes per 100,000 persons.

Adult Violent Crimes, 2010, per 100,000 Persons

Geographic Area Number Rate

Los Angeles County 50,223 511.5

California 163,957 440.1

Source: California Department of Justice, Office of the Attorney General, 2010; U.S. Census 2010

12.7% of adults in the county indicated they had experienced physical or sexual violence by an intimate part-ner since the age of 18, and 3.1% had been the victims of intimate partpart-ner violence in the past year. These rates are lower than found in the state.

Experienced Physical or Sexual Violence

By Intimate Partner Since Age 18 12.7% 14.8% By Intimate Partner in Past Year 3.1% 3.5% Source: California Health Interview Survey, 2009

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California’s 58 counties are ranked according to access to health care with 1 being the county with the best fac-tors to 58 for that county with the poorest facfac-tors. Los Angeles County is ranked near the bottom of California counties for health access.

Health Access Ranking

Geographic Area County Ranking (out of 58) Los Angeles County 45

Health Insurance Coverage

Health insurance coverage is considered a key component to access health care. 77.2% of the population in Los Angeles County has health insurance. Children, under 18, have the highest rates of insurance coverage at 89.6%. Among adults, ages 18-64, 69.2% in the county have health insurance.

Health Insurance Coverage, Total Population, Children, Under 18, and Adults, 18-64 Geographic Area Total Population Children Under 18 Adults Ages 18-64

California 81.8% 91.1% 75.1%

Source: U.S. Census Bureau, 2009-2011 American Community Survey

A look at insurance coverage by source shows that 44.8% of county residents have employment-based insurance and 17.5% are covered by Medi-Cal.

Insurance Coverage

Medi-Cal 17.5% 14.0%

Healthy Families 2.0% 2.0%

Medicare Only 0.9% 1.1%

Medi-Cal/Medicare 3.5% 2.8%

Medicare & Others 6.7% 7.7%

Other Public 1.6% 2.6%

Employment Based 44.8% 49.6%

Private Purchase 6.0% 5.7%

No Insurance 17.0% 14.5%

In LA County, 13.9% of the population under the age of 65 had no insurance coverage over the course of a year. 9.8% had insurance coverage for only a part of a year.

No Insurance Coverage or Partial Insurance Coverage, under Age 65

No insurance entire past year 13.9% 12.2% Insurance coverage only part of the year 9.8% 9.0%

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Sources of Care

Residents who have a medical home and access to a primary care provider improve continuity of care and decrease unnecessary ER visits. Among the residents in LA County, 91.7% of children and youth have a usual source of care. Among adults, 78.8% have a source of care. 93.8% of seniors have a source of care. County residents have lower rates of usual sources of care than found in the State.

Usual Source of Care

Geographic Area Ages 0-17 Ages 18-64 Ages 65+

California 92.2% 81.5% 95.0%

The source of care for 58.5% of county residents is a doctor’s office, HMO, or Kaiser. This is lower than the state rate. Clinics and community hospitals are the source of care for 23.1% in the county. 16.2% of residents have no regular source of care.

Sources of Care

Los Angeles County California

Dr. Office/HMO/Kaiser 58.5% 61.2%

Community clinic/Government clinic/Community hospital 23.1% 22.7%

ER/Urgent Care 1.3% 1.1%

Other 0.9% 0.8%

No source of care 16.2% 14.2%

16.7% of residents in the county visited an ER over the period of a year. Children and seniors visit the ER at the highest rates (18.3%). Residents at lower incomes visit the ER at higher percentages than the population as a whole.

Use of Emergency Room

Visited ER in last 12 months 16.7% 17.6%

0-17 years old 18.3% 18.0%

18-64 years old 15.8% 17.2%

65 and older 18.3% 19.2%

<100% of poverty level 20.2% 21.7%

<200% of poverty level 18.5% 19.7%

In Los Angeles County, the ratio of population to primary care physicians is 884:1 and the ratio of population to dentists is 1,354:1. For mental health providers, the ratio is 1,770:1.

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Primary Care Physicians, Dentists, Mental Health Providers, Population Ratio

Geographic Area Ratio of population Ratio of population Ratio of population to primary care physicians+ to dentists+ to mental health

providers*

Los Angeles County 884:1 1,354:1 1,770:1

California 847:1 1,583:1 1,853:1

Source: County Health Rankings, 2012 +data from 2009; *data from 2007

Barriers to Care

Adults in the county experience a number of barriers to accessing care, including: cost of care, lack of a medical home, language barriers, and lack of transportation.

Barriers to Accessing Health Care

Adults Unable to Afford Dental Care in the Past Year 22.3% Adults Unable to Afford Medical Care in the Past Year 11.8% Adults Unable to Afford Mental Health Care in the Past Year 5.9% Adults Unable to Afford Prescription Medication in the Past Year 12.1% Adults Who Reported Difficulty Accessing Medical Care 27.3% Adults Who Reported Difficulty Talking to a Doctor because of a

Language Barrier in the Past Year 15.1% Adults Who Reported Transportation Problems Prevented

Obtainment of Medical Care 7.4%

Source: Los Angeles County Department of Public Health, Office of Health Assessment and Epidemiology, Los Angeles County Health Survey 2007

Delayed Care

Among county residents, 11.6% of residents delayed medical care and 7.5% delayed obtaining prescription medications.

Delayed or didn’t get medical care in past 12 months 11.6% 12.5% Delayed or didn’t get prescription meds in past 12 months 7.5% 8.2% Source: California Health Interview Survey, 2009

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Dental Care

10.9% of children and 1.5% of teens in the county have never been to a dentist. For households that delayed dental care for children and teens, not being able to afford the care or having no dental insurance coverage was the main reason 10% of children and 39% of teens delayed a dental visit.

Children Never Been to the Dentist 10.9% 11.6% Main Reason Children Did Not Visit Dentist in Past Year

– Could Not Afford it/Had No Insurance 10.0% 10.4%

Teens Never Been to the Dentist 1.5% 1.2%

Main Reason Teens Did Not Visit Dentist in Past Year

– Could Not Afford it/Had No Insurance 39.0% 30.6% Source: California Health Interview Survey, 2009

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Leading Causes of Premature Death

In Los Angeles County, 45% of people in 2009 died before they reached age 75. With 75 years set as a cut-off date, everyone who dies younger than 75 is considered to have died prematurely. The top three causes of prema-ture death were: heart disease, homicide, and motor vehicle crash.

Leading Causes of Premature Death (before age 75) by Gender

Male Female Overall

#1 Cause Heart Disease Heart Disease Heart Disease #2 Cause Homicide Breast Cancer Homicide

#3 Cause Motor Vehicle Crash Lung Cancer Motor Vehicle Crash

Source: L.A. County Department of Public Health, Office of Health Assessment and Epidemiology. Mortality in Los Angeles County 2009: Leading Causes of death and premature death with trends for 2000-2009, October 2012. Causes of premature death differ when examined by gender. Among males the leading causes of premature death were: coronary heart disease, homicide and motor vehicle accident. Among females the top causes of premature death were: coronary heart disease, breast cancer, and lung cancer.

Age-Adjusted Death Rates

Age-adjusted death rates are an important factor to examine when comparing mortality data. The crude death rate is a ratio of the number of deaths to the entire population. Age-adjusted death rates eliminate the bias of age in the makeup of the populations being compared. When comparing across geographic areas, age-adjusting is typically used to control for the influence that different population age distributions might have on health event rates. In 2009, there were 57,620 deaths in Los Angeles County. When adjusted for age, the death rate was 583 per 100,000 persons. This is a 3% decrease from 2008.

Leading Causes of Deaths - Age-Adjusted

Cancer, heart disease, and stroke are the top three leading causes of death in Los Angeles County. When compared to the Healthy People 2020 objectives, Los Angeles County has rates of death for heart disease and homicide that exceed the benchmarks.

Leading Causes of Death, Age-Adjusted Death Rate per 100,000 Persons, 2009

Los Angeles County Healthy People 2020 Objective

Number Rate

Cancer 13,909 134 160.6

Coronary Heart Disease 12,725 129 100.8

Stroke 3,301 34 33.8

Chronic Lower Respiratory Disease 2,904 30 98.5

Alzheimer’s Disease 2,125 21 No Objective Influenza/Pneumonia 2,097 21 No Objective

Diabetes 1,964 20 65.8

Suicide 775 7 10.2

Homicide 723 7 5.5

Motor Vehicle Crash 677 7 12.4

Source: L.A. County Department of Public Health, Office of Health Assessment and Epidemiology. Mortality in Los

Mortality

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Births

In 2011, there were 130,312 births in Los Angeles County. The number of births has decreased from 2008 to 2011.

Births by Year, 2008-2011

2008 2009 2010 2011

147,684 139,679 133,160 130,312 Source: California Department of Public Health, 2008, 2009, 2010, 2011

Teen Births

In 2010, teen birth occurred as 8.8% of live births. This rate is higher than the teen birth rate found in the state (8.5%).

Births to Teenage Mothers (Under Age 20)*

Geographic Area Births to Teen Mothers Percent of Live Births

Los Angeles County 11,677 8.8%

California 43,127 8.5%

Source: California Department of Public Health, 2010

Prenatal Care

In Los Angeles County, 2.8% of women with live births entered prenatal care in the third trimester or re-ceived no prenatal care. This is lower than the state rate of 3.2% late entry into prenatal care.

Late Entry (In Third Trimester) or No Prenatal Care, 2010

Geographic Area Late Prenatal Care Percent of Live Births

^Births in which the first month of prenatal care is unknown are not included in the tabulation.

Low Birth Weight

Low birth weight is a negative birth indicator. Babies born at a low birth weight are at higher risk for disease, disability and possibly death. Los Angeles County has a higher percentage of low birth weight babies (7.3%) when compared to the State (6.8%).

Low Birth Weight (Under 2,500 g), 2010

Geographic Area Low Weight Births Percent of Live Births

Birth Characteristics

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Breastfeeding

Breastfeeding is proven to have considerable benefits to both baby and mother. The California Department of Public Health (CDPH) highly recommends babies be fed only breast milk for the first six months of life. Data on breastfeeding are collected by hospitals on the Newborn Screening Test Form. Los Angeles County breastfeeding rates show 90.9% of new mothers use some breastfeeding and 46.8% use breastfeeding exclusively. These rates are lower than found among hospitals the state.

In-Hospital Breastfeeding

Any Breastfeeding Exclusive Breastfeeding

Number Percent Number Percent Los Angeles County 109,686 90.9% 56,478 46.8%

California 481,183 91.7% 264,377 60.4%

Source: California Department of Public Health, Breastfeeding Hospital of Occurrence, 2011

Infant Mortality

The infant mortality rate in the Los Angeles County was 4.6 deaths per 1,000 live births. Infant Mortality Rate, 2010

Geographic Area Infant Deaths Rate per 1,000 Live Births

Los Angeles County 617 4.6

California 2,419 4.7

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Health Status

In Los Angeles County, 18.1% of residents have a self-rated fair/poor health status. 19.7% of adults and 32.5% of seniors consider themselves to be in fair/poor health. These rates of fair/poor health status are greater than found in the state.

Health Status, Fair or Poor Health

Fair or Poor Health 18.1% 15.2%

18-64 Years Old 19.7% 16.8%

65+ Years Old 32.5% 27.6%

Diabetes

Diabetes is a growing concern in the community. 10.9% of adults in LA County have been diagnosed with diabetes. For adults with diabetes, 60.9% are very confident they can control their diabetes, and 77.8% have a diabetes management care plan. However, 25.7% of diabetics have not had a foot exam, and 9.3% have never had an HgA1c test.

Adult Diabetes

Diagnosed Pre/Borderline Diabetic 7.1% 8.0%

Diagnosed with Diabetes 10.9% 8.5% Very confident to Control Diabetes 60.9% 58.6%

Somewhat confident 30.6% 32.6%

Not confident 8.5% 8.8%

Takes oral hypoglycemic medications 73.7% 77.0% Has a diabetic management care plan 77.8% 78.0%

Has never had a foot exam 25.7% 72.2%

Never heard of a HgA1c test 19.5% 14.5%

Never had a HgA1c test 9.3% 10.6%

The rate of diabetes has increased from 8.6% in 2005 to 9.9% in 2011 among the adult population. This is a 15.1% increase.

Adults Diagnosed with Diabetes, 2005-2011

2005 2007 2011 Change 2005-2011

Los Angeles County 8.6% 9.1% 9.9% 15.1% Source: LA County Department of Public Health, 2012

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Heart Disease

For adults in Los Angeles County, 5.8% have been diagnosed with heart disease. Among these adults, 61.4% are very confident they can manage their condition and 65.1% have a management care plan developed by a health care professional.

Adult Heart Disease

Diagnosed with heart disease 5.8% 5.9%

Very Confident to Control Condition 61.4% 58.5% Somewhat Confident to Control Condition 31.4% 32.3%

Not Confident to Control Condition 7.3% 9.2%

Has a management care plan 65.1% 70.9%

High Blood Pressure

A co-morbidity factor for diabetes and heart disease is hypertension (high blood pressure). In Los Angeles County, 27.6% of adults have been diagnosed with high blood pressure. Of these, 70.2% are on medication for their blood pressure.

Diagnosed with High Blood Pressure 27.6% 26.2% Takes Medication for High Blood Pressure 70.2% 70.2% Source: California Health Interview Survey, 2009

Cancer

In Los Angeles County, the cervical cancer rate (9.8 per 100,000 persons) and the colorectal cancer rate (45.1per 100,000 persons) exceed the state rates for these cancers. Breast cancer (117.8), prostate cancer (142.8) and lung cancer (45.6) occur at rates less than the state rates for these types of cancer.

Cancer Incidence, per 100,000 Persons

Breast Cancer 117.8 123.2

Cervical Cancer 9.8 8.3

Colon and Rectum Cancer 45.1 43.7

Prostate Cancer 142.8 146.5

Lung Cancer 45.6 52.4

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Asthma

The population diagnosed with asthma in Los Angeles County is 12.5%. 45.2% of asthmatics take medica-tion to control their symptoms. Among youth, 13.8% have been diagnosed with asthma. The rate of asthma is lower in the county than found in the state. 73.4% of asthmatics are very confident they can control and manage their asthma.

Diagnosed with Asthma, Total Population 12.5% 13.7% Diagnosed with Asthma, 0-17 Years Old 13.8% 14.2% ER Visit in Past Year Due to Asthma,

Total Population 9.5% 10.3%

ER Visit in Past Year Due to Asthma,

0-17 Years Old 15.9% 13.7%

Takes Daily Medication to Control Asthma,

0-17 Years Old 40.8% 38.1%

Very Confident to Control and Manage Asthma 73.4% 76.9% Confident to Control and Manage Asthma 22.9% 14.8% Not Confident to Control and Manage Asthma 3.7% 3.3% Source: California Health Interview Survey, 2009

Disability

In the service area, 28.9% of adults had a physical, mental or emotional disability. The rate of disability in the state was 27.4%. 5.1% of adults could not work for at least a year due to physical or mental impairment. Population with a Disability

Adults with a disability 28.9% 27.4%

Couldn’t work due to impairment 5.1% 4.7%

HIV/AIDS

In 2011, 1,340 cases of HIV/AIDS were diagnosed in Los Angeles for a rate of 13 per 100,000 persons. The rate of HIV/AIDS diagnosed in 2011 has decreased from 2010.

HIV/AIDS Diagnoses, 2010 - 2011

2010 2011

Number Rate Number Rate

Los Angeles County 2,062 20 1,340 13

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County Health Rankings examines healthy behaviors and ranks counties according to health behavior data. California’s 58 counties are ranked from 1 (healthiest) to 58 (least healthy) based on a number of indicators that include: adult smoking, obesity, physical inactivity, excessive drinking, sexually transmitted infections, and others. A ranking of 21 puts Los Angeles County in the top half of California counties for health behaviors.

Health Behaviors Ranking

Geographic Area County Ranking (out of 58) Los Angeles County 21

Overweight and Obesity

In Los Angeles, one-third of the adult population is overweight (33.2%). 18.6% of teens and 12.1% of children are overweight.

Overweight

Adult 33.2% 33.6%

Teen 18.6% 16.7%

Child 12.1% 11.5%

When adult obesity levels are tracked over time, a 12.9% increase in obesity is seen in the county from 2005 to 2011. In 2011, 23.6% of the adult population was obese.

Adult Obesity

2005 2007 2011 Change 2005-2011

Los Angeles County 20.9% 22.2% 23.6% 12.9% Source: LA County Department of Public Health, 2012

Adult overweight and obesity by race and ethnicity indicate high rates among African American adults (65%) and Latinos (64%). Over half of the White population (51.5%) is overweight and obese. 34.9% of Asians in the county are overweight and obesity.

Adult Overweight and Obesity by Race/Ethnicity

African American 65.0% 64.4%

Asian 34.9% 31.6%

Latino 64.0% 66.3%

White 51.5% 55.0%

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Fast Food

In Los Angeles County, 21.9% of the residents eat fast food 3-4 times a week. Adults, ages 18-64 (25.3%), consume fast food at higher rates than youth (19%) or seniors (8.7%). LA County has higher rates of fast food consumption among all age groups when compared to the state.

Fast Food Consumption, 3-4 Times a Week

Ages 0-17 19.0% 17.0%

Ages 18-64 25.3% 22.6%

Ages 65+ 8.7% 7.7%

Soda Consumption

In LA County, 18.1% of children and teens consume two or more soda or sweetened drinks a day. This rate is higher than the state (14.7%) rate.

Soda or Sweetened Drink Consumption, Two or More a Day

Teens and Children 18.1% 14.7%

Fresh Fruits and Vegetables

In LA County just over half of the children (50.8%) consume five fruits and vegetables in a day. This is a higher rate of fruit and vegetable consumption than found in the state. Fresh fruit and vegetable consump-tion decreases considerably among teens. Only 18.4% of teens consume five or more fresh fruits and veg-etable a day.

Consumption of 5+ Fresh Fruits and Vegetables a Day

Children 50.8% 48.4%

Teens 18.4% 19.9%

Walked to Work

2.9% of workers, 16 years of age and older, in the county walk to work. Walked to Work

Geographic Area Walked to Work

California 2.8%

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Physical Activity

In the county, 68.1% of children engaged in vigorous physical activity. And 80% of youth visited a park, play-ground or open space. However, 10.6% of children and 16.9% of teens were sedentary during the week. Among adults, 79% walked for transportation, fun or exercise.

Physical Activity

Engaged in Vigorous Physical Activity

3 Days/Week – Child 68.1% 67.1%

No Physical Activity/Week – Child 10.6% 11.8% No Physical Activity/Week – Teen 16.9% 16.2%

Teens Take PE Class 68.0% 65.9%

Walked/Biked/Skated to School 49.5% 43.0%

Youth Visited Park/Playground/Open Space 80.0% 79.4% Adults Walked for Transportation, Fun or Exercise 79.0% 77.2% Source: California Health Interview Survey, 2009

Mental Health Indicators

Among adults, 7.3 experienced serious psychological distress in the past year. 14.1% of adults needed help for mental health problems. 15.3% of teens needed help for mental health problems. 10.3% of adults and 7.5% of teens received help for their mental health issues. 9.3% of adults have taken a prescription medication for an emotional or mental health issue in the past year. 47.3% of adults who needed help for an emotional or mental health problem did not receive treatment.

Mental Health Indicators

Adults who had Serious Psychological

Distress During Past Year 7.3% 6.5%

Adults who Needed Help for Emotional-Mental and/or Alcohol-Drug

Issues in Past Year 14.1% 14.3%

Teens who Needed Help for Emotional-Mental and/or Alcohol-Drug

Issues in Past Year 15.3% 12.9%

Adults who Saw a Healthcare Provider for Emotional/Mental Health and/or

Alcohol-Drug Issues in Past Year 10.3% 10.9% Teens Received Psychological/ Emotional

Counseling in Past year 7.5% 9.5%

Has Taken Prescription Medicine for

Emotional/Mental Health Issue in Past Year 9.3% 9.7% Sought/Needed Help but Did Not Receive

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Among adults, 15.6% had moderate to severe interference with work because of mental health issues; 20.3% had moderate to severe interference with family relationships due to mental health issues; and mental health concerns impacted the social lives of 20.5% of adults.

Mental Health Impairment

Did your emotions interfere with your work?

• No 84.4% 84.5%

• Moderate 10.5% 10.8%

• Severe 5.1% 4.7%

Did your emotions interfere with your relationship with friends and family?

• No 79.7% 81.0%

• Moderate 14.0% 12.9%

• Severe 6.3% 6.1%

Did your emotions interfere with your social life?

• No 79.5% 81.0%

• Moderate 12.5% 11.7%

• Severe 8.0% 7.3%

7.6% adults in Los Angeles County had seriously thought about committing suicide, this is less than the rate in the state (8.7%).

Thought about Committing Suicide

Adults who ever seriously thought about

committing suicide 7.6% 8.7%

Cigarette Smoking

14.0% of residents in Los Angeles County smoke cigarettes. This is the same as the state rate. Cigarette Smoking, 2004-2010

Geographical Area Percent of Smokers

California 14.0%

Alcohol and Drug Use

Binge drinking is defined as consuming a certain amount of alcohol within a set period of time. For males this is five or more drinks per occasion and for females it is four or more drinks per occasion. Among adults, 27% had engaged in binge drinking in the past year. In the county 4.2% of teens had engaged in binge drink-ing, and 29% of teens had indicated they had tried an alcoholic drink. These rates of alcohol consumption are lower than in the state.

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Alcohol Consumption and Binge Drinking

Adult Binge Drinking Past Year 27.0% 31.3%

Teen Binge Drinking Past Month 4.2% 5.8%

Teen Ever Had an Alcoholic Drink 29.0% 33.4% Source: California Health Interview Survey, 2009

11.6% of teens in the county have tried illegal drugs and 8.8% have used marijuana in the past year. Teen Illegal Drug Use

Ever Tried Illegal Drugs 11.6% 13.5%

Use of Marijuana in Past Year 8.8% 8.8%

Sexually Transmitted Diseases

In the county, rates of Chlamydia are 455.1 per 100,000 persons, Gonorrhea (96.8), Primary and Secondary Syphilis (6.5), and Early Latent Syphilis (9.2). Females have the highest rates of Chlamydia. Young adults, ages 20-24, and Blacks/African Americans have the highest rates of sexually transmitted infections.

STD Cases, Rate per 100,000 Persons, 2010

Chlamydia 455.1

Gonorrhea 96.8

Primary & Secondary Syphilis 6.5 Early Latent Syphilis 9.2

Source: County of Los Angeles, Public Health, Sexually Transmitted Disease Morbidity Report, 2010

Teen Sexual History

84.2% of teens in the county indicated they had never had sex. Of those youth who had sex, 29.7% had been tested for an STD.

Never Had Sex 84.2% 80.7%

First Encounter Under 15 Years Old 5.7% 7.3%

First Encounter Over 15 Years Old 10.1% 12.0% If Had Sex, Tested for STD in Past Year 29.7% 31.9% Source: California Health Interview Survey, 2009

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Flu and Pneumonia Vaccines

Seniors tend to receive flu vaccines at higher rates than adults or youth. Among seniors, 63.8% had received a flu shot. Adults received flu shots at a lower rate of 27.3%. 45.4% of children received a flu vaccine, and of these, 47.1% received the vaccine at a doctor’s office, Kaiser or HMO, and 24.5.2% received the vaccine at a community clinic.

Flu Vaccine

Received Flu Vaccine, 65+ Years Old 63.8% 65.9%

Received Flu Vaccine, 18-64 27.3% 29.4%

Received Flu Vaccine, 0-17 Years Old 45.4% 49.9% Child Received Vaccine at Dr. Office/ Kaiser/ HMO 47.1% 47.1% Child Received Vaccine at Community Clinic 24.5% 23.6% Child Received Vaccine at Hospital or ER 9.0% 7.1% Child Received Vaccine Some Other Place 19.4% 22.2% Source: California Health Interview Survey, 2009

Seniors are recommended to obtain a pneumonia vaccine. Over half the seniors in Los Angeles County (60.5%) had obtained a pneumonia vaccine.

Pneumonia Vaccine, Adults 65+

Adults 65+, had a Pneumonia Vaccine 60.5%

Source: Los Angeles County Department of Public Health, Los Angeles County Health Survey 2007

Mammograms

The Healthy People 2020 objective for mammograms is that 81.1% of women 40+ years have a mammogram in the past two years. In Los Angeles County, 73.7% of women, age 40+, have had a mammogram.

Pap Smears

The Healthy People 2020 objective for Pap smears in the past three years is 93%. In the county, 84.4% of women have had a Pap smear in the past three years.

Women Mammograms and Pap Smears

Women 40+ Years, had a Mammogram in Past Two Years 73.7%

Women had a Pap Smear in Past Three Years 84.4%

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Colorectal Cancer Screening

In the county, the rate of compliance for colorectal cancer screening is 75.7%, which exceeds the Healthy People 2020 objective for colorectal cancer screening of 70.5%. Of adults advised to obtain screening, 66.5% were com-pliant at the time of the recommendation.

Colorectal Cancer Screening, Adults 50+

Screening Sigmoidoscopy, Colonoscopy or

Fecal Occult Blood Test 75.7% 78.0%

Compliant with Screening at Time of Recommendation 66.5% 68.1% Source: California Health Interview Survey, 2009

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Eighteen telephone interviews were conducted for the Keck Medical Center of USC Community Health Needs Assessment during February and March, 2013. Thirteen of these interviews included a subset of ques-tions that were particular to Keck Hospital of USC. Interview participants included health care providers, researchers, professors and hospital administrators, along with representatives from public health, local com-munity clinics and other comcom-munity-based organizations focused on improving access to care and overall community health among the underserved populations in the area, and organizations that address other com-munity issues such as education, cancer care and support, homelessness, the business comcom-munity, immigration issues and leadership development. The interviewees spoke to issues and needs in the local area.

Overview of Populations Served and Services Provided by Interview Participants

The 18 interview participants serve a variety of populations and geographic areas, including: • Low-income families, predominantly Latino and African American families

• Immigrant families and the undocumented, particularly Latino

• Uninsured and underinsured individuals and families, including Healthy Way LA patients • Residents of SPA 4

• Neighborhood and areas surrounding USC Health Sciences Campus, including Boyle Heights, Ramona Gardens, Pico-Alison, Pico Union and Westlake

• Hospitals and hospital staff

• High-risk and vulnerable youth impacted by issues such as HIV/AIDS, mental health and substance abuse

• Children with autism and their families

• Undergraduates and first generation college students • People with cancer and their families

The services provided by the participants included:

• Outreach to the business community in Boyle Heights.

• Youth development targeted to Latinos, including leadership development, mentoring, computer training and summer jobs program.

• Leadership development among African American women related to women’s health issues, including pre-conception health and achieving healthy birth outcomes.

• Exposure of ethnic minority undergraduates to health professions.

• Through Good Neighbor program, connect USC resources (e.g., faculty, students) with neighborhood/ community needs.

• Through USC Fit Families program, host a fitness clinic weekly to provide fitness, screenings and health/ nutrition education to neighborhood families at a local park.

• Primary care and other health services provided by a Federally Qualified Health Center (FQHC) to medically underserved residents under 133% of poverty level. Other services include dental care, mental health services, optometry, pediatric and pediatric dental services, drug and alcohol program, and prenatal care.

• Public health services, including communicable disease control and services for tuberculosis, sexually transmitted diseases, and immunizations.

• Policy development and changes to the built environment to create sustainable, health-promoting community environments in conjunction with cities and communities.

• Early education for children, 18 months – 5 years.

• Homeless services for men, including emergency shelter along with case management, meals and

Stakeholder Interview Results

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referrals.

• Coordinate annual women’s conference focused on health and wellbeing. • Health disparities research and cultural competency training.

• Research with high-risk and vulnerable youth dealing with HIV/AIDS, mental health and/or substance abuse issues.

• The Southern California Clinical and Translational Science Institute (CTSI) works to test and translate molecular/cellular research to clinical applications (e.g., therapeutic, diagnostic, public health).

• Leadership, civic engagement, and policy and systems change through the Healthy Boyle Heights collaborative to address five priority areas: Children’s health coverage, land use and transportation, violence prevention, schools and neighborhood enrichment, and economic development.

• Public hospital and health center (LAC+USC Medical Center) to provide health care to residents of Los Angeles County.

• Cancer care, support and research, including multidisciplinary care teams; support groups and crisis counseling; education for mental health professionals; wigs, turbans, and prostheses; educational seminars for providers and caregivers; medical oncology/clinical care; yoga, tai chi, and dance classes; relaxation techniques, including guided imagery and mindful meditation; research and clinical trials; and other services.

Interview Topics

Interview participants were asked to share their perspectives on a number of topics • Biggest issues or concerns facing the community

• Challenges people face in obtaining health care and/or social services • Barriers to care for chronic disease treatment and management

• Preventive measures used and recommendations to improve chronic disease prevention, management and treatment

• Scope of the overweight and obesity problem and contributing factors • Services and programs that address overweight and obesity

• Recommendations to further reduce overweight and obesity

• Engaging minority students in health care professions: Barriers, existing programs to prepare students, and recommendations for further engagement

• Role of Keck Hospital of USC in addressing community health needs: Current activities and recommendations for additional activity and collaboration *

• Other notes and comments

Responses and trends relative to each of these topic areas are summarized below.

Biggest Issues or Concerns Facing the Community

Interview participants linked many of the issues and concerns facing the community with the broader issues, frequently mentioned, of poverty and the economic/education/health disparities found among communities of color in the local area and elsewhere.

• The economy, unemployment and jobs.

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access to inexpensive, unhealthy fast foods.

• Lack of access to health care (including specialty care and medications) and mental health services. • Lack of quality schools and education, and a “brain drain” of local youth who are successful in school

due to limited local opportunities.

• Lack of opportunities for youth development and leadership, and concern about the “push-out” policies at schools, resulting from Zero Tolerance policies, which foster a “school to prison” pipeline. • Lack of affordable housing, especially as gentrification is pushing out long-time local residents. • Transportation needs, as there is discussion about cutting back on bus routes and many residents do

not have cars.

• Immigration issues that impact a large undocumented population, including uncertainty regarding how immigration reform will unfold.

• Health disparities found in ethnic populations that are impacted by economic conditions, geographic disparity (i.e., where people live) and lower education levels, including:

o Higher HIV rates among lower-income people of color.

o Higher respiratory and asthma rates among people exposed to air pollution living close to freeways. o Higher obesity and diabetes rates among people with less physical activity due to lack of

neighbor-hood safety and few green spaces to play, as well as lack of access to healthy, affordable food.

o Generational risk factors related to poorer health outcomes among African Americans and dispropor-tionate risks for heart disease, stroke, cancer and infant mortality, related to overall lack of access to care, poor pre-conception health, and other health issues throughout the lifespan.

o Masked and untreated depression among African American women.

Finally, an issue was identified relating to assuring that the local business community, including the smaller “mom and pop” businesses, is healthy; i.e., financially sound, developing business plans and generally adopting good business practices.

Challenges to Obtaining Health Care and Other Health/Social Services

There are a number of health disparities found in the areas surrounding the hospital. Some of the biggest health concerns in the area were identified to include:

• Hypertension • Diabetes • Depression

• Tuberculosis, especially among homeless

• HIV/AIDS and other sexually transmitted diseases • Respiratory and asthma problems

• Safety concerns

• Childhood and adult obesity

The primary challenges to obtaining health care and other services were identified as: • Lack of insurance and cost of services.

• Language and cultural barriers for Latinos, and sometimes illiteracy in their primary language.

• Cultural barriers for African Americans including racism-induced stress, which is exacerbated by the frequent absence of dignity and respect from health care providers, which in turn negatively impacts health outcomes.

• Transportation barriers due to an unfriendly transportation system.

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Afford-able Care Act is implemented and people who are undocumented will not be eligible for Medi-Cal Expansion or to purchase insurance through the Health Insurance Exchange. There will be no revenue stream associated with people who are undocumented, which will reduce their access to care even further. • Long wait times for appointments at community clinics or in the County system, coupled with lack of

evening/weekend hours, resulting in people having to miss work in order to get care or using the emer-gency room as their source of regular care. When people delay seeking treatment, their health issues can become serious medical problems requiring emergency attention. Many of the people using the commu-nity clinic or county systems are working poor with jobs that provide low wages and no insurance, and that do not pay them for time off work, or that penalize them for taking time off.

Other challenges that were identified included:

• Lack of awareness about affordable health care options; “Often it’s those who need it the most who know the least.”

• Lack of education from trusted health providers about Health Care Reform and how it will impact people: who is eligible (and for what) and how to apply.

• Insufficient community clinic infrastructure and capacity to meet community need.

• Large bureaucracy of Los Angeles County health system, which can be daunting to navigate; “Large bureaucratic structures don’t always serve people well.”

• Lack of emphasis on preventive services and lack of medical/health homes to coordinate care. • People do not understand their health benefits and how to use or maintain them.

Many of the challenges to obtaining health services for cancer patients echoed those identified for others in the area, such as transportation barriers, language barriers (for both services and printed materials), and insurance/ cost barriers. Some of the issues more specific to this population included:

• Insurance coverage that does not let them choose a facility for cancer treatment.

• Finding transportation for daily or frequent treatment services, which can be limited by difficulty in getting rides, cost, or not feeling well enough to drive.

• Limited home health services.

• Lack of walk-in services for patients who have urgent issues arise between appointments, necessitating their use of the emergency room, which can be very difficult for them due to long waits and exposure to people who are ill at a time when their immune system may be compromised.

• Inability of uninsured/underinsured to access some specific cancer treatment services, as noted above (e.g., bone marrow transplant, genetic testing).

• Lack of ovarian cancer screening program for Latinas (e.g., Es Tiempo) due to lack of funding.

Some people noted that the Affordable Care Act (ACA) might help to overcome some barriers to care and to improve access by creating new models that focus on prevention versus acute care, and by leveling the playing field and creating more equitable access through increased health coverage in the population.

Barriers to Chronic Disease Treatment and Management

Several interview participants noted that many people are not diagnosed or treated until late in their disease process as they do not have access to or avail themselves of preventive care or screenings, or alternatively, that they do not manage their diseases in the early stages and so their conditions become more complicated and

Community Health Needs Assessment