2017community needs assessment - north star lodge · community needs assessment– directing...

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2017 Community Needs Assessment

Comprehensive Cancer Care

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A Community Needs Assessment (CNA), is established to address health care disparities and barriers to care for patients in a commu-nity. In the cancer care setting, the patient navigation process is to be built from the Community Needs Assessment– directing nav-igation expertise to meet the needs of the local population and barriers to care. Resources to address identified barriers for cancer patients may be provided either on-site or by referral to community-based or national organizations.

This Community Needs Assessment identifies:

• Needs of the population served• Potential to improve cancer health dispar-

ities• Gaps in resources

The results from this community needs assess-ment serve as the building blocks for cancer program development, implementation and evaluation.

PURPOSE of REPORT

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After more than 60 years of serving the Yakima Valley community as Yakima Valley Memorial Hospital, the hospital and its five primary and 20+ specialty care clinics became Virginia Mason Memorial in the fall of 2016. The new name and brand reflect Memorial’s Jan. 1, 2016, affiliation with innovative healthcare leader Virginia Mason Health System in Seattle. Since that time, teams from both sides of the mountains have been working to combine and streamline care and services.

The creation of a health care system with a local presence in each community— where patients receive the same high-quality, coordinated care at Memorial in Yakima or Virginia Mason in Seattle—was a primary focus for the integration.

Local ServicesVirginia Mason Memorial, a private, not-for-profit hospital serving Central Washington’s Yakima Valley remains committed to the community. Our community makeup is 46.5%Hispanic, 46% Caucasian and 3.6% American Indian. While English is the primary language of 60% of our population, 38% speak primarily Spanish. 20.5% fall below the Federal Poverty Level. A total of 29% of adults are obese and 38.3% are overweight; therefore 67.3% of Yakima County’s adult population is either overweight or obese. With that come

higher levels of affiliated health concerns: diabetes, high blood pressure, stroke and obesity-related cancers.

Memorial’s history emphasizes our commitment to meet the changing needs of our diverse community by reinforcing a legacy of collaboration and partnership that strengthens Yakima. Our work involves more than treating the sick; it is about creating and supporting healthy families—physically, socially, and economically.

Cancer care is provided at facilities throughout Virginia Mason Memorial, including North Star Lodge Cancer Center, Òhana Mammography Center, Valley Imaging, Home Health, Cottage in the Meadow (an inpatient hospice facility), and Memorial hospital’s surgery, infusion and inpatient oncology services.

North Star Lodge Cancer Center offers patient- centered cancer care with medical oncologists, radiation oncologists, radiation therapy services and chemotherapy infusion services—all located under one roof. Virginia Mason Memorial is also accredited by the Joint Commission and the Commission on Cancer with commendation.

The cancer program includes comprehensive support services designed to meet patients’ needs including: Financial navigation and advocacy, social services, an on-site pharmacy,

lymphedema therapy, clinical trials, nutrition counseling, genetic counseling, education services, support group programming, classes, the cancer registry and a patient library. Virginia Mason Memorial serves approximately 1,200 new oncology patients each year. About 25% of these patients are treated with both radiation and chemotherapy. Each year, North Star Lodge administers approximately 12,000 radiation treatments and 14,000 chemotherapy treatments. Providing both radiation and chemotherapy in the same location is ideal for patients. North Star Lodge also provides medical oncology care and chemotherapy infusions in two rural clinics—one in Sunnyside and another in Ellensburg. The cancer program has a long and successful history of clinical trials participation with trials open for almost every type of cancer. Memorial and North Star Lodge facilitate multi-disciplinary cancer conferences, where health care providers who specialize in diagnosing and treating cancer come together to share their expertise and recommend the optimal treatment plan for each patient.

There are currently six tumor boards that meet regularly in support of our patient treatment plans:

1. General Tumor Board2. Multidisciplinary Breast Conference3. Thoracic Conference4. Genitourinary Conference

5. Head and Neck Tumor Board6. Gastrointestinal Tumor Board

The Inpatient Oncology Unit is located on the second floor of the hospital and has 15 beds (private and semi-private). The unit also has heart monitors with telemetry support.

Cancer screening and diagnostic services offered at Òhana Mammography Center include tomosynthesis, also known as 3D mammography, ultrasound and stereotactic biopsy services, in addition to nurse navigation and education. Òhana conducts approximately 12,000 mammography screenings and 3,000 diagnostic exams annually. Òhana’s annual outreach effort is Fiesta de Salud, a well-attended community health fair focused on reaching Spanish-speaking members of our community.

Compass Care provides additional support for patients with cancer. Compass care includes inpatient teams, a home-based palliative care service and hospice services. In 2014, Memorial received the Circle of Life Award from the American Hospital Association for innovative palliative and end-of-life care.

The Yakima Valley’s first inpatient hospice facility, Cottage in the Meadow, opened in September 2012 to address end-of-life care for the terminally ill. In 2017, Cottage was expanded from 12 to 20 beds, the state maximum.

INTRODUCTION

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North Star Lodge is one of only two cancer treatment centers in the state of Washington that is participating in the Centers for Medicare and Medicaid Innovation (CMMI) Oncology Care Model (OCM). According to CMMI, the Oncology Care Model “aims to provide higher quality, more highly coordinated oncology care at the same or lower cost to Medicare.” The goal for North Star Lodge is that participation in this demonstration project will result in positive changes in cancer care delivery through care transformation—ensuring that the care delivery model is patient-focused and cost-effective. Since implementing this model in 2016, efforts have been made in the areas of patient navigation, care-plan development, shared- decision making, complex case reviews, primarily focusing on social determinants of health, which impact patient care.

Memorial primarily serves rural Yakima County, which is comprised of 14 cities and towns, and spans 4,296 square miles. Secondary service areas include Kittitas and Klickitat counties. The city of Yakima borders the Yakama Nation Reservation, which consists of five, small, rural towns. Approximately 24% of Yakima County residents live in unincorporated areas, and it is assumed that a larger percent of the Native American population lives in unincorporated areas of the reservation. This poses many challenges to accessing quality health care. Approximately, 46.5% of the Yakima County population is Hispanic and the county is home to over 10,000 migrant and seasonal farmworkers and their dependents.

JOURNEY with the ONCOLOGY CARE MODEL DEMOGRAPHICS of OUR COMMUNITY

Yakima County

Washington State

United States

Total Population 246,402 6,899,123 314,107,072

Total Population (United States Census Bureau, 2010-2014)1

Local Population Demographics; Ethnicity, Language, Education, Income and Employment

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Percentage of population by marital status is a significant indicator as research has shown a direct connection between marriage and health and mortality; with married persons living longer and being healthier than unmarried persons, and this is especially true for men.3 Yakima County is similar in rates of married in comparison with the state and national percentages.

Yakima County

Washington State

United States

Never Married 32.6% 30.5% 32.5%

Married 48.6% 50.8% 48.4%

Married but Separated 2.6% 1.7% 2.2%

Divorced 10.7% 12.1% 10.9%

Widowed 5.4% 5.0% 5.9%

Percentage of Population by Marital Status (United States Census Bureau, 2010-2014)1

The population in Yakima County is primarily Hispanic/Latino and Caucasian. The American Indian/Alaska Native population is more than three times the state average. Yakima County also has a higher percentage of persons who are foreign-born as compared with the rest of Washington state, and the United States.

The largest percentage of Yakima County residents are in the age group of 25-44, followed by the age group of 45-64. In comparison with the state of Washington, Yakima County has a younger resident population.

Yakima County

Washington State

United States

Hispanic or Latino 46.5% 11.7% 16.9%

White 46.2% 71.3% 62.8%

American Indian & Alaskan Native 3.6% 1.2% 0.7%

Asian 0.9% 7.4% 4.9%

Black or African American 0.6% 3.5% 12.2%

Native Hawaiian and Other Pacific Islander 0% 0.6% 0.2%

Some Other Race 0.1% 0.1% 0.2%

2 or More Races 2.0% 4.1% 2.1%

Percentage of population by Race/Ethnicity (United States Census Bureau, 2010-2014) 1

Yakima County

Washington State

United States

Foreign Born Population 18.3% 13.3% 13.1%

Foreign Born Population (United States Census Bureau, 2010-2014) 1

Race and Ethnicity are combined, therefore all Race groups are Non-Hispanic/Latino.

Age 0-4

Age 5-17

Age 18-24

Age 25-34

Age 35-44

Age 45-54

Age 55-64

Age 65+

Yakima County 8.65% 21.46% 10.13% 13.07% 11.98% 11.95% 10.66% 12.11%

Washington 6.43% 16.62% 9.61% 14.18% 13.23% 13.98% 12.78% 13.17%

United States 6.36% 17.13% 9.96% 13.47% 12.96% 14.09% 12.29% 13.75%

Percentage of Population by Age Group (United States Census Bureau, 2010-2014) 1

The primary language spoken in the Yakima Valley is English, followed by Spanish or Spanish Creole. Yakima

CountyWashington

StateUnited States

English 60.2% 81.2% 79.1%

Spanish or Spanish Creole 38.2% 8.3% 13.0%

Asian & Pacific Islander Languages 0.6% 3.9% 3.7%

Other Indo-European Languages 0.7% 5.6% 3.3%

Other Languages 0.3% 1.0% 0.9%

Primary Language Spoken at Home (United States Census Bureau, 2009-2013)2

A linguistically isolated household is one in which no member 14 years old and over speaks only English or speaks a non-English language. Yakima County exceeds the state and national percentages for linguistic isolation at 17.8%.

Yakima County

Washington State

United States

Percentage of Population that Speak English Less than ‘Very Well’ 17.8% 7.8% 8.6%

Linguistic Isolation (United States Census Bureau, 2009-2013)2

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Research suggests that education is one of the strongest predictors of health. The percentage of Yakima County residents who are high school graduates or higher is lower than the rest of the state of Washington, and the United States. The percentage of persons living in Yakima County with a bachelor’s degree or higher is 50% lower than both the state and national percentages.

Yakima County has a higher unemployment rate in comparison with both the state and national percentages. Employment offers numerous benefits critical to maintaining proper health. Unemployment creates financial instability and barriers to access to necessary health care services.

The per capita income for Yakima County is $19,860. This figure is the average income computed for every man, woman, and child in this specific area. Economic insecurity is often associated with poor health. Yakima County reports a per capita income level lower than both the state and national figures.

Yakima County

Washington State

United States

High School Diploma 26.8% 23.3% 28.0%

Some College, No Degree 21.4% 24.9% 21.2%

AA Degree 7.5% 9.7% 7.9%

Bachelor’s Degree or Higher 15.9% 32.3% 29.3%

Attainment Level for High School Graduates (Age 25+) (United States Census Bureau, 2010-2014)1

Percentage of population ages 16 and older unemployed but seeking work.

(U.S. Department of Labor, Bureau of Labor Statistics. 2008-2015)4(United States Census Bureau, 2010-2014)1

Yakima County Washington State United States

Total Population 246,402 6,899,123 314,107,072

Total Income ($) $4,893,758,464 $215,480,238,080 $8,969,237,037,056

Per Capita Income ($) $19,860 $31,232 $28,554

Per Capita Income (United States Census Bureau, 2010-2014)1

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Affordable housing is critically important to the well-being and health of every individual. Families who pay more than they can afford for housing lack the funds to pay for other necessities such as food, clothing and health care. Data shows that Yakima has a lower than expected percentage of homeowners paying more than 30% of income toward housing and a lower percentage of renters for this same indicator when compared to both the state and the nation.

Yakima County has a higher percentage of individuals living below the federal poverty line compared to both the state and National levels. Poverty can result in an increased risk of mortality, prevalence of medical conditions and disease incidence, depression, intimate partner violence, and poor health behaviors.

There are an estimated 28,450 food insecure people living in Yakima County. The average cost of a meal is $2.84. The additional money required to meet all food needs in Yakima County estimated for 2014 is $14,264,000.

2012 2013 2014

Yakima County 14.7% 12.0% 11.5%

Washington 15.0% 14.6% 13.7%

United States 15.9% 15.8% 15.4%

Percent of the Population Experiencing Food Insecurity (Feeding America 2014)23

Food insecurity refers to United States Department of Agriculture’s measure of lack of access, at times, to enough food for an active, healthy life for all household members and limited or uncertain availability of nutritionally adequate foods.

Yakima County

Washington State

United States

Home Owners 26.5% 29.8% 27.6%

Renters 54.2% 50.6% 52.3%

Percentage of Population Paying More Than 30% of Income Towards Housing (United States Census Bureau, 2010-2014)1

Transportation barriers are often cited as barriers to health care access. A number of studies have found that lack or inaccessibility of transportation may be associated with less health care utilization, lack of regular medical care, and missed medical appointments, particularly for those from lower economic backgrounds. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes.5 Yakima County has a lower percentage of households with no vehicles available in comparison to the rest of the state and nation.

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The lack of health insurance is considered a key driver of health status. This indicator reports the percentage of the total civilian non-institutionalized population without health insurance coverage. Lack of insurance is a primary barrier to health care access including regular primary care, specialty care, and other health services. 1 7 Data indicates that Yakima County has a higher percentage of uninsured population than the rest of the state and nation. The Hispanic/Latino population in the Yakima Valley has a higher percentage of uninsured individuals when compared with Non-Hispanic/Latino persons.

This indicator reports the percentage of adults aged 18 and older who self-report that they do not have at least one person who they think of as their personal doctor or health care provider. Access to regular primary care is important to managing chronic illnesses, preventing major health issues and emergency department visits.9 Yakima County has a higher percent of individuals without a regular doctor than the rest of the state and nation.

Yakima County has a higher percentage of residents covered by Medicaid than the both the state of Washington and the nation, a similar percentage of Medicare participants, and a lower percentage of individuals covered by commercial insurance plans.

Total Population (For Whom Insurance Status is Determined)

Total Uninsured Population

Percent Uninsured Population

Yakima County 244,697 39,249 16.00%

Washington 6,792,627 878,242 12.93%

United States 309,082,272 43,878,140 14.20%

(Virginia Mason Memorial CHNA 2016)25

Insurance Coverage by Type (Signal Health, 2017)24

Insurance Coverage by Type for NSL & VMM (* NSL Financial advocates assist with self-pay patients, dramatically reducing our patients paying out of pocket.) (Signal Health, 2017)24

Insurance Coverage of our Local Population


Survey Population (Adults Age 18+) 195,521 5,174,194 236,884,668

Total Adults Without Any Regular Doctor 57,474 1,268,367 52,290,932

Percent Adults Without Any Regular Doctor 29.40% 24.51% 22.07%

Total Population

Total Uninsured Population

Percent Uninsured Population

Hispanic/Latino 117,008 28,482 24.3%

Not-Hispanic/Latino 127,689 10,767 8.4%

Yakima County Uninsured Population by Ethnicity (United States Census Bureau, 2014)8

Adults without Any Regular Doctor (Centers for Disease Control and Prevention, 2011-12)9

Medicare Medicaid Commercial Uninsured

Yakima County 16% 52% 17% 16%

Washington 14% 22% 50% 49%

United States 14% 20% 49% 9%

Medicare Medicaid Commercial Uninsured

North Star Lodge 54.01% 11.62% 33.94% 0.43%

Virginia Mason Memorial 47.22% 23.76% 26.46% 2.56%

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This indicator reports the percentage of the population that is living in a geographic area designated as a “Health Professional Shortage Area” (HPSA), defined as having a shortage of primary medical care, dental or mental health professionals. A shortage of health professionals contributes to access and health status issues.70 Yakima County is considered a shortage area for mental health, dental, and the migrant/seasonal farmworkers population.


Total Area Population 243,231 6,724,540 308,745,538

Population Living in a HPSA 243,231 2,336,615 102,289,607

Percentage of Population Living in a HPSA 100% 34.75% 33.13%

Percentage of Population Living in a Health Professional Shortage Area (U.S. Department of Health & Human Services, 2016)10

Leading Causes of Death

Top 13 Leading Causes of Death (Washington State Department of Health, 2008-2014)11

Yakima County Washington State

Cause of Death 2010 2014 2010 2014

Major cardiovascular diseases 256.33 232.27 202.42 187.33

Malignant neoplasms (cancer) 168.79 162.27 169.98 156.35

Accidents 48.82 42.43 37.30 40.46

Alzheimer's disease 31.18 42.69 43.57 44.03

Chronic lower respiratory diseases 42.72 35.49 40.29 38.12

Diabetes mellitus 25.24 19.72 21.55 21.35

Chronic liver disease and cirrhosis 12.83 16.35 10.44 11.18

Intentional self-harm (suicide) 14.18 15.98 13.78 15.36

Influenza and pneumonia 10.33 10.41 8.31 9.5

In situ neoplasms benign neoplasms and neoplasms of uncertain or unknown behavior NA 7.92 NA 4.27

Nephritis nephrotic syndrome and nephrosis 11.32 6.72 7.89 6.19

Parkinson's disease NA 6.14 NA 3.08

Assault (homicide) 10.16 6.00 2.65 7.74

Rate per 100,000 resident population. NA = Data Not Available. Ranking ordered by highest leading cause of death in Yakima County in 2014.

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Top 13 Leading Causes of Death in Yakima County by Race Ethnicity (Washington State Department of Health, 2008-2014)11

Cause of Death White Black American Indian/Alaskan Native

Asian/Pacific Islander Hispanic/ Latino

Major cardiovascular diseases 248.57 380.78 417.88 163.19 166.68

Malignant neoplasms 173.1 172.7 355.19 59.75 77.62

Accidents 51.21 63.6 124.26 0 37.51

Alzheimer's disease 43.95 45.51 58.74 64.41 30.32

Chronic lower respiratory diseases 43.38 0 20.71 0 6.43

Diabetes mellitus 17.27 35.92 47.34 0 36.41

Chronic liver disease and cirrhosis 10.39 35.92 127.21 0 19.65

Intentional self-harm (suicide) 22.56 0 91.66 0 10.42

Influenza and pneumonia 7.83 0 44.38 20.7 13.48

In situ neoplasms benign neoplasms and neoplasms of uncertain or unknown behavior 9.68 0 0 0 1.41

Nephritis nephrotic syndrome and nephrosis 3.75 0 66.54 0 12.72

Parkinson's disease 5.92 0 0 0 121.93

Assault (homicide) 3.84 75.4 11.45 0 6.33

*Rate per 100,000 resident population

Risk Factors in our Community: Obesity, Inactivity, Diet and Tobacco Use

According to the National Rural Health Care Association and Rural Healthy People 2020, health care providers and patients in rural areas face obstacles that are vastly different than those in urban areas. Economic factors, language barriers, cultural separation, educational short-comings, lack of legislative recognition and the sheer isolation of living in remote rural areas all contribute to a lack of health care access and disparities for rural Americans.

Ethnicity plays an important role in the prevalence of types of cancer. Nationally, according to the census in 2014, African American men have the highest rate of cancer, followed by Caucasian, Hispanic, American Indian/Alaska Native men, and Asian/Pacific Islander. Among women, Caucasian women have the highest rate of getting cancer, followed by African American, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women. Yakima County has lower cancer incidence rates for all types of cancer when compared to Washington state.

Risk factors for cancer also include alcohol and tobacco use, diet, lack of exercise, and obesity. Many cancers are preventable by reducing risk factors such as use of tobacco products, physical inactivity and poor nutrition, obesity, and ultraviolet light exposure. Other

cancers can be prevented through vaccination against human papilloma virus and screening and treatment for Hepatitis C. Screening is effective in identifying some types of cancers including breast cancer (using mammography), cervical cancer (using Pap tests), lung cancer (Lung Cancer Screening), colorectal cancer (using fecal occult blood testing, or colonoscopy), skin cancer (full body skin exam), and prostate cancer screening (PSA blood test and DRE).

In Yakima County, 29% of adults aged 20 and older self-report that they have a Body Mass

Index (BMI) greater than 30.0 (obese). In Yakima County, a total of 38.3% of adults aged 18 and older self-report that they have a Body Mass Index (BMI) between 25.0 and 30.0 (overweight). An estimated 67.3% of Yakima County’s adult population is either overweight or obese. Being overweight or obese is linked to up to 42% of new cancers including: esophageal, colorectal, breast cancer in post-menopausal women, uterine, kidney, gastric, liver, gallbladder, pancreatic, thyroid, ovarian and multiple myeloma. (Source: NEJM)

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Survey Population (Adults Age 18+) 167,759 4,889,245 224,991,207

Total Adults Overweight 64,243 1,712,893 80,499,532

Percent Adults Overweight 38.30% 35.00% 35.80%

Percentage of Overweight Adults (Behavioral Risk Factor Surveillance System (BRFSS) 2006-2012)13

Adequate physical activity and a healthy balanced diet can reduce the risk of many chronic health issues. Exercise alone can decrease the chances of developing cardiovascular disease, type 2 diabetes, metabolic syndrome, and certain types of cancers. Yakima County has a higher percentage of adults who are physically inactive or sedentary than found in Washington state and the U.S.

Percentage of population living within half a mile of a park by race/ethnicity (Centers for Disease Control and Prevention, 2010)16

Total Population

White (not including

Hispanic)

Black (not including

Hispanic)

Other (not including

Hispanic)

Multiple Races

(not including Hispanic)

Hispanic

Yakima County 49% 40% 61% 33% 45% 58%

Washington 48% 47% 64% 59% 53% 53%

Access to recreation and fitness facilities encourages physical activity and other healthy behaviors.

In Yakima County an estimated 124,808, or 77.9% of adults over the age of 18 are consuming less than 5 servings of fruits and vegetables each day. This indicator is relevant because current behaviors are determinants of future health, and because unhealthy eating habits may cause significant health issues, such as obesity and diabetes.13

Tobacco use is the largest preventable cause of death and disease in the United States.14 Each year, approximately 480,000 Americans die from tobacco-related illnesses. Further, more than 16 million Americans suffer from at least one disease caused by smoking. Smoking-related illness in the United States costs more than $300 billion each year, including nearly $170 billion for direct medical care for adults and more than $156 billion in lost productivity.14 Yakima County has a similar percentage (15.6%) of adults who currently smoke when compared with Washington state, and a lower percentage than that of the entire U.S. (18.1%).

Total Population (Age 18+)

Total Adults with Inadequate Fruit / Vegetable

Consumption

Percent Adults with Inadequate Fruit / Vegetable

Consumption

Yakima County 160,216 124,808 77.90%

Washington 4,918,282 3,669,038 74.60%

United States 227,279,010 171,972,118 75.70%

Number per 100,000 population of recreation and fitness facilities as defined by North American Industry Classification System (NAICS) Code 713940.

Percent of Adults with Inadequate Fruit/Vegetable Consumption (Behavioral Risk Factor Surveillance System (BRFSS) 2006-2012)13

Total Population Age 18+

Total Adults Regularly Smoking

Cigarettes

Percent Population Smoking

Cigarettes (Age-Adjusted)

Yakima County 166,966 26,214 15.60%

Washington 5,083,627 787,962 15.60%

United States 232,556,016 41,491,223 18.10%

Adults—Current Smokers (Behavioral Risk Factor Surveillance System (BRFSS) 2006-2012)13Recreation and Fitness Facility Access (U.S. Census Bureau, 2013)15

2008 2009 2010 2011 2012 2013 Trend

Yakima County 8.63 8.63 6.58 6.17 6.58 7.4

Washington 10.96 11.24 11.48 11.58 11.72 11.75

United States 9.91 9.71 9.57 9.44 9.44 9.73

Number per 100,000 population of recreation and fitness facilities as defined by North American Industry Classification System (NAICS) Code 713940.

Data does not include vaping, e-cigarettes or chewing tobacco.

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Virginia Mason Memorial is committed to providing comprehensive education and disease prevention opportunities for the community and VMM offers classes and events on many diseases and medical challenges including diabetes, smoking cessation, walk-in screening mammograms, cancer support groups, cardiac care, chronic disease self-management, childbirth education, childhood obesity, and women’s health programs. Many of these courses and events are free of cost to participants or have a nominal fee, and all are offered in both English and Spanish.

Òhana conducts 12,000 mammography screenings and 3,000 diagnostic exams annually. Reducing barriers to care and increasing access to high-quality, accurate screenings is vital to improving health outcomes and reducing late-stage cancer diagnoses for women in the region. For those patients with positive screening results, a nurse navigator guides the newly diagnosed breast cancer patient from communicating biopsy results through treatment. This navigator ensures the patient understands the diagnosis and keeps on schedule with her cancer treatment. Once treatment is completed, the navigator meets to educate on her “new normal” and what to expect for the future in Survivorship. Monthly survivorship support group meetings are also held for these patients. Òhana has a successful history of connecting

low-income, underserved, minority women with breast health services. Community partners such as the Breast & Cervical Health Outreach Program, the local Spanish speaking radio station KDNA 91.9FM, and primary health care providers work closely with Òhana to promote breast health and access to care.

We offer no-appointment walk-in breast cancer screenings every Friday afternoon to ease access to mammograms for all women in our community.

Examining the extent of services provided by Òhana by neighborhood shows differences in screening rates in the Yakima metropolitan service area. Some of this may be explained by the market area traditionally served by Òhana, although some may be in neighborhoods with low utilization of pre-ventive services. The areas with low screening rates should be examined in further detail to understand why the screening rates are relatively low.

CANCER PREVENTION & SCREENING

Age-Adjusted Percentage

Yakima County 73.2%

Washington 75.4%

United States 78.5%

Percentage of female Medicare enrollees, age 67-69 who received a mammogram in past 2 years (Behavioral Risk Factor Surveillance System (BRFSS) 2006-2012)13

Women age 50+ who report having mammogram in past 2 years (Behavioral Risk Factor Surveillance System (BRFSS) 2006-2012)13

2004 2006 2008 2010

Yakima County 70.1% 80.4% 78.2% 77.2%

Washington 78.6% 80.1% 80.5% 77.5%

Memorial Òhana Mammography Screening Rates—Females Age 50-74 2015

Opportunity: Increase mammogram compliance for women on Medicare.

Opportunity: Increase mammogram utilization in women over 50 who report not having a mammogram within the past two years.

Opportunity: Develop an action plan and tactics to reach women over 50+ living in poor mammogram utilization areas of our community.

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In comparison with the rest of the state of Washington and the nation, Yakima County has a lower incidence of cancer when considering all types of cancer. Yakima County also has a lower death rate from all cancers, with the exception of lung cancer compared with both the state and national levels. The incidence of cancer has decreased in Yakima County according to statistics comparing the time periods of 2007-2011 and 2012-2014. Also, according to the National Cancer Institute, although the incidence of certain cancers has increased nationally, the overall death rate from cancer in the United States has declined since the 1990s. This has resulted in an increase in cancer survivors.

CANCER INCIDENCE & MORTALITY RATESCancer Incidence Rates 2007-2011 vs. 2012-2014 (All Types) (Washington State Cancer Registry, 2012-2014)26 (Centers for Disease Control & Prevention, 2014)19

Incidence Rate 2007-2011

Incidence Rate2012-2014

Yakima County 454.7 398.2

Washington 528.7 507.9

United States 445.5 454.8

Where data were available, health and social indicators in Memorial’s service area were compared to Healthy People 2020 objectives. The bolded items are indicators that do not meet established objectives; non-bolded items meet or exceed benchmarks.

2012-2014 Cancer Incidence and Mortality—Age adjusted rates per 100,000 (Washington State Cancer Registry, 2012-2014)26 (Centers for Disease Control & Prevention, 2014)19

Incidence Death per 100,000

Healthy People 2020 Objectives

(Death)

Yakima County 18 398.2 162.1 160.6 per 100,000

Washington 18 507.9 158.4

United States 454.821 171.2 21

*Rate per 100,000 residents

Breast Cancer Incidence and Mortality (Washington State Cancer Registry, 2012-2014)26 (Centers for Disease Control & Prevention, 2014)19



(Death)

Yakima County 18 121.1 20.8 20.6




Colorectal Cancer Incidence and Mortality (Washington State Cancer Registry, 2012-2014)26 (Centers for Disease Control & Prevention, 2014)19



(Death)





Prostate Cancer Incidence and Mortality (Washington State Cancer Registry, 2012-2014)26 (Centers for Disease Control & Prevention, 2014)19



(Death)

Yakima County 18 80.3 16.9 21.8




Lung Cancer Incidence and Mortality (Washington State Cancer Registry, 2012-2014)26 (Centers for Disease Control & Prevention, 2014)19



(Death)





Bladder Cancer Incidence and Mortality (Washington State Cancer Registry, 2012-2014)26 (Centers for Disease Control & Prevention, 2014)19


Yakima County 18 17.9 3.9




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Cancer rates in the Hispanic population are low based on overall population demographics. It is believed that this number is skewed by inaccurate or missing documentation of ethnicity in the

patient’s medical record. This has been identified as an organization- wide issue for Virginia Mason Memorial. * The relative youth of this group may also be a factor in lower cancer rates.

Opportunity: Outreach to address lung cancer in women.

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Every patient cared for in the cancer care continuum has a unique set of needs that change throughout the course of their disease and treatment. To ensure that these needs are met, our cancer patients complete a psychosocial distress screening survey to determine their individual needs. The tool was adapted from the National Comprehensive Cancer Network (NCCN) distress thermometer tool and covers needs in five practical areas which include the following: practical distress, emotional distress, spiritual/religious distress, family distress, and financial distress. Patients receive referrals to appropriate services in-house and in the community to address the needs identified with the tool. A list of current resources available to address these needs is listed below.

1. Need or barrier: Practical distress in the areas of child care, housing, insurance, financial, transportation, work/school, self-care, mobility, treatment decisions, medication. There are means of assistance available through the following resources:

a. The 2 full time social workers at North Star Lodge work together with care teams to assist patients and connect them to resources to helping to reduce or overcome practical issues.

b. A full time, bilingual coordinator manages all transportation assistance for patients who lack reliable or affordable transportation. Community ride assistance is available through People for People. There is a transportation and interpretation services coordinator who helps patients access these types of resources.

c. The American Cancer Society assists with educational resources and some practical resources such as motel rooms for patients traveling far from home for necessary treatments or procedures.

d. The Patient Emergency Fund at North Star Lodge, created by The Memorial Foundation and funded by philanthropic individuals and groups within the community, assists patients with unexpected expenses related to treatment and the impact of cancer on individuals and families.

e. The Financial Assistance Team at North Star Lodge assists patients through attainment of insurance, co-pay or drug financial assistance companies. They also assist in payment arrangements on a case-by-case basis.

f. Home care is available by referring to home health agencies for home care medical or practical assistance. The social worker is available to assist teams in accessing home care for patients when appropriate.

g. The Palliative Care Team is part of the Compass Care program and is available to help patients facing life limiting illnesses and their families. This is a home-based care model with social workers and nursing staff home visits that is focused on relieving suffering and improving quality of life. Palliative Care works with medical providers and other in-home care services to provide patient-centered and family-oriented care.

RESOURCES for DISTRESSDistance Traveled of All Sites Cancer Diagnosed in 2004-2014 (Virginia Mason Memorial Cancer Registry, 2004-2014 data)28

Distance Traveled N %

≤ 5 miles 1506 18.02%

5-9 miles 836 10.00%

10-24 miles 2239 26.79%

25-49 miles 3072 36.76%

50-99 miles 616 7.37%

>=100 miles 78 0.93%

Unknown 10 0.12%

TOTAL 8357 100%

2. Need or barrier: Emotional distress such as depression, fear, anxiety, sadness, worry, and loss of interest in usual activities. There are resources available through the following resources:

• Breast Health Nurse Navigator at `Ohana assist newly diagnosed patients with breast cancer. Navigators help patients on what expect during their breast cancer treatment.

• Intake coordinators in both Medical Oncology and Radiation On-cology assist patients with scheduling first visits and explaining next steps.

• Registered nurses experienced in oncology care assist patients every step of the way during treatment, education sessions and ongoing care. Each oncologist has a full-time RN dedicated to the provider’s patient panel, and infusion is staffed by experienced oncology nurses.

• The Wellness House of Yakima offers a variety of free services such as support groups, counseling, peer mentors, and a lending library. It also has a wig & hat lending boutique and a cancer care boutique to assist patients with bras, camisoles, and prostheses after a mastectomy.

• A resource library with a variety of informational material (books, magazines, pamphlets, etc.,) to either keep or check out for patients and family members/friends is available.

• The North Star Navigator newsletter is published every other month and offers information about many support classes and events. Programs like LifeBio, Lamplight Bible Study, Survivors club/Wednesday walkers, Look Good-Feel Better, Sound Sleep-Sound Rest, and the North Star Knitters group are available free of cost.

• An RN Nurse Navigator, social worker, and a counselor are available to help navigate patients and families experiencing emotional distress.

• Compass Care support is available in the home.

3. Need or barrier: Spiritual/Religious distressa. Memorial Hospital Clergy and clergy volunteers are available

to patients who report distress in this area as identified through referral from nurses or providers. Patients are welcome to ask for a visit from clergy at any time during treatment.

4. Need or barrier: Physical distress such as pain, fatigue, weakness, fever, shortness of breath, mouth sores, dry/itchy skin, nausea/diarrhea/ constipation, appetite, memory/concentration, sleep, sexuality or body image, poor balance, drugs or alcohol, and numbness/tingling in hand or feet.

a. Oncology providers at North Star Lodge (6 Medical Oncology providers, 2 midlevel providers and 3 Radiation Oncology providers) aim to reduce and minimize physical side effects of disease and treatment at every patient visit or on a PRN basis as needed through telephone triage.

b. Oncology nurses and pharmacists visit with patients and families during treatment to assess patients.

c. Nutritionists at North Star Lodge are oncology certified and help patients set goals and identify strategies to maintain adequate nutritional status during treatment. Free supplements are provided to patients who are unable to purchase these products.

d. Lymphedema therapy at North Star Lodge addresses patients who develop lymphedema as a result of treatment to minimize symptoms and learn self-management.

e. 4 RN Nurse Navigators serve as additional assets for supporting oncology patients at North Star Lodge.

f. Telephone triage to assess symptom severity and gring patients in for same-day or next-day care is available to all North Star Lodge patients.

5. Need or barrier: Family distress such as issues that arise with children, partners, fertility, or the health of family member.

a. Childcare can be arranged at the Children’s Village drop-in childcare center situated adjacent to the North Star Lodge campus.

b. The social worker assists families with issues that arise as needed on a case-by-case basis.

c. Referral to a licensed counselor is available for individuals and families.

d. Fertility issues are addressed by oncology providers and their care team during clinic visits.

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1. Provider and care-team education about tools to improve information exchange with patients and to enable self-management.

• Implemented Equicare patient portal to provide the ability for patients to access their own medical records.

• Initiated 13-point Treatment Care Plans consistent with the recommendations from the Institute of Medicine beginning in 2016.

• Track navigation work flows in Equicare.

2. Improve access and referral rates for appropriate advanced illness management services such as palliative and hospice care, and ensure standard process for obtaining advance directive and documenting in the patient record.

• Developed business plan for Palliative Care Nurse Practitioner to provide services at North Star Lodge once per week.

• Implemented process to upload advance directives to the Health Information Exchange and tracked compliance.

• Sponsored Ethics and End of Life Education Symposium for health care providers and the community of Yakima.

3. Improve documentation of patient ethnicity upon admission to allow for more accurate segmentation of data to identify cultural needs.

• The Cultural Competency Action Plan was implemented throughout Virginia Mason Memorial. It consists of collection of race, ethnicity, age and language (REAL) data from all patients. So far, Hospital and Clinic baseline data has been collected.

• Developed communications for staff and patients describing why we have begun collecting REAL data and the importance of it.

• Since 2015, Virginia Mason Memorial has implemented a Cultural Competence Training Program.

• Implemented ALTA language testing for all new hires that will be interpreting for patients.

Current patient navigation services are provided by a breast care navigator located at `Ohana breast imaging center and 4 full-time nurse navigators housed at North Star Lodge. The breast care navigator at `Ohana provides patient education and support from the time of diagnosis through the patient’s referral to a surgeon. The care team at North Star Lodge includes a 2 full-time social workers, 4 full-time RN Nurse Navigators, a full-time bilingual transportation and appointment care coordinator and a financial assistance team made up of 5 insurance specialists and a pharmacy technician. This group works together with physician/nurse teams to link patients to the appropriate resources listed above.

Community Collaborators • Wellness House• American Cancer Society• Aging and Long Term Care• Hospice and Home Health Care agencies

(Virginia Mason Memorial, Heartlinks, Kittitas, Yakima Regional)

• People for People• Yakima Dial-A-Ride• Union Gap Dial-A-Ride• HopeSource (Ellensburg)

4. Expand navigation services including design process and identify resource to perform repeat distress screening for cancer patients in treatment.

• Established a Patient Navigation Program that includes a staff of four disease-specific nurse navigators.

• Breast cancer navigations services provided at ‘Ohana Mammography Center that assists patients at multiple touch points.

• Implementation of distress screening utilizing the National Comprehensive Cancer Network (NCCN) screening tool. This screening is conducted on all patients. It includes an assessment of sources of stress categorized as practical problems, family problems, emotional problems, spiritual/religious concerns, and physical problems.

• Expansion of social work team to 2 full-time social workers to conduct distress screenings, address pyscho- social needs of patients and manage and track referrals to outside providers.

• Social work team also completes PHQ-2 depression screenings. Patients who screen positive are further evaluated with a PHQ-9.

• Created the position of financial advocate at North Star Lodge and

hired five staff members to serve patients in this capacity. These financial advocates reach out to patients, discuss the cost of treatment and details about insurance coverage. In 2016, 803 patients were screened by financial advocates, and benefit reviews were conducted for 1275 patients.

• Implemented a patient assistance coordinator in the pharmacy. Initially gained this position through a grant, and due to success of this initiative gained approval for budgeted position. This program is estimated to complete 158 patient assistance applications, fill 1569 specialty outpatient prescriptions, help patients with collecting $486,747 of financial assistance, and secure $3,057,456 in free drugs awarded.

• Began GI navigation at Yakima Gastroenterology Associates involving both nurses and medical assistants. The purpose of this service is that there is verification that all studies and necessary patient information is compiled and accessible to the provider at the time of visit.

5. Develop dedicated survivorship care program.

• Implemented the use and deployment of survivorship care plans. This includes a summary of treatment and a care plan to patients who have completed treatment. Initial focus for this initiative was breast cancer patients as it was our most common diagnosis at the time. The percentage of patients required to receive this document per Standard 3.3 of the Commission on Cancer in 2016 was ≥25%. The percentage achieved by North Star Lodge was 29%, therefore meeting and exceeding the expectation set forth. The development and provision of survivorship care plans has now been expanded to other cancer diagnoses.

• Monthly meetings of the Breast Cancer Survivorship Support Group are held to provide opportunities for breast cancer survivors to meet. Guest speakers provide education and support to these survivors including dietitians, nurses from both radiation and medical oncology, physical therapy coordinators, representatives from the Wellness House, the owner of a medical prosthetics clinic, and a private practice psychologist.

Cancer Care Line Priorities Identified in 2014 Community Needs Assessment: Achievements and Progress in Meeting Identified Needs

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6. Surveyed rates of tobacco use in Yakima County have increased from 2011 to 2012 and are higher than the state and national percentages. Yakima has a comparable incidence rate of lung cancer to state and national statistics, but the reported death rate is higher for unknown reasons. Consider the feasibility of an evidence- based lung cancer screening program for the community.

• Group events held at the Harman Center for Low-dose Lung CT Screening. The data below represents the results of these screenings starting in 2015 (see chart on next page)

• Community group shared decision making visits are held at the Harman Center led by a physician from Virginia Mason Memorial.

• Any provider in the community can order Low-dose Lung Cancer Screening per the USPTF guidelines and requirements.

7. Exercise has been shown to not only prevent certain types of cancer, but also to improve patient tolerance of treatment and hasten the recovery process. In light of the fact that Yakima has a high obesity rate and a lower activity rate, Memorial has devoted resources to developing community exercise programs. In addition to these preventative programs, the cancer care line will consider partnering with community exercise programs to develop a more formal exercise program for cancer patients.

• Oncology Walking Group is provided to patients of North Star Lodge.

• Virginia Mason Memorial’s Oncology Rehab and Exercise Program (MORE) is available to patients in the cancer program. This program provides services specific to the needs of this patient population by a physical therapist trained in oncology physical therapy. This includes exercise guidelines for oncology patients,

physical therapy management of oncology patients, cancer pain and cancer related fatigue, manual therapy for oncology patients, and vestibular and balance considerations. This program has engaged community partners to help meet the need for these services as well.

Additional Accomplishments since 2014

1. Focus on Patient-Centered Care• A medication preparation process was

implemented in the North Star Lodge Pharmacy to reduce wait times. To accomplish this, inexpensive medications that were time intensive to prepare were identified and pharmacy staff began to prepare them in advance of patient arrival. This process improvement has resulted in a savings of 6 minutes per patient, and the ability for RNs to treat their patients without as much delay.

• Implemented an in-house flow cytometry process improvement to facilitate faster return of diagnosis to the ordering physician. A change was made to this process so that pathology specimens are now prepped locally and shipped to be read in Spokane. It has resulted in a quicker turn-around time for patients and the physicians who are waiting for this diagnosis and supports treatment in a timelier manner. Turn-around times were reduced from an average of 95 hours down to an average of 76 hours.

• A process improvement project was identified to improve VTE core measures compliance rates for

oncology patients. A large portion of fallouts (33%) were attributed to patients with an oncologist as the admitting physician. VTE prophylaxis was embedded within the computerized provider order entry system and education was provided to all oncologists. Fallouts in core measure compliance rates dropped from 33% to .99% with this process improvement.

• Virginia Mason Memorial implemented software technology that allows radiation doses to be reduced by 60% during CT Scans. This is a patient safety initiative to limit unnecessary radiation exposure while still producing high quality and effective images.

2. Multidisciplinary Team Care• Implemented the Oncology Care

Model Program for Medicare patients. Care for these patients includes the structure of an Oncology Medical Home and treatment care plans.

• Addition of video conferences with Virginia Mason-Seattle to review patient cases. Added gastroenterology, and head and neck cancers, leveraging video-conferencing to allow for a multi-disciplinary team of specialists from a tertiary care center to provide input on patient care.

• In collaboration with Virginia

Mason—Seattle, created a Colorectal Care Pathway.

• Added a complex case review model between Virginia Mason Memorial and North Star Lodge. Navigators and social workers come to the hospital and review complex cases.

3. Access & Referral• Identified a gap in breast screening

based on a demographic assessment of screening rates by census block groups. Initiated community breast screening for patients of Memorial Physicians clinics. Standing orders implemented in MP clinics for diagnostic workup in the case of positive breast screens. `Ohana placed calls to patients based on primary care percentage of screening. Completed documentation on status after calls and call-back percentages. Continue to track on-going percentages for this initiative.

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2017 Cancer Care Line Priorities 1. Continued engagement in the Oncology

Care Model Pilot (OCM) with CMS, with a focus on improving both the quality and cost of cancer care. Our local focus for the OCM is:

a. Reducing Emergency Department visits of oncology patients and using triage pathways and other interventions to see patients @ NSL (when appropriate) instead of the ED.

b. Improving our end-of-life care and increasing our hospice length-of-stay (LOS) and collaborating with Compass Care to achieve this goal.

c. Addressing cost savings opportunities in the treatment of our cancer patients—where does our care cost more and how can we reduce the cost without compromising care?

2. Expanding our Lung Cancer Screening Program (LCS) to improve the likelihood of finding lung cancer in the earliest stages, when it is potentially curative. This will include collaboration with Virginia Mason Surgical Thoracic providers to streamline surgical care of early-stage lung cancer patients. With a higher incidence rate of lung cancer for women in this community, working closely with primary care providers and the Women and Children Service will be vital.

3. Increasing our ability to offer same day or next day appointments at NSL to new patients and for real-time symptom management. This is a patient-centered, patient experience service improvement.

4. Developing seamless care transitions with specialty clinics locally and with Virginia Mason Medical Center in Seattle— to assure specialty cancer services are available to patients quickly and effectively.

5. Focusing on delivering patient and family centered care to every oncology patient we serve, including improving our end-of-life care transitions. Work with Compass Care to develop a consistent communication process with patients and providers to improve end-of-life support.Goal: Providing time to prepare for death when we cannot cure.

Other screening and prevention opportunities in our community Lifelong infections with specific strains of HPV are associated with an increased risk for developing several types of cancer: Head and neck cancers, cervical cancer and anal cancers.

HCV infection is a known risk factor for liver cancer. Researchers estimate that annual med-ical costs of chronic HCV and associated liver disease, liver cancer and death will more than double over the next ten years. Between 2011

and 2015 Hepatitis C infections increased by 50% in Washington State. An estimated 15-20 of the liver disease deaths in Yakima County each year are attributable to Hepatitis C infection (source: Yakima County Health Department). We have opportunities in our local community to provide community education around screening for HPV and HCV viruses and work to:

• Improve HPV vaccination in eligible groups, and

• Increase HCV testing and subsequent treatment in positive individuals to reduce the risk for future cancers associated with these viral infections.

1 United States Census Bureau; http://www.census.gov/quickfacts/table/PST040214/53077; United States Census, 2010-2014 American Community Survey—5 Year Estimates

2 United States Census Bureau; http://www.census.gov/data/tables/2013/demo/2009-2013-lang-tables.html; United States Census, 2009-2013 American Community Survey multi-year data

3 Robards, J., Evandrou, M., Falkingham, J., & Vlachantoni, A. (2012). Marital status, health and mortality. Maturitas, 73(4), 295–299.4 U.S. Department of Labor, Bureau of Labor Statistics. 2008-20155 Syed, S.T., Gerber, B.S. & Sharp, L.K. J Community Health (2013) 38: 976. doi:10.1007/s10900-013-9681-17 Community Commons, IP3 and CARES. Community Health Needs Assessment Health Indicators Report. Yakima County, Washington. Accessed

July 2016. Available at: http://www.communitycommons.org8 U.S. Census Bureau, 2014 American Community Survey 1-Year Estimates9 Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System. Additional data analysis by CARES. 2011-12.10 U.S. Department of Health & Human Services, Health Resources and Services Administration, Health Resources and Services Administration.

April 201611 Washington State Department of Health, Center for Health Statistics, Death Certificate Data, 2008-2014, August 2015.12 Small Area Income and Poverty Estimates (SAIPE); Estimated Poverty (percent); 2009-2014;

http://www.healthindicators.gov/Indicators/Estimated-Poverty-percent-Source-SAIPE_10004/Profile13 Behavioral Risk Factor Surveillance System (BRFSS). Accessed from: Centers for Disease Control and Prevention, National Center for Health

Statistics. 2006-2012.14 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General.

Atlanta: GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Printed with corrections, January 2014

15 U.S. Census Bureau, County Business Patterns. Additional data analysis by CARES. 2013.16 Centers for Disease Control and Prevention; National Environmental Public Health Tracking Program, 2010 data;

http://ephtracking.cdc.gov/showHome.action17 Dartmouth College Institute for Health Policy and Clinical Practice; Dartmouth Atlas of Health Care; 2009-2013.18 Washington State Cancer Registry; County by Cancer Site Tables: 2012-2014; https://fortress.wa.gov/doh/wscr/WSCR/Report.mvc/Report.19 Centers for Disease Control and Prevention; United States Cancer Statistics; 2014 State vs. National Comparisons;

https://fortress.wa.gov/doh/wscr/WSCR/Report.mvc/Report20 Centers for Disease Control and Prevention; National Vital Statistics System; Deaths: Final Data for 2014; https://www.cdc.gov/nchs/nvss/deaths.htm21 National Cancer Institute; Cancer Statistics. 201722 National Cancer Institute; Cancer Stat Facts; Female Breast Cancer, Lung and Bronchus, Colon & Rectum, Prostate, & Urinary. 2014 data.23 Feeding America; Food Insecurity, 2014; http://map.feedingamerica.org/county/2014/overall/Washington/county/Yakima24 Signal Health, 2017.25 Virginia Mason Memorial, 2016. Community Health Needs Assessment.26 Washington State Cancer Registry, 2012-2014 Data.27 Virginia Mason Memorial Cancer Registry, 2012-2016 Data.28 Virginia Mason Memorial Cancer Registry, 2004-2014 Data.

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