PINAL COUNTY 2017 Community Health Needs Assessment

December 7, 2017

1

Contents

Acknowledgements ..................................................................................................................... 2

Executive Summary ...................................................................................................................... 3

Introduction ............................................................................................................................ 3

Methodology ......................................................................................................................... 3

Key Findings ............................................................................................................................ 3

Pinal County Community Profile ................................................................................................. 4

Pinal County – Community Definition .................................................................................... 4

Pinal County Demographics - Overview ............................................................................... 5

Pinal County Demographic Profile – Population Growth and Density .............................. 7

County Health Rankings .......................................................................................................... 9

Identifying Community Health Priorities ..................................................................................... 9

Identifying Community Health Priorities: Access to Health Services ................................ 10

Identifying Community Health Priorities: Trends in Mortality ............................................. 11

Identifying Community Health Priorities: Trends in Morbidity and Infectious Disease ... 14

Identifying Community Health Priorities: Sun Life Family Health Center Community

Health Survey and Focus Groups ......................................................................................... 15

Sun Life Family Health Center Community Health Survey ............................................. 15

Sun Life Family Health Center Focus Groups ................................................................... 15

Proposed Health Priorities .......................................................................................................... 16

CHNA Health Priority Areas ....................................................................................................... 17

CHNA Priority Area 1: Physical Activity and Nutrition ......................................................... 17

CHNA Priority Area 2: Substance Abuse .............................................................................. 19

CHNA Priority Area 3: Mental Health .................................................................................... 20

Appendix A-E (attached)

2

Acknowledgements

This Community Health Needs Assessment was conducted in partnership with Pinal

County Public Health Services District, Banner Health, Sun Life Family Health Center, and

other key stakeholders. This work was made possible by the dedication of community

partners, as well as funding support by the Arizona Department of Health Services.

3

Executive Summary

Introduction

During 2016-2017, Pinal County Public Health Services District worked in partnership with

Banner Health and Sun Life Family Health Center to conduct a Community Health

Needs Assessment (CHNA) with the goal of describing the current state of health

among county residents as well as identify major priority areas and resources for

improving health outcomes. A CHNA is an invaluable tool for leveraging data,

resources, and partnerships to identifying gaps in health services and provide strategic

direction for future community health improvement efforts.

Methodology

Primary data were collected from focus groups and surveys with community members

and community-based organizations on health status, healthy environment, and

access to healthcare. Secondary data of morbidity and mortality was accessed from

Vital Records (Death Certificates and Hospital Discharge Data) as well as statewide

infectious disease reporting systems (MEDSIS and PRISM) and included access and

utilization of healthcare services, mortality trends, and morbidity and infectious disease

rates. Data were analyzed descriptively by geography (primary care areas) and

population based rates to determine areas of health disparities and high priority.

Results of these data collection and analysis efforts were a list of proposed priority areas

for community health improvement. A series of meetings and interactive workshops

were held to build consensus around the key priority areas where improvement is most

needed and can feasibly be addressed, identifying where work is already being done

and where to focus future efforts. Additional survey data collected by Sun Life Family

Health Center is included in this report as Appendices.

Key Findings

Pinal County is demographically similar to the state of Arizona and ranks well overall

compared to other Arizona counties. The county, however, is very diverse with respect

to its geography, population, and many indicators of health status and access to care.

This diversity creates many challenges and opportunities for specific areas and

populations within the county.

The following three priority areas were identified by the CHNA as the most urgent areas

for improvement where progress could feasibly be made:

Physical Activity and Nutrition (Obesity)

Substance Abuse

Mental Health

4

Pinal County Community Profile

Pinal County – Community Definition

Pinal County is the third most populous of Arizona’s 15 counties, encompassing a

population of over 400,000 residents in a 5,373 mi2 area in central Arizona between

Maricopa, Gila, Graham, and Pima counties. Home to diverse geographical features

including multiple state parks and national monuments and an equally diverse

population, Pinal County also is home to Arizona’s native populations from the Gila

River, Ak-Chin, Tohono O’odham, and San Carlos Apache tribal communities.

Figure 1: Counties of Arizona

Figure 2: Pinal County Zip Codes

5

Pinal County Demographics - Overview

A demographic overview of the county is provided in Table 1 and the distribution of

age and sex displayed in Figures 3 and 4. Many demographic measures for the county

as a whole are similar to those of Arizona, however Pinal has a slightly older population

on average, and an over-representation among men in the 15-49 year old age groups.

Pinal

County Arizona

Population 418,540 6,931,071

Households 127,599 2,890,664

Sex Male 52.0% 49.7%

Female 48.0% 50.3%

Age

Under 5 years 6.5% 6.5%

5 to 9 years 7.4% 6.9%

10 to 14 years 7.1% 6.9%

15 to 19 years 6.3% 6.9%

20 to 24 years 5.6% 7.2%

25 to 34 years 13.6% 13.3%

35 to 44 years 13.3% 12.5%

45 to 54 years 11.4% 12.7%

55 to 59 years 5.5% 6.1%

60 to 64 years 6.2% 5.7%

65 to 74 years 11.0% 8.9%

75 to 84 years 4.8% 4.7%

85 years and over 1.4% 1.8%

Median age (years) 37.6 36.8

Race/Ethnicity

White 79.4% 78.4%

Black or African American 4.6% 4.2%

American Indian and Alaska Native 5.3% 4.4%

Asian 1.7% 3.0%

Native Hawaiian and Other Pacific Islander 0.4% 0.2%

Some other race 5.5% 6.5%

Two or more races 3.1% 3.2%

Hispanic or Latino (of any race) 29.1% 30.3%

Not Hispanic or Latino 70.9% 69.7%

Socioeconomic

Status

Median Household Income $ 49,477 $ 50,255

Individuals below poverty level 17.3% 18.2%

Households with children under federal poverty

level 19.6% 21.2%

Households With Food Stamp/SNAP benefits in

the past 12 months 12.9% 13.5%

Table 1: Selected Demographic Characteristics of Pinal County and Arizona

Source: American Community Survey 2011 – 2015 Five Year Estimates

6

Figure 3: Age and Sex Distribution of Pinal County

Source: American Community Survey 2011 – 2015 Five Year Estimates

Figure 4: Median Age by Census Tract

Source: American Community Survey 2010 – 2014 5-Year Estimate

2.94%

3.64%

3.58%

3.24%

3.27%

3.66%

3.82%

3.71%

3.52%

3.03%

2.97%

2.77%

2.74%

3.12%

2.62%

1.82%

1.01%

0.68%

2.86%

3.50%

3.38%

2.95%

2.34%

2.65%

3.08%

3.04%

2.84%

2.53%

2.69%

3.04%

3.16%

3.53%

2.71%

1.75%

1.00%

0.83%

Under 5 years

5 to 9 years

10 to 14 years

15 to 19 years

20 to 24 years

25 to 29 years

30 to 34 years

35 to 39 years

40 to 44 years

45 to 49 years

50 to 54 years

55 to 59 years

60 to 64 years

65 to 69 years

70 to 74 years

75 to 79 years

80 to 84 years

85 years and over

Pinal County - Age and Sex Distribution

Male Female

7

Pinal County Demographic Profile – Population Growth and Density

Arizona is one of the fastest-growing states in the nation, and Pinal County follows in this

trend. Pinal was the second fastest growing county in the United States from 2000-2010,

experiencing a doubling in population during a ten year period. In the subsequent 5-

year period from 2011-2015, Pinal County’s population grew 7.5%, higher than the

overall growth rate of Arizona and the national average. During this period, the age

groups which experienced the most growth were 14-17 and 65 and older.

Figure 5: Population Growth, Pinal County and Arizona, 2010-2015

Source: American Community Survey Annual Estimates

Pinal County is a predominantly rural county, with most regions having a low population

density of 500 persons per square mile or less. Population centers in the county include

Apache Junction, Casa Grande, Coolidge, Florence, Maricopa, San Tan Valley, and

Queen Creek.

2010 2011 2012 2013 2014 2015

Pinal County 379,384 378,044 382,349 385,360 396,521 406,584

Arizona 6,408,208 6,468,732 6,553,262 6,630,799 6,728,783 6,828,065

5,890,000

5,990,000

6,090,000

6,190,000

6,290,000

6,390,000

6,490,000

6,590,000

6,690,000

6,790,000

6,890,000

350,000

360,000

370,000

380,000

390,000

400,000

410,000

Pinal County Population, 2010 - 2015

8

Figure 6: Population Density by Census Tract

9

County Health Rankings

The Robert Wood Johnson Foundation’s County Health Rankings & Roadmaps is a

comprehensive ranking of health status at the county level based on vital health

indicators including Physical Environment, Social and Economic Factors, Clinical Care,

Health Behaviors, and Length and Quality of Life, providing a standardized set of

metrics on health status relative to neighboring communities, as well as a benchmark to

gauge improvement over time. For the past 5 years, Pinal has ranked within the top 4 of

Arizona’s 15 counties. More information about the rankings and methodology is

available at http://www.countyhealthrankings.org.

RWJF County Rankings:

Arizona (2016)

Rank County

1 Maricopa

2 Greenlee

3 Yuma

4 Pinal

5 Pima

6 Yavapai

7 Santa Cruz

8 Cochise

9 Coconino

10 Graham

11 Mohave

12 Gila

13 La Paz

14 Navajo

15 Apache

Identifying Community Health Priorities In order to identify potential priority areas for the CHNA, Pinal County Public Health

Services District reviewed data in three categories representative of potential

community health priority areas: Access to Health Services, Mortality, and Morbidity.

Data for the Community Health Needs Assessment were compiled by Primary Care

Area (PCA), geographic areas which are defined by the demographic and healthcare

utilization patterns of residents. Arizona contains 126 PCAs, of which 9 are under the

jurisdiction of Pinal County. These include Apache Junction, Casa Grande, Coolidge,

Eloy, Florence, Gold Canyon, Maricopa, and Saddlebrooke. Primary Care Areas are

Figure 7: RWJF County Health Rankings Methodology and Arizona rankings

10

regions useful for identifying communities according to where and how they might

utilize healthcare, taking into account shared population characteristics and proximity

to hospitals, healthcare providers, and other health resources.

Identifying Community Health Priorities: Access to Health Services

Most regions of Pinal County are classified as Health Professional Shortage Areas.

Overall in Pinal County, there is one Primary Care Provider for every 944 residents. This is

three times lower than the average for the state of Arizona, which is one PCP for every

296 residents. The ratio of people to providers varies throughout the county. The most

medically underserved region is the Coolidge PCA, where there is only one PCP for

every 2,878 residents.

Figure 8: Primary Care Providers per Resident by Primary Care Area

This is also reflected in the data on where Pinal County residents seek care, as many

residents need to travel long distances to be seen by a provider. The map below shows

where Pinal County residents are most likely to be seen for a hospital inpatient visit, with

many residents seeking care in Maricopa and Pima counties.

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Primary Care

Area (PCA)

Residents

per PCP

Medically

Uninsured

Medicare

Beneficiaries

Travel time to

Nearest

Provider

Medically

Underserved

Area (MUA)

Apache

Junction 1,323:1 13.7% 27.1% 0 to 20

minutes Yes

Casa Grande

438:1 13.5% 16.1% 0 to 20

minutes Yes

Coolidge

2,878:1 12.9% 13.4% 0 to 20

minutes Yes

Eloy

1,729:1 13.5% 12.5% 0 to 20

minutes Yes

Florence

1,213:1 11.9% 22.9% 0 to 20

minutes Yes

Gold Canyon

840:1 6.9% 38.8% 0 to 20

minutes Yes

Maricopa

1,541:1 15.0% 7.2% 21 to 30

minutes Yes

Queen Creek

435:1 6.4% 6.3% 0 to 20

minutes No

Saddlebrooke

693:1 8.9% 38.6% 0 to 20

minutes No

San Tan Valley

1,340:1 12.0% 6.1% 21 to 30

minutes No

Table 2: Healthcare Access and Utilization Indicators by Primary Care Area

Source: ADHS Primary Care Area Statistical Profiles (http://azdhs.gov/prevention/health-systems-

development/data-reports-maps/index.php#statistical-profiles-pca)

Identifying Community Health Priorities: Trends in Mortality

The overall mortality rate in Pinal County is slightly lower than the average for the state

of Arizona, both seeing a significant decrease over the past decade.

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Figure 9: Age Adjusted Mortality Rate of Pinal County and Arizona, 2004-2014

Source: ADHS Population Health and Vital Statistics – Deaths (http://pub.azdhs.gov/health-

stats/menu/info/trend/index.php?pg=deaths)

The top causes of mortality in Pinal County are also similar to the rest of the state, but

vary according to key demographic factors. A major predictor of mortality in the

county is age. While older individuals predominantly die of heart disease, cancer, and

other chronic conditions, those under 45 are most likely to die due to accidents and

injuries, a broad category which includes motor vehicle accidents, poisoning and drug

overdose, firearm discharge, as well as falls and other accidents. As noted earlier, Pinal

County has many diverse communities of both younger and older residents with diverse

healthcare needs. These leading causes of death informed a focus on both chronic

health conditions and accidents and injuries as health priorities for the CHNA.

Figure 10: Top Causes of Death by Age Group

Source: Vital Statistics Information Management System (VSIMS)

757.3772.5

727.3

663.2659.6 653.2

679.9699.6

687.2 687.8676.0736.0

737.8

694.7

688.3

623.5607.7

642.0

668.5648.4

636.2

608.3

500

550

600

650

700

750

800

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

A G E - A D J U S T E D M O R T A L I T Y R A T E , 2 0 0 4 - 2 0 1 4

ARIZONA Pinal

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Heart Disease Cancer EndocrineDisease

Diseases of thedigestive system

Accidents andInjuries

Not elsewhereclassified

All Others

Leading Causes of Death by Age Group(Percent of deaths by International Classification of Disease (ICD) category

44 and Under 45+

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Primary Care

Area (PCA)

Mortality

(Deaths per

100,000)

Cancer

Mortality

(Deaths per

100,000)

Heart

Disease

Mortality

(Deaths per

100,000)

Accidents

and Injuries

Mortality

(Deaths per

100,000)

Infant

Mortality

(per 10,000

Live Births)

Apache

Junction 675.1 133.2 136.1 62.8 0.0

Casa Grande

665.3 150.5 141.2 38.7 13.9

Coolidge

688.9 168.0 154.2 40.2 0.0

Eloy

585.0 184.1 114.4 27.3 102.0

Florence

640.8 153.7 153.3 21.8 0.0

Gold Canyon

469.8 130.7 86.3 12.8 0.0

Maricopa

611.2 145.3 181.1 28.6 72.5

Queen Creek

701.2 178.5 145.0 43.1 43.6

Saddlebrooke

539.5 111.7 107.9 57.0 0.0

San Tan

Valley 633.3 154.0 141.5 39.4 28.8

Table 3: Mortality Trends by Primary Care Area

Source: ADHS Community Profiles Dashboard, 2013 (http://www.azdhs.gov/gis/community-profiles-

dashboard/index.php)

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Identifying Community Health Priorities: Trends in Morbidity and Infectious

Disease

Primary Care

Area

(PCA)

Heart Disease

Hospital

Admissions

(per 100,000)

Diabetes

Hospital

Admissions

(per 100,000)

Accidents

and Injuries

(per 100,000)

Infectious

Diseases

(Non-STI)

(per 100,000)

Sexually

Transmitted

Infections

(per 100,000)

Apache

Junction 1,810 141 7,887 307 409

Casa Grande

1,271 144 6,672 382 785

Coolidge

1,587 226 10,140 396 992

Eloy

827 116 5,100 292 619

Florence

1,294 90 5,894 238 644

Gold Canyon

2,087 38 5,077 239 116

Maricopa

864 120 3,748 288 592

Queen Creek

- - - - -

Saddlebrook

e 1,544 96 5,363 67 130

San Tan

Valley 812 72 6,140 238 328

Table 4: Morbidity and Infectious Disease Rates by Primary Care Area

Source: MEDSIS, PRISM, and Hospital Discharge Data

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Identifying Community Health Priorities: Sun Life Family Health Center

Community Health Survey and Focus Groups Sun Life Family Health Centers conducted a Community Health Survey and series of

focus groups with partner organizations and community members to better understand

the health needs from the perspective of community members, health providers, and

community coalitions. The findings from these primary data collection efforts

contributed to the list of proposed health priority areas for this Community Health Needs

Assessment.

Sun Life Family Health Center Community Health Survey

The Community Health Survey was administered by Sun Life during a one month period

in October 2016. Surveys were available in paper form at Sun Life Family Health Center

facilities and electronic format via SurveyMonkey, distributed via partner agencies by

email and on online. The paper and electronic versions of the Survey were available in

two languages (English and Spanish).

The survey consisted of 31 questions and touched on self-reported health status,

chronic medical conditions, health care access and insurance status, and availability

and affordability of fresh fruits and vegetables. A total of 391 surveys were received

from Pinal County community members in 2016. The results of the survey showed that a

majority of respondents have been diagnosed with multiple chronic conditions, such a

hypertension, diabetes, and obesity. Additionally, a majority of survey participants cited

having health care insurance and access to a personal doctor or medical provider.

Results of the survey are shown in full in Appendix A. Some key findings from the 2016

survey compared to past 2012 survey results were a high percentage of chronic health

conditions were reported by Pinal County residents compared to the U.S.:

Sun Life Family Health Center Agency Questionnaire

The Agency Questionnaire was administered to 20 partner agencies throughout Pinal

County and a summary of key findings is provided in Appendix B.

Sun Life Family Health Center Focus Groups

Focus groups were held at Sun Life Family Health Center Offices in Casa Grande,

Coolidge, Eloy, Florence, Maricopa and San Manuel/Oracle as well as agency partner-

hosted meetings in Apache Junction and San Tan Valley. A total of 60 focus group

participants contributed information on health status and access to healthcare

16

services. In addition to identifying specific barriers in different communities of Pinal

County, 86% of all focus group participants identified that there are not enough primary

care providers in their community, and more than half (57%) of focus group

respondents said they delayed health care due to lack of money or health insurance.

Another key finding was that 36% of focus group participants identified transportation

as a barrier to accessing health care services in the County.

Proposed Health Priorities Pinal County Public Health, in partnership with Banner Health and Sun Life Family Health

Centers, facilitated a Joint Priority Setting meeting in which representatives of

community organizations were brought in for an interactive workshop to determine joint

health priorities for the Community Health Needs Assessment. Upon reviewing the

county demographic information, access to care indicators, mortality and morbidity

statistics, as well as community health surveys and focus groups conducted by Sun Life

Family Health Center, the CHNA partners developed a list of 10 proposed health priority

areas for the county, shown in Figure 11.

Figure 11: Proposed health priority areas for Joint Priority Setting Meeting

During the Joint Priority Setting meeting, CHNA partners as well as community

organizations engaged in interactive presentations and facilitated dialogue to come to

consensus on the three priority areas based on the following criteria:

1. Magnitude and scope of problem

2. Increasing or decreasing data trends

3. Health disparities or inequality

4. Is it a Winnable Battle?

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The results of the joint priority setting exercise are summarized in Figure 12, with Physical

Activity and Nutrition, Mental Health, and Substance Abuse selected as the priority

focus areas. Physical Activity and Nutrition was selected by 68% of exercise participants

as the top health priority area for the county.

Figure 12: Results of the Joint Priority Setting exercise

CHNA Health Priority Areas

CHNA Priority Area 1: Physical Activity and Nutrition

Physical Activity and Nutrition was chosen by the majority of participants as a top

health priority for the county. As shown below, Pinal County trails both state and

national trends for obesity and physical activity1. Food insecurity is an issue for all

Arizonans, with state trends exceeding national trends. Pinal county has a lower food

insecurity level than most Arizona counties at 14.7%. Nearly 1 in 4 children in Pinal

County is food insecure, but the rate has declined over time.

Community Partners identified the following areas where efforts should be focused

around Physical Activity and Nutrition:

• Health Care/Employee Health

• Strengthening partnerships to maximize impacts

• WIC and food assistance program education and outreach

1 RWJF County Health Rankings, http://www.countyhealthrankings.org

52%

68%

13%19%

39%

48%

23%19%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Joint Priority Setting Workshop Results

18

• Develop a nutrition program

• Cooking demos and healthy eating classes with a PCP Rx

• Community Design

• Improve infrastructure such as sidewalks, parks, and recreation

• Incorporate walking, hiking and biking trails in city/county planning

• Increase Farmers Markets, community or neighborhood gardens

• Schools

• Implement policies such as recess and access to healthy food/snacks

• Improve safe walking and bike routes to school

• K-12 health education curriculum

The following were also identified as activities and efforts which partner organizations

are already engaged around Physical Activity and Nutrition:

• K-12 health education provided by UANN/Pinal County

• UANN gardening workshops for youth and adults

• Building a Community Center

• Diabetes education program

• CDSMP classes (Stanford model)

• Market on the Move

• WIC nutrition education

• Casa Grande Parks & Rec Let’s Move Coalition

• Educate youth athletes about nutrition and healthy behaviors

• Yearly fun run/walk

• Health care workforce education and training

• CHW certificate training program

• Sponsoring Get Out and Play Day events

• CG chamber help get info on programs out to the business community

19

CHNA Priority Area 2: Substance Abuse

Substance abuse is a major area of concern for all Arizonans, including those living and

working in Pinal County. The State Governor’s Office has made substance abuse and

the opioid crisis a state-wide priority. In Pinal County, several organizations have been

leading community efforts to prevent substance abuse including opioid abuse and use

of tobacco, drugs and alcohol among children and teens.

Community Partners identified the following areas where efforts should be focused

around Substance Abuse:

• Treatment & Prevention

• Public messaging on consequences of long term drug use and economic

impact of opiate epidemic

• Understand effects of poverty and generational abuse

• Substance abuse facilities for youth treatment

• School-based health centers and K-12 education

• Opioid withdrawal assistance

• Partner with civic and religious organizations

• Integrate primary care, mental health, substance abuse treatment and

services

• Address behavioral health needs when applicable

• Chronic Pain Management

• Chronic Pain Provider/Program

• Target providers with awareness of the issue

• Provide training/education to dispense less controlled substances and

refer patients to physical therapy or other methods for chronic pain

management

• More pain management case workers or care providers that work

specifically with those suffering from chronic pain and controlled

substance abuse issues

The following were identified as activities and efforts which partner organizations are

already engaged around Substance Abuse:

• Public education

• Pinal County provides K-12 evidence-based prevention education

• Educate community on risks of addiction to pain medications

20

• Provide education at community events and schools

• CG Chamber help to get info out to business community

• Multidisciplinary committee to address pain medication use/abuse

• Chronic Disease Self Management Pain Program (Stanford model)

• Train Community Health Workers at CAC

• Behavioral Health providers

• Pinal County Substance Abuse Council (includes 8 coalitions)

• Treatment Resource Center

CHNA Priority Area 3: Mental Health

Community Partners identified the following areas where efforts should be focused

around Mental Health:

• Schools

• Funding for support for counseling and social skills in schools

• Teach mental health self care strategies in schools, such as after school

yoga meditation

• Early education, detection and intervention

• Health Care System

• Integrate primary care, mental health, substance use treatment and

services

• Increase highly qualified and affordable behavioral and mental health

care

• Start an advocacy group for mental health with family members and

providers

• Recognition and options for getting diagnosed

• More chronic/psych hospitals

• Mental health “first aid” training of more people

• Community and Other Special Populations

• Understand affected populations: Who has mental health issues? Different

considerations for different ages, owners, ethnicities, occupations?

• Work with veterans to help with PTSD issues

21

• Provide training to correctional facilities and link to services

The following were identified as activities and efforts which partner organizations are

already engaged around Mental Health:

• Establishing a Mental Health Outpatient Clinic at Banner Casa Grande by

6/1/2017

• Behavioral Health/Primary Care integration

• Acute Care Behaviorist Program

• Behavioral Health (LCSW) in Primary Care

• Staff Behavioralists available to see patients

• All patients receive Mental Health screenings at each visit

• Medical school students placed at Behavioral Health facilities

• Partner with Cenpatico on SMIs

• Pick up services for Mental Health referrals

• Referrals at Community Health Centers for Behavioral Health and Substance

Abuse services