PARKVIEW ADVENTIST MEDICAL CENTER
Community Health Needs Assessment & Implementation Strategy
TABLE OF CONTENTS
Executive Summary………………………………………………………… 1
I. Service Area and Population…………………………… 2
II. Community Health Needs Assessment Partners…4
III. Community Health Needs Assessment Method & Process….. 4
IV. Identified Community Needs……………………………. 5
A. Needs Identified ……………………………………………………… 5
iii. Heart Disease ………………..6
iv. Mental, Dental Health& Social Support..6
v. Access to Care……………… 7
vi. Substance Abuse……………7
vii. Nutrition & Physical Activity………………….7
viii. Physical Environment…….8
x. Family and Community Involvement…….9
B. Process for Prioritizing……………………………………………. 10
C. Prioritized Needs……………………………………………………. 11
V. Community Resources to Address Needs………….13
A. PAMC Internal Resources……………
B. External Community-Based Resources………
VI. Implementation Strategy…………………………………14
A. How PAMC Will Address Health Needs………
i. PAMC Community Health Model……
B. Needs NOT Addressed In PAMC Plan…………
Appendix I. PAMC Service Area 2010 Census Data…………….14
Appendix II. Key Stakeholder Interview Summary…………….15
Appendix III. PAMC Service Area 2010 HIP Survey Results.15
Appendix IV. Community Involvement in PAMC CHNA………17
Rich in tradition, history, and natural beauty, Brunswick is a community of talented, innovative and involved citizens. Brunswick’s residents are fortunate to have access to beautiful recreational areas, high quality educational and medical resources, and growing employment opportunities.
Bordered by the Androscoggin River and Atlantic Ocean with its 67 miles of coastline, Brunswick is a coastal community, offering residents and visitors an array of recreational opportunities. With convenient access to I-295 and Route 1, Brunswick is located 30 miles north of Portland.
Brunswick is home to world-class businesses, including L.L. Bean manufacturing, Bath Iron Works (design/engineering), Owens Corning (composite fabrics) and Molnlycke (surgical and wound care product manufacturer). With its proximity to boat builders and other marine trades along the Maine coast, advanced technology training resources and innovative businesses, Brunswick has positioned itself as the epicenter of the state’s emerging composites manufacturing cluster. Brunswick is home to both Parkview Adventist Medical Center and Mid Coast Hospital and is a service center for neighboring communities.
In Brunswick, community means friendly neighborhoods and markets; inspiring art and culture in world-class venues; unique shopping and great food; healthy outdoor activities in a beautiful environment; a diversity of churches and denominations; and learning opportunities that never end. Bowdoin College, located in the heart of Brunswick’s downtown, infuses the region with spirited, intelligent 18-22 year olds from late August through late May. These students rely on the restaurants, shops and health care services provided by the two hospitals.
In 2012, Brunswick was named one of the Top 20 “Best Small Towns in America” by Smithsonian Magazine due to the high concentration of arts and culture, museums and historical sites per capita.
In 2010, Brunswick was named “Best place to retire”.(Money Magazine)“A classic New England fishing village, Brunswick is picturesque but not isolated, bustling but not hectic”.
I. Service Area and Population
From the 2011 Census, some 14,500 residents who call Brunswick home might likely agree with Money Magazine’s findings. Brunswick is located in the northernmost pocket of Cumberland County, with a population of 14,500. The town is primarily white (91%), with asian (2.8%) and two or more races (2.3%). Brunswick’s median income of $42,654 per household is on par with the Cumberland County average. Many of Parkview’s patients live just over the county border in Sagadahoc County, with a population of 35,200, a poverty rate of 10.5% (Margaret Chase Smith Policy Center) and median income of $52,071.
Both counties are primarily white (Cumberland County 95.7 %) ; (Sagadahoc County 96.5%) with black—Cumberland (1.06%), black—Sagadahoc (.92%) and two or more races at Cumberland (1.13%) and Sagadahoc (1.21%). Cumberland County has (53% males) and (47% females) with the highest number of people in the (birth-24) year age range (31.7%) and Sagadahoc County has (48%males) and (52%females) with the highest number of people in the (25-44) year age range (30.5%).
The State of Maine has again claimed the distinction of being the oldest state in the nation. In this state, Cumberland County has the largest cluster of younger Mainers,
while Androscoggin County has the ‘oldest’ population in the oldest state in the country. Sagadahoc is right in the middle.
The closure of the Brunswick Naval Air Station (BNAS) dealt the Greater Brunswick area a large economic blow, felt in every pocket of the community. Scores of military families received transfer orders to move to Jacksonville, Florida and other bases. Those who moved away took thousands of children out of the Brunswick schools, which meant the need for restructuring, and in some cases, closing several schools. Several locally owned businesses closed, due to lack of activity. And yes, many people lost jobs. The base closure forced the area to do things differently, forced business owners to be smarter and forced the town to lure international and national businesses to the region. Though economists suspected Brunswick and neighboring hamlets might turn into ghost towns, something odd happened: rather than fold, the region became stronger, determined to succeed despite the departure of the military stronghold. Within 18 months of the closure of BNAS, the town formed MRRA, the Midcoast Regional Redevelopment Authority. Through MRRA’s efforts, the Brunswick Landing (redevelopment of the former Brunswick Naval Air Station; and Foreign Trade Zone) and the Brunswick Executive Airport (BXM) were created. As Maine’s premier technology business park and a center for innovation, Brunswick Landing features 3,300 acres of prime real estate, over 2 million square feet of commercial and industrial space, a world-class aviation complex, and on-site educational institutions. Other major employers and redevelopment efforts include:
· Brunswick Business Park
· Cooks Corner Redevelopment
· Midcoast Regional Redevelopment Authority (MRRA)
· Town of Brunswick
· Bath Iron Works
· L.L. Bean Manufacturing
· Molnlycke Health Care
The 2012 unemployment rate was 7.1%. According to the state of Maine’s “Unemployment & Labor Force report (maine.gov), Brunswick’s unemployment rate (4.9%) is well below the average. According to the state statistics, Brunswick’s ‘civilian labor force’ stands at 34,184, with 32,513 gainfully employed and 1,671 unemployed.
According to the US Bureau of Labor Statistics, Cumberland County, Maine’s largest county, reported an employment gain of 0.6 percent from September 2011 to September 2012. The Bureau of Labor Statistics defines “large” counties as those with employment of 75,000 or more as measured by 2011 annual average employment. Regional Commissioner Deborah A. Brown noted that Cumberland ranked 233rd among the 328 large counties for employment growth nationally.
Nationally, employment increased 1.6 percent during this 12-month period, as 276 of the 328 largest U.S. counties gained jobs.
Employment in Cumberland County stood at 172,400 in September 2012 of total employment within the state. Nationwide, the 328 largest counties made up 71.0 percent of total U.S. employment.
The average weekly wage in Cumberland County fell 1.6 percent to $799 in the third quarter of 2012. Nationally, the average weekly wage decreased 1.1 percent over the year to $906.
Employment and wage levels (but not over-the-year changes) are also available for the 15 counties in Maine with employment below 75,000. All of these smaller counties had average weekly wages below the national average.
Large County Wage Changes
The above average 1.6-percent wage drop in Cumberland County ranked 165th among the 328 largest U.S. counties. Nationwide, 274 large counties experienced over-the-year decreases in average weekly wages.
Large County Average Weekly Wages
Cumberland County’s average weekly wage of $799 placed in the middle-third of the national ranking at 211th in the third quarter of 2012.
Average Weekly Wages in Maine’s Smaller Counties
All 15 counties in Maine with employment below 75,000 had average weekly wages lower than the national average of $906. Lincoln reported the lowest weekly wage among the smaller counties, averaging $560, followed by Piscataquis at $584. Sagadahoc reported the highest weekly wage of any county in Maine, averaging $833 per week.
When all 16 counties in Maine were considered, all had weekly wages that were lower than the national average. Two reported average weekly wages at or below $599, nine reported wages from $600 to $699, four had wages from $700 to $799, and one had wages above $800. The higher paid counties were concentrated along the southern Atlantic coastline and New Hampshire border.
***Tables and additional content from Employment
and Wages Annual Averages 2011 are now available online at www.bls.gov/cew/cewbultn11.htm. Voice phone: (202) 691-5200; TDD Message Referral Phone Number: 1-800-877-8339.
II. Community Health Needs Assessment Partners
Parkview works in collaboration with Mid Coast Hospital and the OASIS health network; additionally, PAMC’s management agreement with Central Maine Healthcare factors into the assessment insofar as utilizing ‘shared’ physicians.
III. Community Health Needs Assessment Methodology and Process
In 2010, in a collaborated effort between the University of Southern Maine and Market Decisions, Inc, an assessment was conducted, designed to identify the most important health issues in the state of Maine, both overall and by county, using scientifically valid health indicators and comparative information. The assessment identified priority health issues where better integration of public health and healthcare can improve access, quality and cost effectiveness of services to residents of Maine. The project represents OneMaine’s efforts to share information that can lead to improved health status and quality of care available to Maine residents, while building upon and strengthening Maine’s existing infrastructure of services and providers. The data used for determining the community health needs of Cumberland County was primarily obtained from the OneMaine Community Health Needs Assessment (CHNA). Additionally, Eastern Maine Health System, MaineGeneral Health, MaineHealth systems, the University of New England Center for Health Planning, Policy and Research (CHPPR) and the University of Sou7thern Maine’s Muskie School for Public Health contributed collaborative public health expertise. Using a methodology developed by CHPPR over decades of work, the assessment integrates primary data from a telephone survey to heads of households with secondary data retrieved from state databases (ED usage, Mortality, Cancer Registry, etc.) That data is reviewed in the context of multiple health related domains to develop a composite view of health status, behavioral risks and barriers to access and care. Results were compared to national and state benchmarks to produce priorities.
IV. Identified Community Needs
A. Needs Identified
Maine is the 23rd most obese state in the nation. After three decades of increases, adult obesity rates remained level in every state but one. (not Maine) Maine’s adult obesity rate is 28.4 percent, up from 19.9% in 2003 and 10.9% in 1990. More men (30.2%) than women (26.6%) are obese in Maine and the highest rate of obesity is among 45-64 year olds (32.5%). While Parkview does not have surgical services on campus, PAMC physicians do refer patients to the Bariatric Surgery Center at Central Maine Medical Center, in Lewiston, a 35-minute drive from PAMC. The Center’s Director, Dr. Jamie Loggins, MD, runs Central Maine Bariatric Surgery which includes two highly skilled surgeons (Loggins) and Dr. Stephen Bang, D.O., as well as highly trained bariatric dieticians, nurses and techs. In addition to surgery, the team offers a full-spectrum of services including nutrition, healthy eating, healthy lifestyle classes and a full spectrum of support.
Diabetes is a complex disease that can lower a person’s quality of life and dramatically reduce their life expectancy. Diabetes is the 7th leading cause of death in the U.S., accounting for nearly 234,000 deaths in 2008. According to the US Centers for Disease Control and Prevention, approximately 25.8 million people in the US have diabetes; of these, 18.8 million people have been diagnosed with diabetes and 7 million people have not yet been diagnosed. Among adults in the US, diabetes is the leading cause of kidney failure, nontraumatic lower extremity amputations, and new cases of blindness. Diabetes is also a major cause of heart attack and stroke—people with diabetes are two to four times more likely to die from heart disease or stroke than people who don’t have diabetes.
Here in Maine, between 1995 and 2010, the prevalence of diabetes increased from 3.5% to 8.7%, and this rate is identical to the 2010 national median.
In 2009, Maine’s diabetes-related death rate (65.8 per 100,000 population) was significantly lower than that the US (71.2 per 100,000 population).
The prevalence of pre-diabetes among Maine adults who are obese was 3.5 times higher than among Maine adults who are at a healthy weight. Nearly one in five (18.2%) Maine adults who are obese have been diagnosed with diabetes, a prevalence rate almost 6 times higher than those at a healthy weight.
The prevalence of diabetes was significantly higher among Maine adults who do not engage in the recommended amount of physical activity (11.0%) compared to those who do. (5.9%)
In Brunswick, Parkview’s Diabetes Educator reported to the Diabetes Control and Prevention Program that she saw 49 patients from Jan 1 through Dec 13 or 2013. All but one had Type 2 Diabetes. All were Caucasian. This educator conducts quarterly Diabetes Education classes for members of the community. In addition to information, the department offers cooking demonstrations to teach proper cooking techniques for diabetes. Additionally, Parkview’s Dietician meets with pre-diabetes and diabetes patients.
Nearly 1 out of four deaths in Maine is due to heart disease. 2,815 Mainers died from heart disease in 2006 (22.9% of total deaths in Maine); 670 Mainers died from stroke in 2006 (5.4% of total deaths in Maine).
Among those 75 years and older, there was a a 30.5% decline in the age specific death rate due to cardiovascular diseases in 1999-2009. Among those 65-74 years of age, there was a 45.7% decline in the age-specific death rate due to cardiovascular disease from 1999-2009. Among those 35-64, there was a 17.9% decline in the age-specific death rate due to cardiovascular diseases from 1999-2009.
Parkview offers high level support to patients through its relationship with Central Maine Medical Center; specifically, Cardiologists and Cardiac Surgeons with Central Maine Heart and Vascular Institute (CMHVI) who rotate into Parkview seeing patients on the PAMC campus and on the Lewiston-based CMMC campus.
The Maine Cardiovascular Health Program (MCVHP) works collaboratively with the 28 established Healthy Maine Partnership (HMP) coalitions to address chronic disease prevention through policy and system changes.
iv. Mental Health, Dental Health and Social Support
While Parkview has no specific program assigned to mental health, PAMC internal physicians are trained to identify, diagnose, and treat patients and refer higher level mental health issues and disorders. Mid Coast Hospital is the assigned area hospital for Mental Health coverage and treatment.
Additionally, Brunswick non-profit service agencies have coalesced, joining forces to provide care, funding and attention to those in need; requiring a wide array of free service and treatment. The Tedford Shelter and Mid Coast Hunger Prevention Center (MCHP) provide housing and nourishment to those who have lost their homes, their jobs and their hope during the economic downturn. Several Parkview nurses and social workers offer their time each week to homeless individuals at MCHP, where they teach stress and weight management, as well as healthy cooking classes. Additionally, the Brunswick-based OASIS clinic, staffed by physicians and nurses from both Parkview Adventist Medical Center and Mid Coast Hospital, as well as pediatric dentists, offer free services to the underserved. OASIS is a health network that offers free health and dental care as well as prescription assistance to uninsured, low-income residents in Southern Midcoast Maine. OASIS has continually served as a beacon of help and hope for thousands in the region.
v. Access to Care
Brunswick’s median age in 2013 is 41.4 years old. This compares with 2000, when the median age was 35.5 years. (In 1970, the median age was 24.3 years) In addition to the two hospitals (PAMC and MCH), residents can find care at the Urgent Care center in downtown Brunswick (operated by MCH). Brunswick has experienced the aging trend which has spilled into other regions throughout Maine. In 2010, 19.4% of Brunswick’s residents were over 65. That tops Maine’s average of 15.9% by nearly four percent. The town has picked up the reputation as being a prime region for retirees to relocate. In fact, Money Magazine named Brunswick one of the country’s top communities in which to retire. To that end, Brunswick is home to four assisted living facilities and nursing homes including Thornton Oaks, Mid Coast Senior Health Center, Thornton Hall Assisted Living and Interim Healthcare; additionally, Sunnybrook Village Senior Living. The Highlands (in nearby Topsham) provides multi-layered, multiple needs care for its residents. Brunswick’s retirement community is in a growth mode. This growth has created an additional opportunity for additional healthcare services to meet their needs: Urology, Gastrointerology, Oncology, Cardiology, Pulmonary, Diagnostic Imaging are among those services.
The extent of PAMC’s Substance Abuse prevention programs is the Smoking Cessation Program—a multi-week approach to helping members of the community to stop smoking. Mid Coast Hospital has a Walk in program called the Addiction Resource Center. ARC offers a full range of professional treatment services for people with alcohol or drug related problems. ARC also provides family and co-dependency services to those affected by someone else’s alcohol or drug use. ARC also treats people with substance abuse problems and mental health issues. ARC conducts professional assessments and then recommends the best treatment options for problem usage, harmful drinking and drug use patterns, dependency and addiction. ARC offers individual, family and group counseling as well as intensive outpatient programs (day and evening), medication assisted treatment, family intervention, and prevention services.
vii.Nutrition & Physical Activity
Parkview takes an active role in helping the Brunswick community improve their nutrition, diet and exercise patterns/choices. Parkview, a Seventh-day Adventist hospital, was founded in 1959 on the tenets of the church which embraces and preaches prevention. Members of the church generally eat a plant-based, vegan diet and embrace a healthy lifestyle that features drinking water, no caffeine or alcohol, abundance of sunshine and fresh air as well as daily activity. From its beginning, Parkview has reached out to the Brunswick community, offering cooking classes, exercise programs, Diabetes awareness and prevention programs, and the multiple award-winning Life Style Choices program. LSC is a 10-day program designed specifically for adults who have or who are at risk of developing a chronic health concern such as diabetes, hypertension, high cholesterol, coronary artery disease, obesity, arthritis, etc. A Registered nurse with a Master’s Degree in public health directs the program. She has additional training in clinical preventive medicine. The medical director is an internal medicine physician who specializes in lifestyle medicine and chronic disease reversal.
Participants attend the program from 5:00 PM to 8:30 PM five days a week for two consecutive weeks. Each class contains no more than 50 people and provides three plant-based meals each day. Participants are together for the evening meal so they eat that together. Breakfast and lunch are sent home with them each evening for the following day. Following the evening meal, physical therapists are present to work with individuals on physical activity. After a demonstration and reverse demonstration, participants who are physically able head outside for a brisk walk. Those with mobility issues are facilitated in the physical therapy gym. Following the physical activity aspect of the program participants reconvene for a cooking demonstration followed by a daily presentation by one of the program specialists.
A wide-range of topics are covered including nutrition, and how nutrition and physical activity affect various disease processes with special attention given to diabetes, cancer and heart disease. In addition, the program covers new research such as advanced glycosylated end products (AGE), epi-genetics, Diabetes Type 3, etc. with a focus on making difficult material readily understandable and relevant to adult learners. Pre and post testing includes a lipid panel and fasting glucose, blood pressure, weight, body composition, hydration level, grip strength, flexibility, a timed mile walk and hip and waist measurement. There is an extensive post program questionnaire completed the last night of the program.
In the early years of Life Style Choices, pre and post program cardiac stress tests were performed on each participant in order to document the positive effects. The results consistently showed improvements in cardiac function, even among those who showed no cardiac issues on the pre-testing. Performing cardiac stress tests on every participant began to be no longer cost effective and were discontinued. However, we continue perform them on participants with strong cardiac indicators or history and the results continue to consistently show improvement.
The program was developed through collaboration between the hospital, a local physician and the health principles of Adventist Health. For more than 50 years Parkview Adventist Medical Center has been committed to promoting the health principals espoused by Adventist Health, all of which are well documented in the literature to reduce the risk of disease. The cost of chronic disease to our economy and to the quality of life of individuals who suffer from chronic disease is also well documented. This program grew out of a desire to eliminate those costs as much as possible and to use the principals espoused by Adventist Health for disease management. It costs the hospital approximately $850 per participant to operate the program. Life Style Choices is funded through the hospital wellness department.
The primary catchment area was intended to be the Mid Coast region of Maine surrounding the hospital, which has approximately 200,000 residents. However we are blessed to have patients come from all over the state of Maine and from many other states around the country. In fact, this program has attracted participants from several different foreign countries.
Each 10-day session is intense and has proved successful. Dr. Timothy Howe, MD, an internal medicine physician, oversees the program. His vegan, increased activity approach has helped patients lose weight, lower LDL cholesterol and high blood sugar and blood pressure. The outcomes for this program have been tracked over the past 15 years and have been very consistent. In just 10 days, participants experience reductions of 30 to 50 points in their total cholesterol, 30 points in triglycerides, 20 points in LDL cholesterol, 5 pounds of weight, etc. while also enjoying increased energy, better sleep and an overall increase in well-being. In addition, participants are able to reduce and in some cases eliminate altogether the amount of medication they take for diabetes, hypertension and high cholesterol. This translates into a cost savings for individuals and reduced side effects from those medications.
The program has also been effective for patients suffering from urinary incontinence, fibromyalgia and other types of chronic problems. One participant reported that she was scheduled for surgery for urinary incontinence but as a result of attending the LSC program, she no longer needed the surgical intervention.
We regularly receive patients who have run out of other options for treatment. For various reasons they are no longer surgical candidates and many have been sent home to “get their affairs in order”. David was just such a patient. He was in his late 70’s and his heart disease was so advanced and his co morbidities so complicated that his physician informed him that there was nothing left for them to do. David told us, “I wasn’t ready to die. They told me to go home and get my affairs in order. Instead I called the Lifestyle Choices program and they gave me my life back! I was supposed to be dead three years go, but because of what I learned at the Lifestyle Choices program, I’m headed to Brazil for vacation!”
Richard had a similar experience. “I joined the program, but had to take 3 nitroglycerine tablets just to get from my car in the front of the hospital into the
classroom. By the end of the program I was walking a mile each day totally free of pain and now I’m walking 3-miles every day. And I’ve lost 53 pounds!”
Mid Coast Hospital, also in Brunswick, has adopted a program of its own called the Center for Weight and Lifestyle Change. The multi-disciplinary outpatient weight loss program meets once a week at the hospital. The program is run by a dietician, a nurse, a psychotherapist and a medical director. Both programs encourage long term lifestyle changes that will instill improved, lifelong health habits.
Brunswick’s location lends residents a bountiful array of options for outdoor health. With four seasons to enjoy, our parks and public spaces and programs boast endless opportunities for residents and visitors to live an active lifestyle, offering a wide variety of options for people of all ages in diverse settings. Our common spaces range from lush places for play, parks, wooded trails, river access, and a gateway to the beautiful islands of Casco Bay.
· Androscoggin River Bicycle Path, for walking and biking, recipient of the East Coast Greenway Alliance Trail of Merit Award
· Androscoggin River Walk
· Mere Point Boat Launch, access to northern Casco Bay and the Maine Island Trail
· Historic Town Commons Trails
· Maquoit Bay Conservation Lands
· Cox Pinnacle Trails and Crystal Spring Farm Trails
· Information regarding these sites, parks and recreation programs and more can be found at www.brunswickme.org/departments/parks-recreation/ and www.btlt.org. Brunswick Parks and Recreation received the Sports Illustrated Good Sports Community Award.
Brunswick offers healthy living and outdoor adventures for all ages. Brunswick is a forward-thinking, health-conscious and prevention-centered town. Care providers place great importance on the whole person: mind, body, spirit. From acupuncture to therapy to surgery, beautiful Brunswick provides the perfect backdrop to inspire good health!
· Hospitals: Parkview Adventist Medical Center and Mid Coast Hospital
· Primary care specialists, allied health services, hospice
· Walk-In Clinic
· Yoga, fitness, golf, martial arts and more
Parkview Adventist Medical Center is a founding participant in the community transportation program called The Brunswick Explorer. The Brunswick Explorer picks up and delivers all over Brunswick from the downtown shopping areas to both hospitals (Parkview and Mid Coast Hospital, which is 2 miles from downtown), People Plus (a community hub for both the elderly and young), grocery stores, library, Bowdoin College and beyond. Fare for the Explorer is $1,making the service affordable to the community at large.
x.Family and Community Involvement
Parkview is involved in an array of community programs including CHIP at Curtis Memorial Library (Community Health Information Partnership. Parkview and MidCoast Hospitals are partners in the CHIP Program, which provides current quality health and wellness information in a variety of formats to residents of the MidCoast (Greater Brunswick) region. Over the past ten years, CHIP has bought thousands of items that are available at Curtis Library or through inter-library loan to residents of the area. Parkview has played an active role in the Brunswick area American Heart Association fundraisers. (the past three years the “Heart Ball” has raised just under $10,000 for the Maine Chapter of the AHA). Parkview works in collaboration with Mid Coast Hospital, Central Maine Medical Center as well as a variety of other companies and business in the Brunswick region. Parkview supports the Southern Midcoast Maine and Freeport Chambers of Commerce and participates in annual and semi-annual fundraisers. Additionally, Parkview provides space, free of charge, for groups to gather.
CME courses are offered, as area addiction prevention classes, United Way presentations, and community outreach discussions and talks by physicians and surgeons.
Parkview is involved with the two local high schools: Brunswick High School and Mt. Ararat. Students from these schools take part in quarterly community service projects in which they tour the hospital and engage in Q & A with physicians, nurses and members of the PAMC staff. Additionally, Parkview works closely with the Tech 10 Regional High School which offers a CNA training course. These CNA’s in training get hands-on
experience in Parkview’s Med Surg area and work closely with RN’s.
In addition, Parkview has played a pivotal role in annual fundraisers for The Dempsey Challenge for the Patrick Dempsey Center for Cancer Hope and Healing, The American Cancer Society, The Lung Association, Alzheimer’s and the Muscular Dystrophy Association.
Brunswick offers an educated workforce with Bowdoin College, Southern Maine Community College, Southern New Hampshire University and the University of Maine Engineering Department all operating within the Brunswick community. (*NB (note well): UMaine’s Engineering Department students are engaged in an innovative, hands-on program, (in space that’s based on the former BNAS campus) giving students an integrated approach to earning the first two years of a four year engineering degree, taught by professors recognized nationally for their expertise. Additionally, Brunswick’s strategic location bolsters the town’s attraction as a destination town, with excellent dining, excellent schools and consistently high-level medical care.
B. Process for Prioritizing Health InfoNet is a prime example of Maine health care providers’ willingness to share information for the betterment of patient care. This state computerized initiative allows a patient’s records to follow them, electronically, wherever they need care. For instance, if a patient is hurt on vacation in Fort Kent, their hometown health records in York can be accessed through Health InfoNet in mere seconds.
C. Prioritized Needs
Health Needs Identified
Maine has several socio-demographic characteristics that may impact the health indicators in Cumberland and Sagadahoc Counties. For instance, Cumberland County has the youngest population in the state. This age group skews high in percentage of population for using (and abusing) alcohol and drugs. This also factors in a higher than average Emergency Department visits for drug and alcohol related treatment. Additionally, childhood obesity paired with teenage drinking place Maine youth at both immediate and future risk of poor health and underscores a need for prevention interventions involving local organizations. High rates of two or more so-called ‘youth risk behaviors’ were identified in 6 northern Maine counties; while hospital admission rates of youth for depression and suicidal tendencies are highest in 6 midcoast and southern Maine communities INCLUDING Cumberland and Sagadahoc counties.
Behavioral health risk factors such as smoking, obesity and sedentary lifestyle continue to be priority health issues in several, mostly rural counties and throughout the state. Smoking rates are high in Maine (22%) despite Smoking Cessation efforts (such as the successful program offered at Parkview Adventist Medical Center—PAMC). Obesity is a significant health concern. Currently, approximately 112,000 adults in Maine are obese, having a body mass index greater than or equal to 30(28% in Maine). This is comparable to the US rate of 28%, with several counties well above the state average.(38%+) Cumberland county reports 24% and Sagadahoc County reports 23% of obese adults. Leading a sedentary lifestyle is prevalent in many counties.
Risk Factor Prevalence
Despite the known harmful effects of smoking as the leading cause of respiratory illnesses, the proportion of the population with COPD or asthma who continue to smoke is high in most regions. Patients suffering from these conditions who continue to smoke is high in most regions of Maine. Patients suffering from these conditions who continue to smoke will have difficulty keeping their disease from progressing, as well as managing additional side effects from their illness.
Smoking prevalence is higher among those with diagnosed respiratory illnesses, especially COPD and asthma. Across the state, 36% of patients with COPD and 25% of patients with asthma continue to smoke. The highest proportion of patients with COPD who continue to smoke are in Sagadahoc (49%) and Washington (53%) counties. Cumberland county(9.3%) has the lowest smoking prevalence among those with current asthma.
The Respiratory health profile of the populations of Maine suggests risk factors, disease morbidity and mortality are high in many Maine counties, especially rural regions. Smoking continues to be a challenge in many areas of Maine, and explains a large proportion of the disease and death rates. Access to and availability of primary prevention and treatment modalities for chronic obstructive pulmonary disease (COPD) and other lung disease are priorities for follow-up.
Asthma is gripping the nation (literally). According to the CDC, Asthma affects an estimated 16.4 million adults in America (18 years and older) and 7 million children.
According to state numbers, Maine asthma rates among adults are the highest in the country (9% of all adults). Among children, 8.4% of kindergarten students and 8.9% of all other students have asthma. It is estimated that there are 65,000 (or more) school absences each year in Maine due to asthma. The rate of asthma in Maine has doubled in the last 20 years, with the burden falling disproportionately on low income and minority communities. In 2008, there were more than 4,500 hospitalizations due to asthma, and more than 45 deaths due to asthma. While medicine is becoming more readily available to asthma patients, education remains a concern. According to the CDC, of 389 patients asked whether they’ve ever been taught how to recognize early signs/symptoms of an asthma episode, only 71% responded yes. Of 382 who were asked whether they have ever been given an asthma action plan, a mere 37% responded yes. Just 9% of the 397 polled answered yes to ever taking a course on how to manage asthma. Education is a critical tool in reaching asthma patients.
COPD has risen to alarming rates in Maine. According to the ME CDC and the American Lung Association, more than 48,000 women (8% of Maine’s population), suffer from the chronic respiratory disease COPD. Women are 37 percent more likely than men to be diagnosed and now account for more than half of all COPD deaths nationally. COPD refers to a group of progressive lung diseases that make breathing difficult, including emphysema and chronic bronchitis. It is the 3rd leading cause of death in the US and trails heart disease and cancer. Smoking is the primary cause of COPD, although it’s been linked to genetics and some environmental pollutants. In April 2013, The American Lung Association released its 14th annual “State of the Air” report. The report covered the two most widespread types of air pollution: ozone, the main ingredient in smog and air-particle pollution, sometimes called soot. These particles can lodge deep in lung tissue and even pass into the bloodstream. Spikes in pollution, according to the American Lung Association, can contribute to heart attacks and stroke, while exposure over months and years contributes to cancer.
State Infectious Disease Data
The Maine CDC Division of Infectious Disease18 provided incidence rates for HIV/AIDS,
sexual transmitted diseases, and viral hepatitis. Chlamydia/Gonorrhea: 2008 data, from the Maine CDC Division of Infectious Disease, HIV, STD and Viral Hepatitis Program.19 Hepatitis C: 2007-2009 data. HIV: from the 2009 Annual Surveillance Report Maine CDC Division of Infectious Disease
According to results in a Maine HIV/STD Surveillance Program Summary Report, Cumberland County’s cases of Chlamydia dropped by two percentage points from 2011 to 2012—746 cases. Mid Coast Maine reported 278 cases for 2012. Gonorrhea cases, however, were up in Cumberland (110—11 more than in 2011); and MidCoast’s cases jumped by 12. Syphilis cases increased in Cumberland by four (10 cases in 2012) while there were no cases reported in 2012 in Mid Coast Maine (2 reported in 2011). Some good news on the HIV front: Cumberland reporting improved numbers (26 cases in 2011, 20 reported in 2012); Mid Coast also saw improvement—1 case in 2012, while there were two the year prior. AIDS cases in Cumberland also improved (14 in 2011) 5 in 2012; MidCoast had no cases in 2012 (3 cases in 2011).
Maine has among the highest age-adjusted cancer incidence and mortality rates in the US. While US incidence rates have been declining in recent years, Maine’s cancer rates have remained high. The reason Maine’s rates are high is not clear, but may be a reflection of improved screening rates. Although Maine’s all-cancer mortality rate has been declining, the 2005-2007 rate was the 7th highest in the nation.
Lung Cancer mortality/incidence ratios are highest in Franklin (96%) followed by Sagadahoc (91%) counties compared to the state average (73%). The rate is higher for women than men in Sagadahoc county. Early lung cancer detection, while differing by county, does not differ much by gender.
Prostate Cancer is the most frequently diagnosed cancer among the male population. Prostate cancer incidence rates are elevated in Sagadahoc county in addition to Hancock, Lincoln, Piscataquis and Washington counties. Incidence rates of prostate cancer have increased in Maine over the past 10 years as the population ages. Over two-thirds of men age 50+ report having a Prostate Specific Antigen (PSA) test in the past 2 years; Cumberland, Kennebec and York county men have the highest rates.
V. Community Resources to Address Needs
A. PAMC Internal Resources Programs including LifeStyle Choices, Smoking Cessation, Living with Diabetes educational program; Grief Counseling
B. External Community-Based Resources Brunswick: A Healthy Lifestyle (collaborative guide between Brunswick Downtown Association and Marketing professionals from 20 organizations in Brunswick) Brunswick’s location lends residents a bountiful array of options for outdoor health. With four seasons to enjoy, our parks and public spaces and programs boast endless opportunities for residents and visitors to live an active lifestyle, offering a wide variety of options for people of all ages in diverse settings. Our common spaces range from lush places for play, parks, wooded trails, river access, and a gateway to the beautiful islands of Casco Bay.
* Androscoggin River Bicycle Path, for walking and biking, recipient of the East Coast Greenway Alliance Trail of Merit Award
* Androscoggin River Walk
Mere Point Boat Launch, access to northern Casco Bay and the Maine Island Trail
* Historic Town Commons Trails
* Maquoit Bay Conservation Lands
* Cox Pinnacle Trails and Crystal Spring Farm Trails
* Information regarding these sites, parks and recreation programs and more can be found at www.brunswickme.org/departments/parks-recreation/ and www.btlt.org. Brunswick Parks and Recreation received the Sports Illustrated Good Sports Community Award. Brunswick offers healthy living and outdoor adventures for all ages. Brunswick is a forward-thinking, health-conscious and prevention-centered town. Care providers place great importance on the whole person: mind, body, spirit. From acupuncture to therapy to surgery, beautiful Brunswick provides the perfect backdrop to inspire good health!
* Hospitals: Parkview Adventist Medical Center and Mid Coast Hospital
* Primary care specialists, allied health services, hospice
* Walk-In Clinic
- Yoga, fitness, golf, martial arts and more
VII. Implementation Strategy
A. How PAMC will Address Health
i. PAMC Community Needs Health Model The Affordable Care Act (ACA) creates the perfect opportunity for community health facilities, such as PAMC, to accelerate community health improvement programs and approaches to improved health. Giving the community at large free and easy access to educational, inspirational forums will allow for population wide health interventions as well as measurable results. Parkview’s fully transparent mode of operation will help to improve community engagement in healthcare (their own and others’) and will require PAMC to continue its practice of accountability.
B. Needs Not Addressed in PAMC Plan
Response and Deficit in Region
The identification of the above issues reveals a deficit in services to counter both adult and youth health risk behaviors. Additionally, the assessment outlines that nutrition and physical activity being the primary determinants of obesity, need to be encouraged both in schools and at home to prevent diabetes. Smoking is implicated in many preventable deaths, and most smokers start in their teens. Similarly, alcohol and drug use behaviors are established early in life, usually before the legal age. These risk behaviors have been identified in clusters. Trends in high risk behaviors….including Cumberland and Sagadahoc, with high rates of one risk behavior often have high rates of others.
Appendix I PAMC Service Area 2010 Census Data Primary Care Quality and Effectiveness
Access to and availability of high quality, primary care, especially for those with chronic health conditions, is a continuing challenge in Maine. This is an issue in many Maine counties and may be due to inadequate availability of providers and lack of health insurance or lack of patient self-management, among other patient, health system or population issues.
Hospital Inpatient and Emergency Department (ED) Data
Discharge datasets for inpatient admissions and emergency department visits are from the Maine Health Data Organization16. For each dataset, the two most recent years of available data were acquired. Inpatient admission data is from Q4 2007 through Q3 2009. Emergency department data is for 2007 and 2008.
The Maine Cancer Registry (MCR)17 is a statewide population-based cancer surveillance
system. The MCR collects data on all newly diagnosed and treated cancers in Maine residents, except in situ cervical cancer and basal and squamous cell carcinoma of the skin. Data was obtained from the MCR for 2005 through 2007 to compute incidence rates and staging levels of selected cancers.
Appendix II Key Stakeholders Interview Summary PAMC Stakeholders share the vision of the founders of Parkview Adventist Medical Center in 1959: the primary concern is utilizing Prevention through the tenets of the Seventh-day Adventist faith to keep community members health. However, when community members do become ill, the hospital’s main objective is to gently care for patients through the guidance and love as exemplified by the Teachings of Jesus Christ.
Appendix III PAMC Service Area 2010 HIP Survey ResultsHousehold Survey Questionnaire Design: The household survey questionnaire used in the OneMaine CHNA was developed collaboratively by the OneMaine Health Collaborative, the University of New England Center for Community and Public Health (CCPH), The University of Southern Maine Muskie School of Public Service, and Market Decisions. An initial review of elements contained in prior community health needs assessments was conducted by CCPH, in consultation with the CHNA
Steering Committee, to determine specific data needs. A preliminary draft of the survey
instrument was submitted to the three hospital systems of OneMaine in April, 2010. In
subsequent weeks, refinements to the draft survey were made in a series of meetings with all key constituents, and a final pretest version of the survey was completed and tested. The survey gathered information from Maine residents in the following areas:
• Health Services Access and Utilization
• Functional Health Status and Chronic Conditions
• Chronic Disease Management
• Youth Health and Health Care
• Primary Care
• Height and Weight
• Dental Care
• Mental Health
• Risk Factors
• Intimate Partner Violence
• Health Insurance
• Health Care Barriers
• Community Health Needs
• Wellness Activities and Programs
• Alternative Therapies
• End of Life Care
The data collection phase began on June 17, and was completed by September 16, 2010. A total of 7,099 Maine residents were interviewed during this period.
The sampling process used during the CHNA survey consisted of three steps designed to meet overall statewide targets, as well as specific targets within each of Maine’s sixteen counties.
The target population consisted of all adults in families living in permanent residences in Maine.
Qualified households were considered those in which someone resided at least six months of the year. Persons residing in households where no adult age 18 or over was present were excluded. The sampling approach relied on the use of a Random Digit Dial (RDD) land-line telephone sample and a cell phone sample.
The Health Status Profile created for the state and for each county, required a comprehensive set of indicators to measure critical aspects of Maine’s health care delivery system, including health status, access to care, and quality of care. Health status – the present state of wellness or illness in a community – is defined by indicators of beneficial and harmful health behaviors, the presence of symptoms and conditions indicative of illness and wellness, measures of the burden of illness
in a community, the prevalence and incidence of specific diseases, and mortality. Because health status is the most important factor driving the demand for health care services, the first step in this assessment was to describe the health status of Maine and its 16 counties. To accomplish this, a comprehensive set of health and medical indicators for each of the 16 counties and the state was constructed and analyzed.
Most indicators were derived from public data sources, including state birth and death records, hospital inpatient and emergency department (ED) datasets, cancer registry data, U.S. Census data, state infectious disease data, the Maine Integrated Youth Health Survey (MIYHS), and the Behavioral Risk Factor Surveillance System (BRFSS) survey (see Appendix I). Other indicators were derived from a random sample household telephone survey conducted specifically for this study.
The goal of the sampling approach was to obtain both statewide and county level population information on a range of health and healthcare issues. The sampling methodology relied on a three stage sampling approach:
• Stage 1: A stratified RDD sample with 16 independent sampling strata identified by the 16 counties in Maine. This stratification was included in the sampling design to obtain a minimum of 400 completed surveys in each Maine county, and allow analysis of the data at the county level.
• Stage 2: A statewide cell phone sample including households with only cellular phone service, in order to include households and residents without access to a land-line telephone. Cell phone only samples can currently be designed to target a state or telephone area code but not smaller geographic units within a state. Given this constraint, the study relied on a random sample of cell phone numbers within the 207 area code for a statewide sampling frame.
• Stage 3: A statewide over-sample of residents aged 18 to 34. One of the concerns in conducting survey research is that those aged 18-34 tend to be under-represented among those completing surveys. To help offset this lack of response for those age 18-34, it was decided to incorporate an over sample of this age group into the overall sampling methodology. The goal of the sampling strategy was to gather data from a minimum of 6,700 Maine households, with a minimum of 400 residents from each of Maine’s 16 counties. Within this target goal of 6,700, the sampling methodology was also designed to complete a minimum of 300 surveys with “cell phone only” households.
Below are brief descriptions of key secondary datasets used for this assessment.
Appendix IV Community Involvement in PAMC CHNA References
The following research consultants contributed advice and development to the creation of the assessment: Carol Bell, Healthy Maine Partnership Director; Kelly Bentley, Healthy Maine Partnership Director; Gail Dana-Sacco, Wabanaki Center (serving Maine Tribal populations); Patricia Hart, Maine Development Foundation; Barbara Leonard, MPH, Maine Health Access Foundation (philanthropic foundation focused on access to care in Maine); Becca Matusovich, Maine Center for Disease Control; Lisa Miller, Bingham Foundation (philanthropic foundation); Dora Ann Mills, MD, Maine Center for Disease Control; Elizabeth Mitchell, Maine Health Management Coalition (representing the state’s major employers, insurers and providers); Trish Riley, Governor’s Office of Health Policy and Finance (GOHPF); Brian Rines, Advisory Committee for Healthy System Development (overseen by GOHPF); Rachel Talbot-Ross, Maine Chapter, NAACP; Ted Trainer, Public Health Coordinating Council; Shawn Yardley, City of Bangor’s Department of Health and Welfare. In the local area served by the assessment, multiple parties were engaged in dissemination of the assessment findings and establishment priorities.
For the most recent OneMaine Community Health Needs Assessment (CHNA) a modified version of the University of New England’s Center for Community and Public Health (CCPH)’s Community and Institutional Assessment Process (CIAP) was used. The CIAP uses epidemiological modeling of demographic, health access, utilization and related population based health and health related indicators, together with qualitative information from health service providers and the community, to identify health status and service need issues in a geographic area and population. The CIAP starts with a comprehensive epidemiological-based health profile organized by health domain or condition such as cardiovascular health, respiratory health, cancer health, etc. Indicators for most domains are organized by risk factors, prevalence (or incidence) of disease or condition, care management indicators and care outcomes. The analysis of indicators within each domain provides information to identify and subsequently explore which aspects of the health care delivery system may be over- or under-performing for
that particular domain (e.g. primary prevention, secondary prevention, etc.). This results in a list of priority health issues and questions for follow-up with domain related providers, community leaders, agencies and the public, to determine delivery system strengths and deficits that may be driving the indicators.
For the OneMaine CHNA the CIAP methodology was used to produce a list of priority health issues and questions for follow-up, with recommendations for next steps to address these issues.
The OneMaine health systems brought this information to their individual communities to gain insight on the specific delivery system issues that might be the focus of change in each community. The goal is to eventually improve results for these indicators.
Indicators within each domain are produced as actual population rates or proportions. They are not adjusted for age, gender or other population artifacts. Unadjusted or “crude” rates capture the true burden of disease in a population – that is, the estimated size of the population that the health care system needs to consider. This information is critical for health services planning and is lost if rates are adjusted. To better understand the status of a health domain in a population, the actual rates are analyzed by the following sub-populations: gender; age groups; and/or race and ethnicity, provided the data are available and it is appropriate from a population health or clinical
perspective. In the CIAP one generally does not test for statistical significance of rates between two or more populations. This assessment is not hypothesis testing research, and much of the information leading to the identification of priority health issues is by examining a pattern of indicators for a particular health condition. The fact that any one rate in a series of indicators is statistically significant does not add additional information for identifying or planning health interventions for a population. Once a pattern of indicators that taken together suggests a follow-up analysis is warranted, one might want to consider statistical testing in special circumstances to further examine a particular area of the population.
The One-Maine assessment focuses on the state as a whole, and on each of Maine’s 16 counties. Thus, the Health Status Profile contains 18 columns of indicators – one for the state and one for each county. National indicators are in an additional column, and compare Maine to the US.
However, the number of US indicators is limited in part by the difficulty of obtaining unadjusted national data. Due to the overwhelming number of data points, analyzing indicators by domains for 16 counties and the state presented a challenge. To identify domain and sub-domain differences by county that are different from the state and thus require additional follow-up, the study team adopted the use of the “10% rule”.
The application of this rule meant that indicators 10% or more above or below the state are worth noting for follow-up. Generally, the domain specific analyses in the report used this rule.
In sum, the CHNA methodology using CIAP is a systematic analysis of scientific based health and health related indicators about a population that informs the development of better health services planning. The analysis conducted using the above approach is meant to tell a story, a story based on a series of indicators that define the dimensions of health in a population. This leads to an initial identification of priority health issues for further action. Follow-up with qualitative information from key informants leads to the identification of specific actions and services which, if implemented, are likely to improve the indicators for that domain, thus improving care and the health status of the population.
To help guide the process used for the OneMaine assessment, a CHNA Steering Committee with representatives from the three OneMaine health systems was convened. This committee’s role was to provide input on: (a) identification of existing data sources for the study; (b) content of the community household telephone survey questionnaire; (c) interpretation of survey findings; (d) review of recommendations, and; (e) data dissemination and a follow-up plan. The CHNA Steering Committee also ensured that information from other local health assessments was integrated into the OneMaine CHNA.
In addition to the OneMaine CHNA Steering Committee, an Advisory Committee was convened with statewide representation from a diverse group of stakeholders. Committee members represented public health, state government, businesses, foundations, and multicultural organizations. The Advisory Committee provided critical input into the needs assessment, from initial concept to how the data would be shared with communities. The OneMaine Health Collaborative formed the Advisory Committee to ensure that the data would meet the needs of end users.
To better understand the status of a health domain in a population, the actual rates are analyzed by the following sub-populations: gender; age groups; and/or race and ethnicity, provided the data are available and it is appropriate from a population health or clinical perspective. In the CIAP one generally does not test for statistical significance of rates between two or more populations. This assessment is not hypothesis testing research, and much of the information leading to the identification of priority health issues is by examining a pattern of indicators for a particular health condition. The fact that any one rate in a series of indicators is statistically significant does not add additional information for identifying or planning health interventions for a population. Once a pattern of indicators that taken together suggests a follow-up analysis is warranted, one might want to consider statistical testing in special circumstances to further examine a particular area of the population.
The One-Maine assessment focuses on the state as a whole, and on each of Maine’s 16 counties. Thus, the Health Status Profile contains 18 columns of indicators – one for the state and one for each county. National indicators are in an additional column, and compare Maine to the US. However, the number of US indicators is limited in part by the difficulty of obtaining unadjusted national data. Due to the overwhelming number of data points, analyzing indicators by domains for 16 counties and the state presented a challenge. To identify domain and sub-domain differences by county that are different from the state and thus require additional follow-up, the study team adopted the use of the “10% rule”.
The application of this rule meant that indicators 10% or more above or below the state are worth noting for follow-up. Generally, the domain specific analyses in the report used this rule. In sum, the CHNA methodology using CIAP is a systematic analysis of scientific based health and health related indicators about a population that informs the development of better health services planning. The analysis conducted using the above approach is meant to tell a story, a story based on a series of indicators that define the dimensions of health in a population. This leads to an initial identification of priority health issues for further action. Follow-up with qualitative information from key informants leads to the identification of specific actions and services which, if implemented, are likely to improve the indicators for that domain, thus
improving care and the health status of the population.
To help guide the process used for the OneMaine assessment, a CHNA Steering Committee with representatives from the three OneMaine health systems was convened. This committee’s role was to provide input on: (a) identification of existing data sources for the study; (b) content of the community household telephone survey questionnaire; (c) interpretation of survey findings; (d) review of recommendations, and; (e) data dissemination and a follow-up plan. The CHNA Steering Committee also ensured that information from other local health assessments was integrated into the OneMaine CHNA.
Population Estimates and Demographics
Population data for each county by age was accessed from the US Census using 2008 Census estimates. These estimates were also used to determine all rates (e.g. hospitalization rates) that included population based denominators. Since inter-census population estimates do not include education, income and employment breakdowns, 2000 Census data was used for the education indicator. Although preliminary 2010 Census data were released in early 2011, only overall state
population figures are available, not information on geographic, gender, or age groups within the state. Median household income was obtained through the Maine State Planning Office data center, and data for unemployment by county was obtained through the Maine Department of Labor. The 2004 Health Resources and Services Administration (HRSA) Area Resource File was used to estimate Medicaid participation by county.
Births and Mortality
The Office of Data Research and Vital Statistics at the Maine Centers for Disease Control at the Maine CDC provided birth and mortality datasets for 2007, 2008 and 2009.
Maine Integrated Youth Health Survey (MIYHS)
The Maine Integrated Youth Health Survey (MIYHS) is designed to assess the health status of Maine’s youth, and determine the positive and negative attitudes and behaviors that influence healthy development. The MIYHS is a collaborative effort of the Maine Center for Disease Control and Office of Substance Abuse in the Department of Health and Human Services, and the Department of Education. It replaces the Youth Risk Behavior Survey (YRBS), the Maine Youth Drug and Alcohol Use Survey (MYDAUS), the Youth Tobacco Survey (YTS) and the Maine Child’s Health Survey, and incorporates questions from Search Institute’s Assets Survey.
Data from the 2009 Maine Integrated Youth Health Survey was used to determine indicators related to the health status of Maine youth.
Maine’s Behavioral Risk Factor Surveillance System (BRFSS) is a population-based survey conducted throughout the year with robust sampling for state-level estimates. However, for many county-level estimates, more than one year of data must be combined in order to get an adequate sample size at this geographic level. Since BRFSS questionnaires are revised annually, and many questions are not asked every year, the two most recent years of data collection for all BRFSS indicators needed were identified and combined for estimates.