Overview

This chapter presents a discussion of how to identify the health care needs of your particular community. Included is a discussion on how to develop a profile of the population to be served and to identify indicators of their health status.

METHODOLOGY

Understanding Your Market - There is no one "right" methodology for defining the health care needs of the population. The National Association of Community Health Centers has developed one guide which can serve as a model for understanding the community health care needs. The ultimate objective is to identify the health care needs of the population in order to set realistic goals and plan effective strategies for developing a health care center to serve your community. Exhibit 5-1 presents an example of the different components that go into determining the health care needs for your community and information resources for each component.

Below, we have outlined the general steps necessary to identify the health care needs of your community. These steps highlight the community health issues that must be understood in order to best serve your service area population. The specific data items that should be collected during this process will be discussed in more detail later in this chapter.

• The geographic size;
• Barriers, i.e., geographic, economic, language or cultural;
• Distribution and growth of the population; and
• Availability and accessibility of health care services.

Defining The Population - Once the service area has been determined, collect baseline information on the population. This baseline information will be used to define the types of services needed, the anticipated use rate and availability of special funding.

Developing A Health Profile For The Community - Community health status figures reflect the conditions of the local economy. By assessing the health profile, programs can be developed which directly target the priority health care needs unique to this community. Further, the profile can be used to evaluate the success of the program. An example of a Vital Statistics Worksheet is presented in Exhibit 5-2.

Once the size and characteristics of the population and their health status have been determined, an assessment of their health care needs can be made.

Develop a Scope of Service Inventory - Put together an inventory of providers for those within your community and those providing services to your population but located elsewhere. This inventory should include hospital-based services and outpatient programs, clinics, physicians' offices, crisis centers, dental offices, mental health and substance abuse programs.

Identifying the Gaps In Service - To identify gaps in health care services available to your target population, match the need identified with the resources available in the community (health care professionals and facilities) which are accessible to this population. These should include service, facility related and health care provider gaps. Those areas where gaps appear should be high priority for the primary care center.

Identifying Payment Sources - Evaluate the potential payment sources for the health services identified for the site. For example:

• Is this an area with a large managed care presence?
• Do you have a significant number of Medicaid-eligible individuals in the service area?
• Should you consider writing a Community Health Center grant to help offset the cost of uncompensated care to a low-income (indigent) population that is also uninsured?

SERVICE AREA

When setting the goals and objectives for the primary care center, it is essential to know how to assess the health care needs of the community it serves. The first step is to define the population to be served. That is, decide who is, and who is not, a member of the defined community. Once the population has been defined, the most important health care needs of this community can be identified. The preliminary definition of your target population will evolve out of the community goal setting activities. During these activities, the community's goals and objectives for the development of the primary health care center will be formulated. Included in these goals will be guidelines for defining the service area.

For example, the community may decide to develop a center to serve the needs of their immediate county or to serve the indigent population residing in a particular city neighborhood. This decision may then be used as the baseline for undertaking a more formal assessment of the service area.

Typical service areas can include the following:

• Urban health centers may serve an area consisting of a grouping of census tracts or zip codes.
• The service area for rural centers may be a county or grouping of counties.
• A site may serve a particular population group residing in a defined section of the community, e.g., HIV/AIDS, Homeless, Migrant Farm workers, Substance Abusers, Public Housing residents, etc.

One approach used to define a service area is to conduct a patient origin study. If there is an existing center, hospital, dental or mental health clinic, review the residence of origin of the patient population for the last three years to determine their home zip code, census tract, city or county. This patient origin study will quickly provide the information needed to define your service area. If there are none in your area from which to get patient origin data; then a hypothetical service area can be defined taking into consideration access Issues.

Your state Primary Care Organization (PCO) [LINK] may have already defined rational service areas. Check to see if this fits your needs. Important factors to be considered when delineating your service area include: access barriers such as transportation, language, geographic or cultural; natural trade areas; time-travel distances; and the location of other relevant service providers, such as hospitals, clinics, health department, community mental health centers, dental clinics, and social service agencies. Your hypothetical service area model can be tested using a telephone or mail-out survey to a sampling of the population residing in the area you have delineated. This survey can be designed to provide the following information:

• demographic profile of the service area population;
• patterns of health care service utilization;
• factors affecting out-migration;
• location preferences for health care services;
• patterns of physician utilization;
• self reported health status;
• image of local health care services, if any;
• image of community; and
• interest in development of a primary care center.

Community agreement on the service area sets the stage for analyzing the health care needs of the target population. It is then possible to prepare a map showing the key elements of the area. The map should show where the population resides, the major transportation corridors and the location of other health care providers. Among other things, this map will help when selecting a site for the center in terms of distance and travel time for the target population.

DATA NEEDS

Obtaining and appropriately analyzing good data are essential components of a rational, valid planning process. The general methodology for defining your community's health care needs at the beginning of this chapter discusses the collection of specific data. This data will allow you to build a relatively objective, quantifiable profile of your community's health status. This profile can be used to identify priority areas and as a baseline in the future to mark progress in meeting the population's health needs.

At a minimum, data will need to be collected on the key population descriptors presented below:

• Basic demographics
  • population size
  • patterns of growth
  • age and gender distribution
  • racial and ethnic background
  • marital status
  • average family size
  • housing status
• Socioeconomic environment
  • income and education
  • seasonality
  • employment status
  • insurance status
  • percent below poverty level
  • domestic violence
  • crime
• Health-related behavior
  • most frequent health problems
  • clinical services used most often
  • prevention and screening
  • other health related behavior, e.g., smoking, substance abuse
• Health status indicators
  • morbidity and mortality
  • birth statistics
  • infant mortality rate
  • leading causes of death
  • incidence of reportable communicable diseases
  • sexually transmitted diseases and AIDS
  • mental illness
  • rules of occupational injury/illness
  • decayed/missing teeth/unmet dental treatment needs
  • oral health status (prevalence of gingivitis, destructive periodontal disease)
  • cancer and heart disease rates
  • environmentally-influenced conditions

Your search for relevant health planning data may take many "twists" and "turns" along the way because in fact there are so many different data sources and formats from which to choose. Interestingly a great deal of the data you may be seeking is mostly readily accessible in terms of national or state aggregates rather than local units. Data mining often becomes more challenging as you try to "peel it down" to the county, community, and target population levels. Don't be discouraged if you can't find what you want right away; it's probably available somewhere that you just haven't discovered yet. In general you will find it easier to find accurate population data thankfully because the Census Bureau has made it possible to track the numbers down to very small units, such as Census Tracts (CTs) and even neighborhood blocks. On the other hand acquiring health status data for smaller "units" of population, such as a CT is often not possible and must therefore be interpolated from the larger data sets that are more readily available.

To get started it is recommended that you first contact your state Primary Care Association, Primary Care Office, State Office of Rural Health, or the Health Resources and Services Administration to see how they can be helpful to you in collecting and analyzing the data relevant to your situation. The foregoing agencies are very resourceful organizations who can usually either provide you with at least some of the data you are looking for or point you in the right direction to obtain it from other sources. Web-links to the above agencies are as follows:

Directory of State Primary Care Associations:
http://bphc.hrsa.gov/OSNP/PCADirectory.htm

Directory of State Primary Care Offices:
http://bphc.hrsa.gov/OSNP/PCODirectory.htm

Directory of State Offices of Rural Health:
http://ruralhealth.hrsa.gov/funding/50sorh.htm

Health Resources and Services Administration:
http://ask.hrsa.gov

Capable as they may be, however, do not expect the above agencies to do all your data collection and statistical analysis homework for you. You (or the consultant under contract with you) must assume the responsibility for assembling and evaluating the full spectrum of information needed to help you get where you want to go. The following references are therefore provided to facilitate your search for various kinds of information that you may need to undertake a thorough planning process.

Demographics

Census Data - Contact the Statistical Information Office, Population Division, United States Bureau of the Census for the name of the contact person in your state. A reference librarian m your local library can also lead you to local census tract data and other population statistics documents. The Web link for the Bureau of the Census is, http://quickfacts.census.gov.

Population Projections - Contact the State Auditor General's Office for the name of the state agency responsible for preparing the official population projections. Also, Claritas/NPDC (Ithaca, NY) has an online demographic data base which includes socio- demographic information for any geographical area, i.e., zip code, census tract, SMSA, county, state. The Web link is http://clusterl.claritas.com/claritas.

Economic Indicators - Contact the Chamber of Commerce and the local economic development agency for information on job growth, unemployment rate, area growth rate, etc. the Web link to your Chamber of Commerce may be found at the following Web site: http://www.2chambers.com.

Health Status Indicators

Community Health Status Indicator Project This is an innovative effort undertaken by the Public Health Foundation to assemble a variety of comparative health indicators and demographic data at the county level. While the entire data base used to be maintained on the Web, that unfortunately is no longer the case. Alternatively the entire data base is on a CD which can be purchased for a modest fee. For further information about obtaining this data, contact the Public Health Foundation at (202) 898-5600 or visit their Web site at: http://www.phf.org/data-infra.htm#Community.

State Health Facts The Kaiser Family Foundation is an excellent source of both health and demographic data worth exploring. If you are looking for data at the state level, this source may also save you some time since they have already done the work of collecting a great deal of information form other original sources. For further information visit their Web site at http://www.statehealthfacts.kff.org.

State Behavioral Risk Factor Survey This survey can provide population estimates of behaviors such as smoking, alcohol consumption, and physical activity. Survey information is available from your state health department or from the Survey Data Branch, Centers for Disease Control and Prevention, Atlanta, GA. See http://www.cdc.gov/brfss for further information.

Vital Statistics Vital statistics information, such as birth and death rates, teen fertility, causes of death, morbidity and mortality, etc. are available from your State Health Department and perhaps your local health department as well. A Directory of State Health Departments can be obtained from www.statepublichealth.org/index.php.

Reportable Disease Records Most health departments will have data on reportable diseases, such as HIV/AIDS and various communicable diseases, etc. Alternatively they also may be obtained at the federal level by contacting the Centers for Disease Control and Prevention at their Web site: http://www.cdc.gov.

Gateway Web-Linkage to Multiple Data Sources One of the more comprehensive sources of health planning data on the Web is maintained by the Rural Assistance Center (RAC). To access various Web-links to a variety of data sources, go to the RAC's Web site at: http://www.raconline.org, click on Information Guides then click on Statistics/Maps/Data. This will bring you to a page with Web-links to the following data sources:

• Community Informatics Resource Center (CIRC)
  http://circ.rupri.org
• Facts About Rural Physicians
  http://www.shepscenter.unc.edu/research_programs/rural_program/phy.html
• FedStats
  http://www.fedstats.gov
• Health Professional Shortage Areas
  http://bhpr.gov/shortage
• Health Resources and Services Administration
  http://www.hrsa.gov
• Medicare/Medicaid Statistics (CMS)
  http://cms.hhs.gov/researchers
• National Center for Health Statistics
  http://www.cdc.gov/nchs
• State Data Centers
  http://www.census.gov/sdc
• State Health Facts Online
  http://www.statehealthfacts.kff.org
• U.S. Census
  http://www.census.gov
• ACF Data and Statistics
  http://www.acf.dhhs.gov/news/stats/index.html
• American Fact Finder
  http://www.factfinder.cenus.gov/home
• American Community Survey
  http://www.census.gov/acs/www
• Bureau of Labor Statistics
  http://stats.bls.gov
• Child Trends Data Bank
  http://www.childtrendsdatabank.org
• Current Population Survey
  http://www.bls.census.gov/cps/cpsmain.htm
• Federal Poverty Guidelines
  http://aspe.hhs.gov/poverty/poverty.shtml
• Kids Count Census Data Online
  http://www.aecf.org/kidscount/census
• National Priorities Project Database
  http://database.nationalpriorities.org
• U.S. Census Bureau
  http://www.census.gov
• U.S. Census: American Indian and Alaska Native (AIAN) Links and Data
  http://factfinder.census.gov/home/aian/index.html
• U.S. Department of Health and Human Services (DHHS)
  http://www.hhs.gov/
• U.S. Welfare Caseloads Information
  http://www.acf.dhhs.gov/news/stats/newstat2.shtml
• Urban Institute's Assessing the New Federalism (ANF) Data Tools
  http://www.urban.org/Content/Research/NewFederalism/Data/ANFData.htm

Miscellaneous Local Data Resources

In addition to the above sources with Web-links, you may also wish to contact local sources of information in your own community. Examples of local resources that you may wish to contact are the following:

Hospital, emergency room and ambulance records Morbidity data can be obtained from hospital records. Transfers from the community to other health care facilities can be obtained from ambulance records.

City Public Safety and Police Records These data sources can provide information on crime and arrest rates, domestic violence incidences, motor vehicle accidents, etc.

Mental Health and Substance Abuse Contact the local CMHC for information on mental illness and substance abuse in the community.

County Health Department Contact the department for information on health services available through the county.

Health Care Facilities Contact the state health planning agency and licensure agency for information on health care facilities in the service area, utilization patterns, discharge data, and specialty services.

Health Care Professionals Contact the local/state associations for information on the number and specialty for the physicians, dentists, physician assistants, nurse practitioners, certified nurse-midwives, social workers, mental health professionals, and dental hygienists in the area.

Target Population Groups

Each community has special populations and circumstances that make it unique. Some of these, such as migrant and seasonal farm workers, large numbers of homeless people and recent immigrants, face problems of dislocation and low income. Other groups, such as HIV-positive persons and pregnant women abusing drugs, need specialized health care services. As the community profiles are prepared, keep in mind these special populations and how that group can best be served in the primary care center. Examples of potential target populations could include:

• Urban poor;
• Rural populations;
• Migrant and seasonal farm workers;
• Homeless people;
• Recent immigrants/refugee population;
• Special occupation groups;
• Specific groups, e.g., children, women of child-bearing age, frail elderly people;
• Unemployed individuals;
• Abusers of alcohol and other drugs;
• HIV-positive individuals; and
• Persons with low literacy skills.

Organization of Data Collection Efforts

As you are now aware, the amount of information that can be gathered and the time spent collecting and analyzing it can be overwhelming. It is therefore important for you to design a data collection instrument in order to bring some focus to the activity. When you know what information you want "a priori," then you are less likely to get side-tracked with interesting, but non-essential information that you do not need. HRSA's Bureau of Primary Health Care (BPHC) has developed a set of data requirements that are essential to preparing an application for Community Health Center grant funding under Section 330 of the Public Health Service Act. A representative sample of the agency's demographic and health disparity data sets are included in Exhibit 5-3, Exhibit 5-4, and Exhibit 5-5 and illustrate the kind of information you may want to pursue further.