Community Benefit Report 2013Meeting the needs of our community matters to Salem Health. That’s why the Community Benefit Committee of the Salem Health Board of Trustees organized a series of five focus groups with local health-related service providers. The question: What are the challenges you face in providing care to vulnerable populations?

Our community’sneeds matter to us

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Recognizing a problem is the first step to solving itWhen we tell the story of Salem Health’s community benefit activities, we often leave out the chapter that tells how we make the decision to fund a program.

The truth is that the activities the community sees are often the final step, begun only after months of research, discussion and planning.

Focus group studies at the end of 2012 helped identify the challenges faced by health care providers in our region. The goal was to brainstorm ways that Salem Health could help with these big-picture issues.

Mental health servicesAll five focus groups brought up the unmet mental health needs of their patients.

Emergency and urgent care providers noted that while they are well equipped to handle medical needs, they often see patients who have mental health issues that are outside their area of expertise. These patients experience depression, anxiety, and suicidal thoughts; addiction; and violent crime—all of which keep them from managing their physical health effectively.

Patients with acute mental illness can range in age from adolescent to geriatric, so their physical health needs and support systems at home also run the gamut.

The providers had many theories on the root causes of untreated mental illness in our community:

• There are not enough psychiatrists and other community health providers who are able to provide effective prescription medication oversight.

• The reimbursement system for mental health services is complicated.

• Primary care providers are unprepared to manage the health issues of patients with mental illness; consequently, few local primary care providers accept patients with mental health diagnoses.

• Public mental health funding is limited.

• Getting a mental health appointment in our community takes months.

How could the need be met?Almost all of the groups suggested recruiting more mental health care providers to the region to better meet the demand, but they also suggested improvements to the existing system.

The safety net provider group pointed out that one potential solution to the issue of unmet mental health needs was better coordination of care and communication among different types of providers.

For example, a referral to a psychologist alone may not provide enough guidance for a patient who is unfamiliar with the health care system. Such patients might benefit from regular follow-up calls or visits, reminders tailored to their preferred communication style, support groups, and counseling to ensure they see appropriate providers at appropriate times.

To create this culture of support and guidance, primary medical providers need education on behavioral health assessment and documentation.

Organizations could advocate for improved reimbursement for services for patients with a dual diagnosis (mental illness paired with substance abuse), which might incentivize more primary care clinics to accept these patients.

Chronic disease managementDiabetes, high blood pressure, bone and joint problems, depression and substance abuse are all examples of chronic diagnoses that require years of consistent care and follow-up to manage. Untreated, they can be deadly. Unfortunately, as multiple groups pointed out, low income, low education, social isolation, language barriers and lack of transportation all work together to discourage vulnerable populations from seeking regular treatment.

The focus groups expressed particular concern about untreated diabetes. Type 2 diabetes is related to obesity and can go undiagnosed for months or years among people who don’t receive regular medical care. Once diagnosed, the condition requires radical lifestyle changes that people may feel unable or unwilling to make without significant assistance. But the changes are absolutely vital: The consequences of out-of-control diabetes are emergencies such as heart attack, stroke, kidney failure, blindness and serious infections.

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How could the need be met?One straightforward way of dealing with the increased incidence of diabetes is providing more resources where the need is greatest. To this end, the community benefit committee of the Salem Health Board of Trustees has recommended developing a diabetes prevention and control plan and hiring a diabetes nurse navigator to lead the effort.

TransportationThe safety net and geriatric groups both saw a lack of reliable patient transportation as a major barrier.

One difficulty is the fact that those who don’t have easy access to health care also frequently face other barriers such as inadequate insurance. When they have challenges accessing health care, it results in less frequent trips, which raises per-trip costs in both time and convenience. That can cause a reluctance to make health-related trips until the last possible moment. That, too, leads to greater cost of care, as well as diminished life expectancy and less desirable health outcomes.

The retirement of the baby-boom generation will put additional strains on the system over the next several years, as patients age out of driving themselves and begin to rely on friends, family members and shuttle services when they need a ride.

While public transportation is an option within Salem, patients in rural and outlying areas may struggle to find a ride into town for appointments. More convenient, affordable transportation options for these patients could lead to more regular appointments and better health outcomes.

How could the need be met?Partnerships and information-sharing between medical providers and transportation providers could help patients find rides more easily. There are many services in Marion and Polk counties already, but each has its own dispatch system and fare structure. A central clearinghouse for this information, geared toward high-risk populations (and accessible to schedulers as appointments are being made) could remove some of the anxiety around traveling for medical care.

What have we learned?Again and again, the focus groups returned to common themes:

• A more robust mental health safety net could ease pressure on providers who are unable to care for such patients.

• Preventing and managing chronic illnesses in primary care clinics could reduce these patients’ need for emergency services.

• Better transportation options could help patients get more regular preventive appointments.

Salem Health could contribute to meeting these needs by:

• Recruiting more providers, especially for primary care and mental health.

• Expanding care management and navigation services, especially for primary care, chronic conditions, mental health and senior patients.

• Supporting continuing education in the areas of mental health and aging for providers across all specialties.

• Partnering with transportation providers who can accommodate people who are medically fragile, low-income or elderly.

The Salem Health Board of Trustees embraced these needs by releasing funds for a series of community partner grants in these areas. In the fall of 2014, the Community Benefit Committee began soliciting proposals from potential partner organizations and agencies.

The focus groups

Emergency and urgent care providers: Physicians and nurses from Salem Hospital Emergency Department, Salem Health Care Management, and Salem Hospital Convenient Care; referring physicians from other clinics.

Safety net providers: Representatives from West Salem Clinic, Salem Free Clinics, Polk County Free Clinic, Salud Medical Clinic and Yakima Valley Farm Workers Clinic.

Primary care providers: Providers from Salem Clinic and Willamette Health Partners.

Mental and behavioral health providers: Representatives from Mid-Valley Behavioral Care Network, Chandras Clinic, Psychiatric Crisis Center, Polk County Behavioral Health and Salem Health.

Geriatric services providers: Representatives from the Oregon Department of Human Services, Community and Provider Services and Center 50+.

Salem Health is made up of Salem Hospital, West Valley Hospital, Willamette Health Partners, Salem and West Valley Hospital Foundations, Salem Hospital Auxiliary, Willamette Valley Insurance Corporation, Inc., and Willamette Valley Professional Services, Inc.

Health care for people unable to payEvery year, Salem Health provides needed health care to people for whom the reimbursement, if any, does not cover the cost of providing services. Without Salem Health, many of these patients would go without treatment. In 2013, Salem Health provided $78 million in unreimbursed health care services. The community benefit was distributed as follows:

• Charity care: The cost of treating uninsured or underinsured community members who could not afford health care totaled $25.8 million. This cost includes services for patients enrolled in the Marion Polk Medical Foundation’s Project Access, a physician-coordinated care network serving uninsured and low-income community members.

• Medicare: Government underpayments for Medicare patients fell short of the actual cost by $33.7 million.

• Medicaid: Government underpayments for Medicaid patients fell short of the actual cost by $18.7 million.

Community servicesAs the largest health care provider in the mid-Willamette Valley, Salem Health actively participates in services that help improve the health of the community. These services include improving access to care through physician recruiting, community health education and prevention programs. Salem Health has an active speaker’s bureau and provides health lectures to community groups, free of charge. Health screenings, support groups and education classes are offered on an ongoing basis. In 2013, people benefitted more than 1,158,480 times from Salem Health-sponsored activities aimed at improving health and well-being.

In 2013, Salem Health gave $4.8 million of unfunded or underfunded health services that typically would not be available to the community if Salem Health did not provide them.

Charity care and unmet cost of Medicaid$44,523,413

Unmet cost of Medicare and other public programs$35,839,085

Community health improvement, subsidized health services and community benefit operations$8,297,998

Research$977,006

Health professional education and workforce development$2,761,433

Cash and in-kind donations$567,213

Caring for our communityCaring for our community means understanding its needs and being actively involved. Salem Health collaborates with community partners to serve those who depend on us for health care. Our investments in talent, services and outreach benefit the mid-Willamette Valley.

Total unreimbursed costs and community benefits: $92,966,148

Cash and in-kind donations by Salem HealthSalem Health provides cash and in-kind donations to community programs such as Project Access, MedAssist and Salem Free Clinics. In 2013, Salem Health gave more than $567,213 in support of these and other health programs.

Community Benefits, Fiscal Year 2013

More information: If you have questions about Salem Health’s contributions to the community, contact the Community Health Education Center at 503-814-CHEC (2432).

Source: Data from Salem Hospital and West Valley Hospital community benefit reports filed with the state of Oregon for Oct. 2012—Sept. 2013.

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