2013 Hunterdon County Community Health Needs Assessment

Transcription

1 2013 Hunterdon County Community Health Needs Assessment June 2013

2

3 2013 Hunterdon County Community Health Needs Assessment Prepared by: Joanna Chua, MPH, CHES Program Coordinator Hunterdon Regional Community Health Adopted: June 28, 2013

4 2013 Hunterdon Community Health Needs Assessment

5 TABLE OF CONTENTS ACKNOWLEDGEMENTS... i EXECUTIVE SUMMARY... ii INTRODUCTION... 1 COMMUNITY... 2 MOBILIZING ACTION THROUGH PLANNING AND PARTNERSHIPS... 4 COMMUNITY HEALTH STATUS ASSESSMENT... 5 Demographics... 5 Population... 5 Age... 7 Race/Ethnicity... 8 Disability... 9 Social and Economic Factors Educational Attainment Employment Income and Poverty Marital Status Housing Crime Physical Environment Air Quality Access to Healthy Food Transportation Clinical Care Healthcare Access and Utilization Oral Health Physician Supply Preventive Services Hospital Utilization and Access Health Outcomes Mortality Leading Causes of Death Cancer Morbidity Maternal and Child Health Mental Health Cardiovascular Disease Other Chronic Diseases Health Behaviors Obesity, Physical Activity and Nutrition Substance Use and Abuse Hunterdon Community Health Needs Assessment

6 Substance Abuse Treatment Bullying Sexual Activity COMMUNITY THEMES AND STRENGTHS ASSESSMENT Introduction Methodology Results FORCES OF CHANGE ASSESSMENT Introduction Methodology Results LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT57 Introduction Methodology Results PRIORITIZATION Assets and Resources CONCLUSIONS REFERENCES APPENDICES Appendix A: List of Partnership for Health Members Appendix B: County Health Rankings Model Appendix C: Focus Group Code Book Appendix D: Data Summary by Health Issue Appendix E: Data Summary by Health Factor Hunterdon Community Health Needs Assessment

7 LIST OF FIGURES Community Health Status Assessment FIGURE 1: Population Trends and Projections... 6 FIGURE 2: Population, by Municipality... 6 FIGURE 3: Population Density (per square mile), by Municipality... 7 FIGURE 4: Age Demographics... 7 FIGURE 5: Race/Ethnicity... 8 FIGURE 6: Percentage with a Select Disability... 9 FIGURE 7: Educational Attainment FIGURE 8: Percentage of High School Graduate or Higher, by Municipality FIGURE 9: Unemployment Rate FIGURE 10: Unemployment Rate, by Municipality FIGURE 11: Median Income, by Municipality FIGURE 12: Percentage of Individuals below Poverty Level FIGURE 13: Individuals below Poverty Level, by Municipality FIGURE 14: Number of People on Government Assistance Programs FIGURE 15: Marital Status FIGURE 16: Percentage of Municipalities with Gang Presence FIGURE 17: Violent and Non-Violent Crime Rate per 1,000 population FIGURE 18: Percentage of Adults Health Care Coverage FIGURE 19: Percentage of Adults Who Did Not See a Doctor Due to Cost FIGURE 20: Percentage of Adults Who Have Never Seen a Doctor for a Routine Checkup FIGURE 21: Hunterdon Hispanics Usual Source of Care FIGURE 22: Percentage of Adults Who Have Seen a Dentist in the Past Year FIGURE 23: Percentage of Adults Who Have Had a Permanent Tooth/Teeth Removed due to Tooth Decay or Gum Disease, by Age FIGURE 24: Physician Density per 100,000 population, by Primary Care and Select Internal Medicine Specialty FIGURE 25: Physician Density by 100,000 population, by Other Select Specialty FIGURE 26: Percentage of Adults Who Use Selected Preventive Services FIGURE 27: Percentage of Adults Who Use Selected Preventive Services FIGURE 28: ED Visits and Hospital Admissions per 1,000 population FIGURE 29: Hospital Utilization for Mental/Behavioral Conditions per 1,000 population FIGURE 30: Premature Death: Years of Potential Life Lost based on 3-Year Averages Hunterdon Community Health Needs Assessment

8 FIGURE 31: Leading Causes of Death per 100,000 population FIGURE 32: Cancer Incidence per 100,000 population, by Site FIGURE 33: Cancer Mortality per 100,000 population, by Site FIGURE 34: Method of Delivery FIGURE 35: Percentage with Prenatal Care in the 1 st Trimester, by Mother s Race/Ethnicity.. 33 FIGURE 36: Percentage of Babies Born with Low Birth Weight, <2,500g FIGURE 37: Depression and Suicide Among Youth FIGURE 38: Percentage of Adults with Cardiovascular Health Issues FIGURE 39: Percentage of Adults with Asthma and Diabetes FIGURE 40: Percentage of Adults Who are Obese (BMI 30) FIGURE 41: Percentage of Adults Who are Obese or Overweight (BMI 25) FIGURE 42: Percentage of Adults Who Engage in Binge Drinking FIGURE 43: Alcohol Consumption, Binge Drinking and Marijuana Use Among High School Students, Past 30 Days FIGURE 44: Perception of Parental and Peer Disapproval of Substance/Drug Use FIGURE 45: Percentage of High School Students Lifetime Use of Drugs FIGURE 46: Lifetime Substance Use Among Middle School Students FIGURE 47: Percentage of Adults Who Currently Smoke Cigarettes FIGURE 48: Percentage of High School Students Who Smoke, Past 30 Days FIGURE 49: Distribution of Substance Abuse Treatment Admissions, by Primary Drug FIGURE 50: Percentage of High School Students Bullied FIGURE 51: Sexual Behaviors Among High School Students Community Themes and Strengths Assessment FIGURE 52: Leading Factors that Contribute to Quality of Life FIGURE 53: Leading Factors that Reduce Quality of Life FIGURE 54: Leading Recommendations to Improve Quality of Life Local Public Health System Assessment FIGURE 55: Rank ordered performance scores for each Essential Service, by level of activity (With range) Prioritization FIGURE 56: Top Health Issues with Corresponding Seriousness and Ability to Impact Scores Hunterdon Community Health Needs Assessment

9 LIST OF TABLES Community Health Status Assessment TABLE 1: Per Capita and Median Household Income TABLE 2: Median Value of Housing and Gross Rent TABLE 3: Crime Rate per 1,000 population TABLE 4: Rates of Juvenile (per 1,000 children) and Adult (per 1,000 adults) Arrests due to Substance Use TABLE 5: Maternal and Child Health TABLE 6: Binge Drinking of 12 th Graders, by Gender TABLE 7: Student Perception that Substance/Drug Use is Not Harmful TABLE 8: Percentage of High School Students Who Used Drugs 40 Times or More TABLE 9: Percentage of High School Seniors (Under 18 years) Who Reported Purchasing Cigarettes from Convenience Store or Gas Station, by Gender TABLE 10: Percentage of High School Students Reported Having Ever Been Bullied in the Past 12 Months, by Gender Local Public Health Assessment TABLE 11: Summary of performance scores by Essential Public Health Service (EPHS) Prioritization TABLE 12: Master List of Top Health Issues with Corresponding Seriousness and Ability to Impact Scores Hunterdon Community Health Needs Assessment

10 ACKNOWLEDGEMENTS Funding for this project was provided through a grant from the Robert Wood Johnson Foundation s New Jersey Health Initiatives program. Special thanks to the many community members who participated in the 6 focus groups and the 14 community stakeholders who participated in the Forces of Change Assessment, for their valuable input. Lastly, thank you to all members of the Hunterdon County Partnership for Health for your support and active participation throughout the whole Community Health Needs Assessment process Hunterdon Community Health Needs Assessment i

11 EXECUTIVE SUMMARY INTRODUCTION The Hunterdon County Partnership for Health is a county-wide initiative that involves more than 30 community service providers, agencies and organizations sharing a common interest in promoting and improving the health, well-being and quality of life of Hunterdon County residents. Since its inception in 1995, this healthier community initiative has led the completion of 4 county-level Behavioral Risk Factor Surveillance System (BRFSS) surveys and the development of a 2007 Community Health Improvement Plan (CHIP). In 2011, Hunterdon Healthcare System (HHS), in collaboration with the Hunterdon County Department of Health, applied for and received a grant from the Robert Wood Johnson Foundation s (RWJF) New Jersey Health Initiatives program. This two-year grant operationalized through Hunterdon Regional Community Health (HRCH), an affiliate of Hunterdon Healthcare System, has enabled the Partnership for Health to lead another round of Community Health Needs Assessment (CHNA) activities. The objectives of the 2013 Hunterdon County Partnership for Health Community Health Needs Assessment are as follows: 1. Develop a comprehensive community health profile that would provide a snapshot of the health and healthcare-related needs of Hunterdon County residents 2. Identify and prioritize health issues/needs 3. Have a CHNA report that would fulfill the new IRS requirement for non-profit hospital and that can be used by other community stakeholders who are interested in using it for their strategic planning METHODOLOGY The CHNA conducted utilized the Mobilizing for Action through Planning and Partnerships (MAPP) framework, which consists of the following 4 assessments: 1. Community Themes & Strengths Assessment Conducted 6 focus groups to identify factors affecting quality of life of residents of Hunterdon County. 2. Local Public Health System Assessment Surveyed 18 individuals to identify the strengths, limitations, gaps and needs of the current public health system in Hunterdon County. 3. Forces of Change Assessment Conducted a brainstorming session with 14 community stakeholders to identify factors, events and trends that influence or will influence the community s health and the delivery and operation of public health services. 4. Community Health Status Assessment Analyzed 13 primary and secondary data sources to develop a comprehensive quantitative data-based county health profile Hunterdon Community Health Needs Assessment ii

12 Throughout the CHNA process, input from members of the Partnership for Health and other community residents, service providers and stakeholders -- especially those representing the underserved, low-income and minority populations -- was taken into account. After consideration and analysis of both qualitative and quantitative data from the 4 individual assessments, members of the Partnership for Health developed a master list of health issues in the county and voted on what should be prioritized. KEY FINDINGS I. COMMUNITY HEALTH STATUS ASSESSMENT A. Demographic and Socioeconomic 3 rd least densely populated county in NJ. Larger proportion of residents have a college or graduate/professional degrees (48%) compared to NJ overall. Higher than state average median income. However, large variation exists across the 26 municipalities. Dramatic 281% increase in food stamp usage between 2007 and Predominantly white, non-hispanic residents. The 2 nd largest race/ethnicity is Hispanics. Larger proportion of residents aged years compared to NJ. Increasing elderly (65 years and above) population. Smaller percentage of residents who are unemployed compared to NJ. Percentage of individuals in Hunterdon living below poverty is lower than NJ. B. Healthcare Access and Utilization Among adult Hunterdon residents, 93.2% have some form of health insurance coverage compared to just 87.2% in NJ. However, only 37.9% of Hunterdon Hispanics have some form of health insurance coverage. Larger percentage of Hunterdon Hispanics reported not having a primary care provider and cited cost as a major barrier to seeing a doctor compared to the general Hunterdon County population. Lower total physician density (per 100,000 population) compared to NJ. However, Hunterdon has a higher ratio of primary care and family physicians compared to the state. Percentages of reported use of preventive services in Hunterdon are higher among women over 40 years of age receiving mammogram and adults over 50 who received sigmoidoscopy or colonoscopy. However, percentage of men over 40 years of age receiving a Prostate-Specific Antigen test is lower than the state average Hunterdon Community Health Needs Assessment iii

13 C. Maternal and Child Health Larger percentage of pregnant women receiving prenatal care in the first trimester compared to state average. However, percentage among Hunterdon Hispanics is significantly lower. Birth rate is significantly lower than NJ and there are higher percentage of C-sections and multiple births in Hunterdon. D. Health Status and Health Outcomes Top reported causes of death were cancer, diseases of the heart and cerebrovascular diseases/stroke, although mortality rates due to these diseases were lower than NJ s rates. Breast and prostate cancers, followed by melanomas of the skin were the most common types of cancer. Lung/bronchus, prostate and colon/rectum cancers were the most frequently reported causes of cancer deaths. Lower percentage of obese and overweight adults compared to NJ. However, prevalence is increasing. E. Substance Abuse and Mental Health Alcohol and marijuana are the most frequently used substance among high school students. Prevalence of binge drinking among Hunterdon adults and percentage of adult heavy drinkers are higher than state average. Lifetime heroin use among Hunterdon high school students is higher than NJ. Lower percentage of adults and youths smoking cigarettes compared to their NJ counterparts. Majority of residents admitted for substance abuse treatment are due to alcohol followed by heroin/opiates. Larger percentage of high school students reported having been bullied on school property compared to NJ s average. II. COMMUNITY THEMES AND STRENGTHS ASSESSMENT A. Factors contributing to quality of life (Strengths) Rural Character Participants cited that parks, open spaces, and other natural resources enhance the beauty of the county while encouraging physical activity by providing opportunity to engage in various outdoor recreation activities. Accessibility and Availability of Healthcare and Social Services Participants mentioned that the county has a lot of available healthcare and social services available for all its residents, and in particular the more vulnerable population, such as the children, seniors, lower income and the growing Latino population. They also pointed out that the focus on preventive care has a positive impact on the community s overall health and well-being Hunterdon Community Health Needs Assessment iv

14 Safety of the Community Respondents identified safety and low crime rate as factors that draw a lot of people to choose to live and raise a family in Hunterdon. Excellent School System Access to high quality education was also frequently cited by focus group participants as one of the main strengths and appeal of the county. Strong Civic Support and Engagement Respondents stated that volunteerism and community support in the county is very strong. Community members and local businesses not only donate money, but more importantly they volunteer their time, knowledge and expertise. B. Factors reducing quality of life (Weaknesses) High Cost of Living Respondents frequently mentioned the high property tax and relatively higher cost of services as factors that reduce quality of life in Hunterdon. High cost of living makes it challenging for a lot of residents to make ends meet and continue to live in the county. This especially affects lower income and/or younger residents. Limited Services and Programs for Latinos Participants cited that although there are more services and programs for Latinos now than before, it is still not enough to adequately meet their need. Language and cultural differences and low health literacy continue to be barriers in accessing needed healthcare services. Mental Health Issues Participants noted that the success-driven culture and naturally competitive environment in the county put tremendous pressure on children, adolescents and adults, which in turn leads to stress and anxiety. Limited Affordable Transportation Options Due to the rural nature of the county, transportation was considered by many to be a major barrier to accessing healthcare and social services for many residents, in particular the elderly, low-income and disabled. Large Low Income Population Participants cited that income affects everything access to care, proper nutrition, opportunities to participate in organized recreational activities, and many more. They stated that in Hunterdon there is a growing number of hidden poor. These are individuals/families who are now struggling to make ends meet, yet do not seek assistance because they are embarrassed or they do not know where to go. III. FORCES OF CHANGE ASSESSMENT 1. Economic Crisis The economic downturn was a major factor among the participants. It has affected and will continue to affect the health and well-being of the Hunterdon community and the delivery of services by the healthcare and local public health systems. In addition, these tough economic times not only affect residents finances, but also their health. The financial stress of figuring out a way to maintain the lifestyle they are used to may have a harmful effect on their mental health as well as their children. 2. Healthcare Affordability and Uninsured Population Although the impact of the healthcare reform on healthcare delivery, affordability and accessibility remains 2013 Hunterdon Community Health Needs Assessment v

15 uncertain, participants believe that these are important issues that need to be addressed as they significantly influence the health of the community. 3. Aging Population and End-of-Life Care The changing demographic, the growing elderly population in particular, will contribute to an increase in demand for specific healthcare, social and supportive services, such as home care, and end-of-life and palliative care. Participants agreed that the public health system and the hospital will need to determine ways to fill the gaps and provide the needed care and services. 4. Substance Abuse, Mental Illness and Gang Activity Participants cited that substance abuse and its high prevalence of comorbidity with mental illness continue to be a pervasive problem in Hunterdon. In addition, because of the high demand for and profitability of drugs, gang activity is increasing in Hunterdon. Increasing accessibility to treatment services for substance abuse and mental illness is imperative to meet the persistent need. Emphasis on prevention efforts is also critical to curb this problem. 5. Government Policies and Priorities The differing priorities of federal, state and local governments are creating confusion and affecting availability and accessibility of services and programs in the county. Focus on the federal level is prevention and public health. However, decreasing budget has led to shifting of priorities away from health and human services and decreasing funding and staffing of various public health services at the local level. IV. LOCAL PUBLIC HEALTH SYSTEM ASSESSMENT Overall, the Hunterdon County public health system which consists of the hospital, local health department, community-based agencies, faith-based organizations, schools and other public health entity, is performing at an optimal level. It should be noted that assessment participants responded the best they could with the information they have. However, the results captured at this point in time may not accurately reflect the current performance of the local public health system due to the uncertainties of how changes in the county Division Public Health Services would impact the county s public health infrastructure and delivery of the 10 Essential Public Health Services. PRIORITY ISSUES Members of the Hunterdon County Partnership for Health reviewed the assessment findings and voted on the following to be its priority health issues based on 2 criteria: (1) seriousness of the issue, which included size and consequence, and (2) ability to impact or make a difference: 1. Obesity/Overweight Although percentage of overweight and/or obese adults in Hunterdon is lower than the state and nation, it has been increasing over the past 15 years. In addition, being overweight or obese substantially increases risk of developing certain chronic diseases such as heart disease and diabetes. 2. Substance Abuse Substance abuse continues to be a pervasive issue in Hunterdon that cuts across age and gender. 3. Latino Health Disparities There is a stark disparity in access to and utilization of healthcare services between the Hunterdon Latinos and the general Hunterdon 2013 Hunterdon Community Health Needs Assessment vi

16 population. They are also more likely to have poorer health outcomes and exhibit more risky behaviors compared to the general Hunterdon population. 4. Aging-related Issues The growing elderly population and their more specialized needs, such as home health and end-of-life care, are challenges that need to be addressed. Gaps in provision of and coordination of services need to be looked at and closed. NEXT STEPS Action teams were formed around each of the 4 identified health issues. Each team will meet and discuss in further detail their respective health issue. They will define attainable goals and objectives and develop clear strategies to address the health issues. All of which will be captured in the 2013 CHIP. The next step in this process will be to use the developed strategies to take action and impact the identified health issues Hunterdon Community Health Needs Assessment vii

17 INTRODUCTION The Hunterdon County Partnership for Health, Hunterdon s healthier community initiative, was co-founded in 1995 by Robert Wise, President and CEO of Hunterdon Healthcare System, John Beckley, former Hunterdon County Health Department director and Bernadette West, PhD, then Executive Director of Local Advisory Board (LAB) III, a central New Jersey regional health planning organization. The Partnership for Health is a county-wide initiative that involves more than 30 community service providers/agencies sharing a common interest in promoting and improving the health, well-being and quality of life of Hunterdon County residents. This is reflected in the Partnership for Health s vision statement of achieving health as defined by the World Health Organization (WHO): Every individual of Hunterdon County has a state of optimal physical, mental, spiritual, and social well-being which allows the individual to pursue the most fulfilling life possible, and not merely a life absent of disease or infirmity. Health and what influences it has evolved with the recognition of the social determinants of health. It is now understood that health is not a result of just one factor but is shaped, promoted and protected by a multitude of factors in our environment including where we live, work, learn and play. These factors include income, education, housing, access to quality healthcare and to healthy food, employment, and transportation, among others. To better understand the health of the community and barriers to achieving health, the Partnership for Health has taken the lead in conducting a wide range of community surveys and needs assessments designed to measure and track community health indicators over the years. More specifically, the Partnership for Health has led the completion of 4 county-level Behavioral Risk Factor Surveillance System (BRFSS) surveys in 1995, 2000, 2005 and Data from these surveys provided a picture of the community s health over the past 15 years. In 2007, a Community Health Improvement Plan (CHIP) was developed to focus on the Top 5 public health issues identified for Hunterdon County at that time (1) Mental Health, (2) Weight/Physical Activity, (3) Cardiovascular Disease, (4) Drugs, Alcohol & Tobacco, and (5) Access to Healthcare. Action teams, made up of experts and other passionate individuals, were formed to work together, and develop goals, objectives and strategies to address these top 5 health issues. In 2011, Hunterdon Healthcare System (HHS), in collaboration with the Hunterdon County Department of Health, applied for and received a grant from the Robert Wood Johnson Foundation s (RWJF) New Jersey Health Initiatives program. This two-year grant operationalized through Hunterdon Regional Community Health, an affiliate of HHS, has enabled the Partnership for Health to lead another round of Community Health Needs Assessment (CHNA) activities. This new assessment will provide an updated look into the most pressing health issues of the Hunterdon community Hunterdon County Community Health Needs Assessment - 1 -

18 CHNA is an essential step in the community health improvement process because it allows the Partnership for Health and its members, including Hunterdon Medical Center, to develop and implement more targeted and cost-effective strategies designed to improve the health status of the population they serve. With the collaborative efforts of the members of the Partnership for Health [see Appendix A for list of members] supported by the RWJF grant staff and outside consultants, a comprehensive 2013 Hunterdon County Partnership for Health CHNA process began in November 2011 and concluded in February 2013 with the following objectives: 1. Develop a comprehensive community health profile that would provide a snapshot of the health and healthcare-related needs of Hunterdon County residents 2. Identify and prioritize health issues/needs 3. Have a CHNA report that would fulfill the new IRS requirement for non-profit hospitals and at the same time can be used by other community stakeholders for their strategic planning The scope and focus of the CHNA was designed to not only be on health outcomes, but also on behaviors, socio-economic status and other environmental factors that impact health, following the University of Wisconsin Population Health Institute s County Health Rankings model [see Appendix B]. This report discusses the findings from the Assessment and will be used to guide the community s and Hunterdon Medical Center s health improvement planning process. COMMUNITY Hunterdon County, established in 1714 is a square mile rural-suburban community located in Western New Jersey. Hunterdon is surrounded by Warren County, Morris County, Somerset County and Mercer County and part of Pennsylvania. Although the 8 th largest county in NJ by total land area, it is the 18 th most populated with 128,349 residents in [1] It is the 3 rd least densely populated county in New Jersey with a population density of per square miles. [2] Historically agricultural, Hunterdon has been transitioning into a more commercial, industrial and residential community. The county, consisting of 26 municipalities, is the home of Hunterdon Medical Center (HMC), the only hospital in Hunterdon. HMC is a 178-bed teaching hospital that treats over 8,600 inpatients annually and has 292,000 outpatient visits per year. [3] Its Emergency Department sees approximately 33,000 patients each year. [3] Since opening its doors in 1953, HMC has focused on primary care and community wellness, and emphasized the importance of providing quality care while achieving a high level of patient satisfaction. This is reflected in its mission and vision statements. Mission: Hunterdon Healthcare System delivers compassionate and exceptional care that improves the health of the community Hunterdon County Community Health Needs Assessment - 2 -

19 Vision: Hunterdon Healthcare System is recognized as a national model for offering community focused health improvement that is consumer-centered and driven by a passion for excellence. Map of Hunterdon County and its Municipalities LEBANON TWP HAMILTON BORO GLEN GARDNER BORO CALIFON BORO TEWSKBURY TWP BLOOMSBURY BORO HOLLAND TWP BETHLEHEM TWP HIGHBRIDGE BORO UNION TWP CLINTON TOWN LEBANON BORO CLINTON TWP ALEXANDRIA TWP READINGTON TWP MILFORD BORO FRANKLIN TWP FRENCHTOWN BORO KINGWOOD TWP RARITAN TWP FLEMINGTON BORO DELAWARE TWP EAST AMWELL TWP STOCKTON BORO WEST AMWELL TWP LAMBERTVILLE CITY 2013 Hunterdon County Community Health Needs Assessment - 3 -

20 MOBILIZING ACTION TRHOUGH PLANNING AND PARTERNSHIPS The CHNA conducted utilized the Mobilizing for Action through Planning and Partnerships (MAPP) framework, which was developed by the National Association of County and City Health Officials in partnership with the Public Health Practice Program Office of the Centers for Disease Control and Prevention, as a tool to guide community health improvement. MAPP is a process that is driven by the community and is rooted on partnership development, assessment of needs and assets, and strategic planning on how to use available resources to address the prioritized health needs or concerns. The MAPP process consists of 4 assessments: 1. Community Themes & Strengths Assessment 2. Local Public Health System Assessment 3. Forces of Change Assessment 4. Community Health Status Assessment Throughout the CHNA process, input from members of the Partnership for Health and other community residents, service providers and stakeholders -- especially those representing the underserved, low-income and minority populations -- was taken into account. Furthermore, consultants were hired to provide expertise, additional support and assistance in conducting the CHNA. Consultants included John Beckley, MPH, Steven Godin, PhD, MPH, and Holleran Consulting. John Beckley has over 35 years of experience in the field of public health and was Hunterdon County s health officer/director for 26 years (September 1985-December 2011). He facilitated the Forces of Change brainstorming session. Steven Godin is a professor of Health Studies and director of the MPH Program at East Stroudsburg University. He has over 20 years of experience in community and public health and he facilitated the focus groups. In addition, both John Beckley and Steven Godin provided strategic guidance and support throughout the process. Holleran is a public health research and consulting firm with 20 years of experience in conducting community health assessments. The firm facilitated the prioritization and implementation planning session and analyzed the 2010 Hunterdon County BRFSS and 2012 Hunterdon County Youth Risk Behavior Survey Hunterdon County Community Health Needs Assessment - 4 -

21 COMMUNITY HEALTH STATUS ASSESSMENT The Community Health Status Assessment (CHSA) aims to develop a picture of the health status of the community by gathering data on various health indicators and comparing it to previous year, state or national data. This information was compiled, analyzed and presented in graphs and tables that are easily understandable. Data for the CHSA was obtained from the following primary and secondary sources: A. Primary 1. Hunterdon County Behavioral Risk Factor Surveillance System, 2010 (HC BRFSS) a health-related landline telephone survey of Hunterdon County adult residents conducted between August 23 and October 15, 2010 with a final sample size of 1,104. Survey questions were adopted from the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) study. Phone interview and data analysis were done by Holleran. 2. Hunterdon County Youth Risk Behavior Survey, 2012 (HC YRBS) a health-related paper and pencil survey of Hunterdon County high school students conducted in October 2012 with a final sample size of 2,002. Survey questions were adopted form the CDC Youth Risk Behavior Surveillance (YRBS) study. Data analysis was done by Holleran. 3. United Way of Hunterdon County Latino Health Behavior Risk Factor Survey, 2011 a health-related survey of Hispanic/Latino residents of Hunterdon County conducted between May and July 2011 with a final sample size of 352. Survey questions were adopted from the CDC BRFSS. Data analysis was done by Steve Godin, MPH, PhD. B. Secondary 1. US Census Bureau, American Community Survey, County Health Profiles: Hunterdon County, County Health Rankings, NJ Middle School Risk and Protective Factor Survey, American Drug and Alcohol Survey, NJ Household Survey on Drug Use and Health, Gangs in NJ: Municipal Law Enforcement Response to the 2010 NJSP Gang Survey, NJ Department of Labor and Workforce Development 10. NJ Center for Health Statistics DEMOGRAPHICS Population According to the 2010 US Census, Hunterdon County is home to 128,349 residents, well below the Hunterdon County Planning Board 2002 projection of 136,919. [4] The rate of population growth in the county has been steadily declining since the 1960s. However, the 5.2% population growth between 2000 and 2010 was the lowest since the 1960s. It is estimated that the influx of people coming to reside in Hunterdon will continue to level off over the next 2 decades. Of 2013 Hunterdon County Community Health Needs Assessment - 5 -

22 the 128,349 residents, there is an even distribution of males and females, 49.9% and 50.1%, respectively. [5] FIGURE 1: Population Trends ( ) and Projections ( ), Hunterdon County 140, , , , , , , , , ,776 Population 80,000 60,000 87,361 40,000 20, Data Source: NJ Department of Labor and Workforce Development, Projections of Total Population by County: New Jersey, 2010 to The most populated municipalities are the townships of Clinton, Raritan and Readington. Raritan and Readington are also the largest municipalities by land area in the county, 37.5 and 47.7 square miles, respectively. [2] However, population density is the highest in Flemington Borough and Lambertville City and lowest in the townships of Delaware and Kingwood. FIGURE 2: Population by Municipality, Hunterdon County (2010) 25,000 20,000 Population 15,000 10,000 5,000 0 Alexandria Bethlehem Bloomsbury Califon Clinton Town Clinton Township Delaware East Amwell Flemington Franklin Frenchtown Glen Gardner Hampton High Bridge Holland Kingwood Lambertville Lebanon Borough Lebanon Township Milford Raritan Readington Stockton Tewksbury Union West Amwell Source: US Census Bureau, 2010 Census 2013 Hunterdon County Community Health Needs Assessment - 6 -

23 FIGURE 3: Population Density (per square mile) by Municipality, Hunterdon County (2010) Alexandria Bethlehem Bloomsbury Califon Clinton Town Clinton Township Delaware East Amwell Flemington Franklin Frenchtown Glen Gardner Hampton High Bridge Holland Kingwood Lambertville Lebanon Borough Lebanon Township Milford Raritan Readington Stockton Tewksbury Union West Amwell Source: Hunterdon County: Facts and Figures, Population Density by County and Municipality, 2010 Age The proportion of children (under 18 years), adults (18-64 years) and elderly (65 years and over) residing in Hunterdon is relatively similar to that of New Jersey and the rest of the country. The similarity does not end there. As seen in all parts of the country, some more than others, the proportion and number of elderly are growing. And this is a trend that is expected to continue. According to the Pew Research Center, there will be an average of 10,000 individuals celebrating their 65 th birthday every day until [6] FIGURE 4: Age Demographics, Hunterdon County (2010) 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 12.7% 13.5% 13.0% 34.6% 29.1% 27.6% 26.4% 35.4% 36.5% 23.5% 23.5% 24.0% Hunterdon County New Jersey USA Elderly, 65 years Adult, years Adult, years Children, <18 years Source: U.S Census Bureau, 2010 Census; County Health Profiles: Hunterdon County Health Research and Educational Trust of New Jersey/New Jersey Hospital Association Hunterdon County Community Health Needs Assessment - 7 -

24 In Hunterdon County, the percentage of elderly rose from 10% in 2000 to 12.7% in In addition, the percentage of adults aged years is much higher than the state average, 34.6% and 27.6%, respectively. It is projected that by 2030, elderly, aged 65 years and over will make up over 24% of Hunterdon s population. [7] The aging population and increased longevity, one of the forces of change identified in the FOCA, will certainly have an impact on the health of the community as well as the provision of healthcare and social services. Prevalence of chronic conditions increases with age leading to higher utilization of healthcare services among the elderly. It is expected that the complex care needs of this growing population, both primary and specialty care, will pose challenges to healthcare planning and delivery. Race New Jersey is one of the most diverse states in the country. However, diversity is not spread uniformly throughout the state. Hunterdon is made up of predominantly white, non-hispanic residents (87.7%), a much higher proportion than NJ (59.3%). However, the county has seen tremendous growth in the number of people of a different race/ethnicity in recent years. The Hispanic community in particular, regardless of race, has increased by almost 200% in the past decade, from 2.8% in 2000 to 5.2% in [5] Asians are the 3 rd largest race/ethnic group in Hunterdon and makes up 3.2% of the county population, increasing from 1.2% in [5] This increasing diversity is evident not only in Hunterdon, but across the nation as well and is projected to continue to grow over the next few decades. [8] FIGURE 5: Race/Ethnicity, Hunterdon County (2010) Black, non-hispanic, 2.5% Asian, non-hispanic, 3.2% White, non-hispanic, 87.7% Other race, non- Hispanic, 0.2% Two or More Races, non-hispanic, 1.0% Hispanic/Latino of any Race, 5.2% Source: US Census Bureau, 2010 Census 2013 Hunterdon County Community Health Needs Assessment - 8 -

25 The increasing diversity affects the primary language spoken at home. Although much lower than the state average of 12.1%, the Limited English Proficiency (LEP) population in the county has increased from 2.2% in 2000 to 4.1% in Spanish (4.3%) is the second most common language spoken at home, far behind English (88.9%). Among the LEP population, those speaking Spanish increased from 0.9% in 2000 to 1.9% in [5] The growing diversity - racially, ethnically, culturally and linguistically is an asset to the community, as exposure to these differences has been suggested to promote tolerance, understanding and open-mindedness. [9] However, demographic changes also create challenges for the community as well as the healthcare system. The ability of service providers to effectively and appropriately communicate with the community they serve is vital. Language and differences in cultural norms, beliefs and attitudes, especially about health, can act as barriers to accessing health and social services, and will necessitate increased awareness, understanding and sensitivity of these differences among service providers. Disability As with other communities, having services available and accessible to persons with disabilities is of utmost importance. In 2009, the percentage of Hunterdon County residents with one or more disabilites is lower than the state average. Most common forms of disabilities are difficulties with independent living, mobility and cognitive function. FIGURE 6: Percentage with a Select Disability, Hunterdon County (2009) With and Independent Living Difficulty 3.5% 3.5% With a Self-care Difficulty 1.8% 1.8% With an Ambulatory Difficulty With a Cognitive Difficulty 3.5% 3.5% 3.6% 3.6% With a Vision Difficulty With a Hearing Difficulty 1.9% 1.4% 2.6% 2.5% Total Population with Any Disability 7.9% 10.1% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% New Jersey Hunterdon County Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County Hunterdon County Community Health Needs Assessment - 9 -

26 SOCIAL AND ECONOMIC FATORS Educational Attainment As the demographic data shows in Figure 7, Hunterdon County residents ages 25 years and older have high educational attainment with very little variation across the 26 municipalities [Figure 8]. The municipalities of Union (78.3%) and Flemington (84%) have the lowest percentage of the adults 25 years or older who have a high school diploma or higher. A higher percentage of Hunterdon County residents graduated from college and/or obtained postsecondary education when compared to NJ as a whole, 48% and 34.5%, respectively. [5] FIGURE 7: Educational Attainment, Hunterdon County (2009) Less than 9th Grade, 2.3% 9th-12th Grade, No Diploma, 3.8% Graduate/ Professional Degree, 20.2% Bachelor's Degree, 27.8% High School Graduate, 22.4% Some College, No Degree, 16.2% Associate's Degree, 7.3% Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 In addition, Hunterdon is known for its excellent public school system, with high school graduation rates higher than the state average. [10] The high educational attainment of both adults and youths in the county, is a key contributor to overall quality of life.studies have shown that educational attainment is strongly correlated with an individual s health. It is suggested that better educated individuals are more likely to have access to healthcare and are more health literate. Therefore they have better health outcomes and are more likely to contribute positively to their community. [11] 2013 Hunterdon County Community Health Needs Assessment

27 FIGURE 8: Percentage of High School Graduate or Higher by Municipality, Hunterdon County (2010) 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Alexandria Bethlehem Bloomsbury Califon Clinton Town Clinton Township Delaware East Amwell Flemington Franklin Frenchtown Glen Gardner Hampton High Bridge Holland Kingwood Lambertville Lebanon Borough Lebanon Township Milford Raritan Readington Stockton Tewksbury Union East Amwell Source: US Census Bureau, American Community Survey 5-Year Estimate Employment Although considered one of the wealthiest counties in the country, residents of Hunterdon have not escaped the impact of the economic downturn. The unemployment rate almost doubled from 4.1% in 2002 to 7.0% in The similarity in the trend of the unemployment rate between Hunterdon County and the state is unmistakable. In the past 10 years, the largest rise in unemployment in Hunterdon County occurred between 2008 and 2010, similarly observed across the state. FIGURE 9: Unemployment Rate, Hunterdon County and New Jersey ( ) 10.0% 9.6% 9.5% 8.0% 6.0% 5.8% 4.9% 4.7% 5.5% 7.2% 7.0% Hunterdon County 4.0% 2.0% 4.1% 3.4% 3.3% 3.8% New Jersey 0.0% Source: US Department of Labor, Bureau of Labor Statistics; NJ Department of Labor and Workforce Development, Labor Force Estimates Note: Rate based on individuals 16 years old and over in the civilian workforce Hunterdon County Community Health Needs Assessment

28 Although the overall unemployment rate is lower in Hunterdon County than the state, there are 7 municipalities in the county (Bethlehem, Bloomsbury, Hampton, High Bridge, Holland, Lebanon Township and Stockton) that are experiencing unemployment rates higher than the state average. FIGURE 10: Unemployment Rate by Municipality, Hunterdon County ( ) 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Alexandria Bethlehem Bloomsbury Califon Source: US Census Bureau, American Community Survey, 5-Year Estimates In 2009, a majority of (47.3%) Hunterdon County workers were employed in management, professional and related occupations, much higher than the state average of 39.3%. This maybe a result of the continuing transition of the county from being a historically agricultural industry to a more professional, white-collar industry. This shift was noted in the FOCA as a factor that affects and will continue to affect the economy because of the different skill set individuals entering the workforce are required to have in order to find employment. Income and Poverty Clinton Town Clinton Township Delaware East Amwell Flemington In 2011, Hunterdon ranked the 4 th wealthiest out of 3,141 counties in the United States with a median income of $99,099, behind only Loudon County, Fairfax County and Arlington County, all in Virginia. [12] The American Community Survey (ACS) estimates that the median income in Hunterdon was even higher at $103,879. In either case, this is significantly higher than the state and national average, $71,180 and $52,762, respectively. TABLE 1: Per Capita and Median Household Income, Hunterdon County, New Jersey and USA ( ) Hunterdon County New Jersey USA Per Capita Income $49,521 $35,678 $27,915 Median Household Income $103,879 $71,180 $52,762 Source: US Census Bureau, American Community Survey, 5-Year Estimates Franklin Frenchtown Glen Gardner Hampton High Bridge Holland Kingwood Lambertville Lebanon Borough Lebanon Township Milford Raritan Readington Stockton Tewksbury Union East Amwell Hunterdon County New Jersey 2013 Hunterdon County Community Health Needs Assessment

29 However, a different picture emerges when median income data is analyzed by municipality. Variation across the county is evident, validating focus group and forces of change participants perception that income disparity exists within the county, and that the gap between the haves and have-nots continues to grow. Median income ranges from as low as $53,333 in Flemington to $165,000 in Tewksbury. [13] A self-sufficiency standard study done in 2008 indicated that in order for a family of 4 consisting of 2 adults, 1 preschooler and 1 school-age child to make ends meet (i.e. have their basic needs like shelter, food, clothing and healthcare) in Hunterdon County, they must make at least $72,200 annually, 2 nd highest in NJ, behind Somerset. [14] Of the 26 municipalities, 4 have a median income that is either just at this threshold or below it Glen Gardner ($72,000), Stockton ($67,083), Frenchtown ($66,111) and Flemington ($53,333). [13] This self-sufficiency study also concluded that an adult living by himself/herself in Hunterdon County needs to make at least $29,139 to make ends meet. [14] In 2009, 11.1% of households were making less than $25,000. [13] FIGURE 11: Median Income, by Municipality, Hunterdon County ( ) Source: US Census Bureau, American Community Survey, 5-Year Estimates In spite of its general affluence, 3.6% of Hunterdon County residents are living in poverty, based on the Federal Poverty Level. Although this rate is substantially lower than the state and national average, it went up from 2.6% in 2000 to a 5-year estimate of 3.6% between 2007 and In addition, it is important to note that the poverty thresholds are updated for inflation using the Consumer Price Index (CPU-I), but are not adjusted based on geographic location which influences cost of living. [14, 15] In a location such as Hunterdon where cost of living is higher than average, the above numbers actually underestimate the level of poverty Hunterdon County Community Health Needs Assessment

30 FIGURE 12: Percentage of Individuals Below Poverty Level, Hunterdon County, NJ, USA 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 14.3% 12.4% 9.4% 8.5% 3.6% 2.6% USA New Jersey Hunterdon County Source: US Census Bureau, 2000 Census; US Census Bureau, American Community Survey Once again there is variation across the county, with certain municipalities experiencing greater poverty compared to others. In Flemington for example, 16.1% of individuals are living in poverty, significantly higher than the state average of 9.4% [Figure 13]. In Delaware Township on the other hand, only 0.7% of individuals are living in poverty. In addition, the percentage of Hunterdon County residents 65 years and older living below poverty decreased from 4.2% in 2000 to 3.4% in [13, 16] However, among children under 18 years, it increased from 2.1% to [13, 16] 4.3% in the same time period. FIGURE 13: Individuals Below Poverty Level, by Municipality, Hunterdon County ( ) 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Alexandria Bethlehem Bloomsbury Califon Clinton Town Clinton Township Delaware East Amwell Flemington Franklin Frenchtown Glen Gardner Hampton High Bridge Holland Source: US Census Bureau, American Community Survey Kingwood Lambertville Lebanon Borough Lebanon Township Milford Raritan Readington Stockton Tewksbury Union East Amwell Hunterdon County New Jersey 2013 Hunterdon County Community Health Needs Assessment

31 Although the number of county residents on government assistance programs is much lower than other counties, it has increased considerably during [Figure 14]. Increase in food-stamp usage, now known as Supplemental Nutrition Assistance Program (SNAP), was most notable. It saw a surge of 281% between 2007 and FIGURE 14: Number of People on Government Assistance Programs, Hunterdon County TANF SNAP EAP WIC Source: Health Research and Educational Trust of New Jersey (HRET), County Health Profiles: Hunterdon County 2012 The rising poverty among affluent communities is seen across the country. In fact, food stampusage increased by more than 200% in 6 out of the 10 wealthiest counties across the country. [17] According to the Hunger and Homelessness Survey, unemployment, poverty, low wages and high housing costs are the most common reasons for the increasing requests for emergency food assistance. [18] Hidden poverty was a term used by focus group participants to refer to individuals who were financially well-off but are now experiencing financial difficulties. A lot of them are either too embarassed to ask for help or do not know where to get help, as they never had to do so before. The big concern was how to reach this population to help them when we don t know who they are and they do not want to be identified. Although at a different degree compared to those with lower income, wealthy people are affected by the bad economy as well. They too are experiencing hardship as their standard of living has dramatically changed, explained one focus group participant. Marital Status With regards to marital status, Hunterdon County s population has a larger percentage of people who are currently married and not separated compared to the state and the nation. It also has a lower percentage of people who have never been married or are separated/divorced. The proportion of families living in a household with both husband and wife present in Hunterdon is 62.8%, significantly higher than the state s average of 51.1%. [5] The difference in 2013 Hunterdon County Community Health Needs Assessment