GRAND RAPIDS HEALTH CARE ACCESS PROGRAM (GRHCAP)

Clinic Access and Utilization in Kent County, Michigan

Fred J. De Jong, MAPA, MSW, Ph.D., ACSW, Professor of Research and Statistics, Calvin College, Federal Evaluator, GRHCAP Lauren B. Vander Plas, BSW Program, Calvin College, Mapping Specialist, GRHCAP

September 5, 2007 For inquiries, contact Dr. F. De Jong, [email protected]

*

ACKNOWLEDGEMENTS This mapping project owes its success to many instrumental people involved in its conception and production. We would like to especially thank Dr. Neil Carlson, Center for Social Research, Calvin College, for his invaluable technical assistance role with software access and training, research design, data management, and map production. Mr. Rich Zandstra played an important and necessary role as consortium liaison. We thank Rich for persistently gathering the data from Consortium member organizations, as well as your presence and insight throughout the project. We acknowledge Mr. Jim Smedes, Kent County Health Department, as author of the original Kent County mapping report and for his insights in the research design and technical aspect of map creation. This project was under the leadership of Cherry Street Health Services. We want to thank Executive Director Chris Shea and Director of Operations Kathy Sather for their leadership as well as their oversight and understanding throughout the duration of this project.

1

TABLE OF CONTENTS Acknowledgements………………………………………………....………………page 1 Map Index……………….…………………………………………. ………………page 3 GRHCAP Mapping Project ……………………………………………………… page 4 Introduction and Background Methodology List of Organization Participants Measures Clinic Utilization and Catchment Area……………………………………………page 8 Clinic Utilization by Sub-Populations……………………………………………. page 12 Low-Income Population African American Population Hispanic Population Aged (65 and older) Population Diagnoses Served by Clinics.....................................................................................page 26 Distance to Closest Clinic versus Patient Preferred Clinic in Kent County……page 32 Appendices…………………………………………………………………………. page 36 Appendix A: Mapping Data Distribution Guidelines Appendix B: GRHCAP Clinic Mapping Project Data Collection Guide Appendix C: Excerpt from “Target Areas, Low-Income Analysis, Population Change and Medical Shortage Area”, Clinic Mapping Project Report,, Task Force on Health Care for People of Color, Kent County Health Department, November 2005

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MAPS INDEX Kent County Clinics’ Location, 2005………………………………………………. page 7 Clinic Utilization in Kent County, 2005……………………………………………. page 10 Clinic Catchment Areas, 2005……………………………………………………… page 11 Kent County Population with Household Income of $20,000 or less……………….page 14 Low-Income Patient Utilization of Kent County Clinics, 2005……………………..page 15 Kent County African American Population…………………………………………page 18 African American Patient Utilization of Kent County Clinics, 2005………………. page 19 Kent County Hispanic Population………………………………………………….. page 20 Hispanic Patient Utilization of Kent County Clinics, 2005………………………… page 21 Kent County Aged Population……………………………………………………… page 24 Aged Patient Utilization of Kent County Clinics, 2005……………………………. page 25 Kent County Clinic Utilization by Patients with Asthma, 2005……………………. page 28 Kent County Clinic Utilization by Patients with Depression, 2005…………………page 29 Kent County Clinic Utilization by Patients with Diabetes, 2005……………………page 30 Kent County Clinic Utilization by Patients with Hypertension, 2005……………… page 31 Average Distance Traveled to Clinic, 2005………………………………………… page 34 Additional Distance Traveled to Patient Preferred Clinic: Kent County, 2005…….. page 35

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Clinic Access and Utilization in Kent County, Michigan GRHCAP Mapping Project Introduction and Background The Clinic Access and Utilization Mapping Project is a product of long term collaboration beginning in 2002 between major stakeholders in the Grand Rapids, Michigan, health care delivery system. The Consortium’s goals address unmet needs of the underserved population for health related needs. The consortium also advocates for and supported the formation of a county health coverage plan (Kent Health Plan), an access project focusing primarily on residents of the designated Medically Underserved Population (Project Access), the creation of a standing county Task Force on Health Care for People of Color as well as multi-agency/manufacturer initiative to improve access to affordable and free pharmaceuticals. A federal award in 2005 from the Health and Rehabilitation Service Administration (HHS) for a Healthy Community Access Program provided resources and staff for multiple initiatives over a three year period, one of which is the Mapping Project. This second mapping report updates much of the first set of maps with more recent patient utilization data, an current list of participating clinics, the addition of 4 targeted diagnoses first identified in the GRHCAP proposal, a count of patient visits by selected diagnoses and an analysis of distance traveled to patients’ clinic of choice. Methodology In the summer of 2007, researchers associated with Calvin College received patient level data from Metropolitan Hospital, Saint Mary’s HealthLink health centers, Spectrum Health and Cherry Street Health Services for each of their participating clinics. Twenty-two clinics participated in the study. Only one clinic (Sparta) is located outside of the Grand Rapids City limits. See Map of Kent County Clinic locations on page 8. The data request process entailed requests to each health system to contribute 11 variables regarding all clinic patients in 2005. These data included patient id number, address, age, date of birth, race, payer type, visit count, and number of visits for asthma, depression, diabetes, and hypertension. Originally the data were not contributed in a uniform format by which we could join the datasets. Several decision rules provide guidance when merging health system data sets. • First, data which included duplicate patient IDs numbers were eliminated. • Some duplicates clients between multiple clinics are unavoidable. Each organization uses their own id numbers. If a patient saw two clinics from two different organizations, the patient would be duplicated within the dataset, creating some table percentages in this report to exceed 100%. • If a person went to two different clinics within the same system, we recorded the clinic included in the patient’s last duplicate record within the dataset.

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•

If the patient had two different payer types within the same record or within duplicate records, priority was given to commerical, then non-commerical, followed by Medicare.

Clinic patient addresses were than geocoded upon the merging of the contributed data sets from the GRHCAP. Gecoding is a process by which address level data is assigned coordinates by which to map the data. REGIS, the regional geographic information systems most updated street level data, was used to match addresses to geographic coordinates, which was supplemented by a similar process using Tele Atlas, a software service from a commercial geocoding company. The original data set consisted of 64,657 clients. However some of these addresses were missing information and unable to geocode. Of those with proper addresses (N=63850), the match rate for geocoding was 98%, an excellent result, producing a sample size for mapping of 62570. A large number of these addresses were excluded due to being located outside of Kent County, reducing the sample size for the project is 57,255. After patient addresses were geocoded to include coordinates, these data was then used to place addresses into census block groups. Census block groups are a geographic system used by the United State Census Bureua, which they define as “A subdivision of a census tract (or, prior to 2000, a block numbering area), a block group is the smallest geographic unit for which the Census Bureau tabulates sample data. A block group consists of all the blocks within a census tract with the same beginning number.” No unit of data collection below Census block groups were used in order to protect patient privacy. Data from Geolytics Census Projections 2007 was used for comparing patient data to population data. Our analysis uses percent of total population for a given research question to display clinic utilization. We chose this metric instead of absolute numbers to show a greater sense of the impact clinics’ are having on the particular sub-populations living in particular areas. Also general maps are used to give background to high concentration area in which to guide the readers interpretation of the clinic utilization maps.

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List of Organizational Participants Metropolitation Hospital • Breton Health Center Cherry Street Health Services: • Belknap Commons Health Center • Burton Health Center • Cherry Street Medical • Cherry Street Optical • Creston Health Center • Ferguson Adult Health Center • Grand Rapids Pediatrics • Ottawa Hills Health Center • The Salvation Army Booth Family Services • Westside Health Center • Union High School Health Center • Traveling School Medical Program Saint Mary’s Healthlinks Health Centers • Heartside Health Center • McAuley Health Center • Browning Claytor Health Center • Catherine’s Care Center • Clinica Santa Maria • Sparta Health Center • Wege Family Practice • Wege Internal Medicine Spectrum Health • Residency Practice • Internal Medicine • OB/Gyn

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Kent County Clinics' Location, 2005

Sparta

North Kent County Mark Division

13 Mile

Greater Grand Rapids

Ann

Knapp

Pla inf ie

ld

Creston

Catherines Care Center

Leonard Maryland

Union HS

Coi t

e M on ro

City of Grand Rapids

296

Leonard

Pine

Covell

W alk er

3 Mile

2 Miles

Alpine

Richmond

96

Fuller

1

Turner

0.5

side Hill

Alpine

State

12 Mile

Bristol

Walker 0

Riv er

Sparta Health

Fuller

Orchard 3 Mile

Leffingwell

Gardner

Dean Lake

13 Mile

Westside

Bu tte

rw

or

th

O Brien

Clinica Santa Maria

131

o

Colrain

Alger

Ne lso n

32nd

0

36th

0.45 0.9

Elmwood

Breton

Oke mo s

Kalamazoo

Byron Center

Metro Spectrum

Ottawa Hills

Plymouth

Prairie

Clyde Park

CSHS

Burton

Eastern

Organizations

Burton

Burlingame

Porter

Burton

Adams Boston

Madison

Lee

Browning Claytor

Breton

Wyoming ag Chi c

East Grand Rapids

Hall Division

Gr an d vil le

Freeman

Franklin

Robinson

Lak e

Fuller

Fr on t

Ionia

College

Belknap Commons 196 Spectrum Residency Bridge GR Peds Michigan & InternalMed OB/GYN Lake Michigan Pearl Fulton Ferguson McAuley Salvation Army Cherry St Heartside Wealthy Wege

1.8

32nd

Kentwood 2.7 Miles

StMarys Medical Shortage Area

Data Source: GRHCAP Clinic Utilzation Data 2005 & Geolytics Population Projections 2007 DeJong & VanderPlas, Calvin College, 2007

7

Mapping Section #1: Clinic Utilization and Catchment Area The high level of utilization of the clinics indicates excellent access for the general population to the clinics. The total number of patients within the mapping dataset is 57,255, which is 9.5% of the projected 604,370 population of Kent County for 2005. The first map in this section, Clinic Utilization in Kent County, shows the proportion of patients from a particular block group with the total population of the block group. These percentages range from .5% to 50% of block group total population. Although a small proportion of patients will be double counted if they use more than one clinic, the total number served is very near to the total low-income population in Kent County. Table 1 shows the numbers of Kent County patients for each clinic. Among the 22 reporting clinics, Cherry Street Health Clinic and Wege Family Practice report the highest utilization at over 7,000 patients each in 2005. Clinic Catchment Area The map entitled, Clinic Catchment Area illustrates the area from which each clinic draws 60% of its patients, which is the same proportion used in the original mapping study. The larger the shaded area the greater the dispersion of a clinic’s patients. The catchment area was found by using ArcGIS select by location method in which locations are selected from a particular range, the range continued to increase until it met the threshold of 60%.

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Table 1: Kent County Patients by Clinic, 2005 Clinics Cherry Street Health Services Belknap Commons HC

Total Patients 24340 1026

Burton HC

1039

Cherry St HC

7304

Creston HC

240

Ferguson Adult HC

1463

Grand Rapids Pediatrics

4397

Ottawa Hills HC

285

Salvation Army

628

School Medical Program

1524

Union High School HC

747

Westside HC

5687

Saint Mary’s HealthLinks

22578

Browning Claytor HC

1853

Catherine's Care Center

1867

Clinica Santa Maria

4237

Heartside HC

1077

McAuley HC

451

Sparta HC

2392

Wege Family Practice

7094

Wege Internal Medicine

3607

Spectrum Health

5181

Internal Medicine

1947

Residency Practice

619

OB/GYN

2615

Metropolitan

5156

Breton HC

5156

Grand Total

57255

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Kent County

Clinic Utilization in Kent County, 2005 Patients Per Total Population Percent 0.5% - 2.5% 2.6% - 5% 5.1% - 7.5% 7.6% - 10% 10.1% - 15% 15.1% - 20% 20.1% - 25% 25.1% - 51% Clinics Medical Shortage Area City of Grand Rapids

0

2

4

0

0.5

1

8

Miles 12

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

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Catchment Area By Clinic

Cherry Street

Creston

Ferguson

Salvation Army

Ottawa

Westside

Union

Burton

Breton

Clinica Santa Maria

Wege Family Practice

Saint Mary's Spectrum Catchment Cherry St Catchment Metro City of Grand Rapids Clinic

Grand Rapids Pediatrics

Belknap

Catherine's Care Center Heartside

Sparta Browning Claytor

Wege Internal Medicine

Spectrum Internal Med

Spectrum OB/GYN

McAuley

Spectrum Residency

Data Source: GRHCAP Clinic Utilzation Data 2005 & Geolytics Population Projections 2007 DeJong & VanderPlas, Calvin College, 2007

11

Mapping Section #2: Clinic Utilization by Sub-Populations Clinic Utilization by Low-Income Population Kent County’s clinics largely serve patients with household incomes at or below the poverty threshold. The 22 clinics differ in the manner of accounting for household income among patients. Consequently, the only way to report patient income status across all clinics is to use a broad category of payer type called “non-commercial”. Non-commercial payer types include self-pay, charity care, Kent Health Plan and Medicaid, which in the clinic context constitutes lowincome clinic patients. Table 2 shows the number of patients utilizing the various payer types. The majority of patients (57%) use non-commercial payer types. Graph 1 also shows the breakdown of low-income utilization at the various clinic systems. For purposes of mapping, a patient may only have one payer source. The decision rule is that those patients seen at multiple clinics within an organization or those using multiple types of pay, commercial insurance was given priority followed by non-commercial and ending with those paying with Medicare. Census counts of those with commercial insurance, Medicaid, and other payer types are not readily available to the public. Therefore the mapping project used the Census population’s projections data available, using household income to define low-income population. A household income of $20,000 or less was used the measure of low-income: a number just lower than the $20,650 poverty line for a family of four (U.S. Department of Health & Human Services, 2007). The map entitled Kent County Population with household income of $20,000 or less gives a background understanding to where high and low percentages of the low-income population reside within Kent County. The map of Low Income Utilization of Kent County then shows the proportion of low-income clinic patients to the low-income population. Graph 1: Low Income Clinic Utilization by System, 2005

Low Income Clinic Utilization By System, 2005 N=32,428

Cherry Street Health Services 33%

Metropolitan Hospital 50%

Spectrum Health Saint Mary's HealthLink

11% 6%

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Table 2: Low-income Patient Clinic Utilization: Primary Payer Type by Clinic, 2005 Clinics

Cherry Street Health Services Belknap Commons HC

% of Clinic Total

Noncommercial**

6721

27.61%

196

19.10%

Commercial

% of Clinic Total

Grand Total

1285

5.28%

24340

121

11.79%

1026

% of Clinic Total

Medicare

16320

67.05%

709

69.10%

Burton HC

272

26.18%

764

73.53%

3

0.29%

1039

Cherry St HC

1410

19.30%

5497

75.26%

394

5.39%

7304

Creston HC

61

25.42%

179

74.58%

0

0.00%

240

Ferguson Adult HC

312

21.33%

819

55.98%

331

22.62%

1463

Grand Rapids Pediatrics

2521

57.33%

1869

42.51%

3

0.07%

4397 285

Ottawa Hills HC

99

34.74%

186

65.26%

0

0.00%

Salvation Army

48

7.64%

577

91.88%

3

0.48%

628

School Medical Program

189

12.40%

1332

87.40%

2

0.13%

1524

Union High School HC

217

29.05%

527

70.55%

3

0.40%

747

Westside HC

1396

24.55%

3861

67.89%

425

7.47%

5687

2910

56.44%

1824

35.38%

422

8.18%

5156

2910

56.44%

1824

35.38%

422

8.18%

5156

862

16.64%

3486

67.28%

833

16.08%

5181

Internal Medicine

115

5.91%

1260

64.71%

572

29.38%

1947

Residency Practice

378

61.07%

82

13.25%

159

25.69%

619

OB/GYN

369

14.11%

2144

81.99%

102

3.90%

2615

Metropolitan Hospital Breton HC SpectrumHealth

Saint Mary’s HealthLink

10399

46.06%

10798

47.83%

516

2.29%

22578

Browning Claytor HC

503

27.15%

1147

61.90%

45

2.43%

1853

Catherine's Care Center

1614

86.45%

204

10.93%

29

1.55%

1867

Clinica Santa Maria

547

12.91%

3604

85.06%

21

0.50%

4237

Heartside HC

17

1.58%

909

84.40%

34

3.16%

1077

McAuley HC

201

44.57%

233

51.66%

9

2.00%

451

Sparta HC

1059

44.27%

1074

44.90%

40

1.67%

2392 7094

Wege Family Practice

3969

55.95%

2771

39.06%

160

2.26%

Wege Internal Medicine

2489

69.00%

856

23.73%

178

4.93%

3607

20892

36.49%

32428

56.64%

3056

5.34%

57255

Grand Total

**Non-commercial includes Medicaid, Charity Care, Self-Pay or Kent County Health Plan

13

Kent County Population with Household Income of $20,000 or less

Kent County

Low-Income Population Per Total Population Percent 0% - 1% 1.01% - 2% 2.01% - 4% 4.01% - 8% 8.01% - 10% 10.01% - 15% 15.01% - 20% 20.01% - 41% Clinics Medical Shortage Area

0

2

4

0

0.5

1

8

Miles 12

City of Grand Rapids

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

14

Low Income Patient Utilization of Kent County Clinics, 2005

Kent County

Low-Income Patients Per Low-Income Population PercentofPoorPatsofPop 3.33% - 15% 15.01% - 30% 30.01% - 45% 45.01% - 60% 60.01% - 75% 75.01% - 90% 90.01% - 150% 150.01% - 764.71% Clinics Medical Shortage Area City of Grand Rapids

0

2

4

0

0.5

1

8

Miles 12

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

15

Clinic Utilization by African American and Hispanic Populations The Mapping Project’s initial impetus from the Task Force for Health Care for People of Color focused on the unmet health-related needs of underserved populations. The original mapping project emphasized the access and utilization rates to health clinics of Kent County’s African American and Hispanic residents, since these two groups constitute the largest, minority groups in the county and disproportionately present the underserved and uninsured population. Race was coded into seven groups: non-Hispanic white, African American or Black, Hispanic, American Indian or Alaskan Native, Asian Native Hawaiian, or Other. The mapping project only used those who self-identified as African American/Black or Hispanic. Geolytics Census data also provided projected numbers of African American and Hispanics living in each block group. As seen in Table 3, of the patients seen at all clinics 36% are African American and 57% are Hispanic patients. In comparing the patients to the general population, the African American patients(N=14,019) make up 25% of the projected 57,689 Kent County African American population. Similarly, the Hispanic patients (N=15,276) make up 27% of the 57,643 projected Hispanic population for Kent County. Again, the maps showing the Kent County African American and Hispanic Populations give background to the maps of clinic utilization by these different groups.

Graph 2-3: Clinic Utilization by African Americans and Hispanics by System, 2005 African American Clinic Utilization by System, 2005

Hispanic Clinic Utilization by System, 2005

N=14,019

N=15,276 Cherry Street Health Services

25% 13%

12%

50%

Metropolitan Hospital

38% 53%

Spectrum Health

Cherry Street Health Services Metropolitan Hospital Spectrum Health

Saint Mary's HealthLink

6%

16

3%

Table 3: Client Race by Clinic, 2005 Clinics

6965

% of Clinic Total 28.62%

8010

% of Clinic Total 32.91%

7533

% of Clinic Total 30.95%

1832

% of Clinic Total 7.53%

Belknap Commons HC

346

33.72%

97

9.45%

502

48.93%

81

7.89%

Burton HC

102

9.82%

847

81.52%

72

6.93%

18

1.73%

1039

2426

33.21%

2858

39.13%

1351

18.50%

669

9.16%

7304

Cherry Street Health Services

Cherry St HC

African American

Hispanic

White

Other

Total Count

1026

24340

Creston HC

112

46.67%

7

2.92%

41

17.08%

80

33.33%

240

Ferguson Adult HC

643

43.95%

163

11.14%

576

39.37%

81

5.54%

1463 4397

Grand Rapids Pediatrics

992

22.56%

670

15.24%

2535

57.65%

200

4.55%

Ottawa Hills HC

221

77.54%

20

7.02%

10

3.51%

34

11.93%

285

Salvation Army

252

40.13%

65

10.35%

194

30.89%

117

18.63%

628 1524

School Medical Program

624

40.94%

590

38.71%

219

14.37%

91

5.97%

Union High School HC

159

21.29%

169

22.62%

369

49.40%

50

6.69%

747

1088

19.13%

2524

44.38%

1664

29.26%

411

7.23%

5687

Westside HC Metropolitan Hospital

1648

31.96%

464

9.00%

2376

46.08%

668

12.96%

5156

1648

31.96%

464

9.00%

2376

46.08%

668

12.96%

5156

1909

36.85%

931

17.97%

2200

42.46%

141

2.72%

5181

Internal Medicine

751

38.57%

204

10.48%

956

49.10%

36

1.85%

1947

Residency Practice

181

29.24%

95

15.35%

318

51.37%

25

4.04%

619

OB/GYN

977

37.36%

632

24.17%

926

35.41%

80

3.06%

2615

Breton HC Spectrum Health

Saint Mary’s Healthlinks

3497

15.49%

5871

26.00%

7614

33.72%

5596

24.79%

22578

Browning Claytor HC

1090

58.82%

129

6.96%

307

16.57%

327

17.65%

1853

Catherine's Care Center

46

2.46%

39

2.09%

283

15.16%

1499

80.29%

1867

Clinica Santa Maria

26

0.61%

4059

95.80%

57

1.35%

95

2.24%

4237 1077

Heartside HC

473

43.92%

91

8.45%

475

44.10%

38

3.53%

McAuley HC

112

24.83%

44

9.76%

238

52.77%

57

12.64%

451

11

0.46%

964

40.30%

1004

41.97%

413

17.27%

2392

1383

19.50%

432

6.09%

3632

51.20%

1647

23.22%

7094

356

9.87%

113

3.13%

1618

44.86%

1520

42.14%

3607

14019

24.49%

15276

26.68%

19723

34.45%

8237

14.39%

57255

Sparta HC Wege Family Practice Wege Internal Medicine Grand Total

17

Kent County African American Population

Kent County

African American Population Per Total Population Percent 0% 0.01% - 1% 1.01% - 2% 2.01% - 5% 5.01% - 7% 7.01% - 10% 10.01% - 25% 25.01% - 92.71% Clinics Medical Shortage Area

0

2

4

0

0.5

1

8

Miles 12

City of Grand Rapids

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

18

African American Patient Utilization of Kent County Clinics, 2005

Kent County

African American Patients Per African American Population Percent 0% - 5% 5.01% - 10% 10.01% - 20% 20.01% - 30% 30.01% - 40% 40.01% - 50% 50.01% - 60% 60.01% - 800% Clinics Medical Shortage Area City of Grand Rapids

0

2

4

0

0.5

1

8

Miles 12

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

19

Kent County

Kent County Hispanic Population Hispanic Population Per Total Population 0.42% - 1% 1.01% - 3% 3.01% - 5% 5.01% - 10% 10.01% - 20% 20.01% - 30% 30.01% - 40% 40.01% - 96% Clinics Medical Shortage Area City of Grand Rapids

0

2

4

0

0.5

1

8

Miles 12

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2006 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

20

Hispanic Patient Utilization of Kent County Clinics, 2005

Kent County

Hispanic Patients Per Hispanic Population Percent 0% - 5% 5.1% - 10% 10.1% - 15% 15.1% - 20% 20.1% - 30% 30.1% - 40% 40.1% - 50% 50.1% - 177.6% Clinics Medical Shortage Area City of Grand Rapids

0

2

4

0

0.5

1

8

Miles 12

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

21

Clinic Utilization by Aged Chronic health conditions and acute care episodes prompt many low income older persons to use Kent County’s clinics. Low income aged persons with modest fixed incomes can find themselves ineligible for Medicaid while they live in their own homes and experience outpatient expenses outside of Medicare’s coverage. Unaddressed health care needs can become disabling and lead to added pain, decreased function and eventually institutionalization. Mapping the aged for the first time in this project recognizes this important need and target population for clinic services. Each participating clinic contributed a data set including patient age. These ages were then put into 4 different categories: 0 to 15 years old, 16 to 44 years old, 45 to 64 years old, 65 and older. Table 4 shows patient age by clinic in 2005. Saint Mary’s and Cherry Street Health Services clinic systems provide care to the largest numbers of elderly. The map entitled Kent County Aged Population shows the percentage of those 65 years and old living in a particular area. Geolytics Census projection data provided the population of those 65 years and older in each block group. The map entitled Aged Patient Utilization of Kent County Clinics, 2005 shows the ratio of Aged Patients to the Aged Population of Kent County.

22

Table 4: Patient Age by Clinic, 2005 Clinics

9887

% of Clinic Total 40.62%

9444

% of Clinic Total 38.80%

3974

% of Clinic Total 16.33%

1035

% of Clinic Total 4.25%

Belknap Commons HC

103

10.04%

491

47.86%

374

36.45%

58

5.65%

1026

Burton HC

680

65.45%

294

28.30%

57

5.49%

8

0.77%

1039 7304

Cherry Street Health Services

Cherry St HC

0 to 14

15 to 44

45 to 64

65 and older

Grand Total 24340

2186

29.93%

3122

42.74%

1615

22.11%

381

5.22%

Creston HC

2

0.83%

237

98.75%

1

0.42%

0

0.00%

240

Ferguson Adult HC

0

0.00%

521

35.61%

713

48.74%

229

15.65%

1463

3592

81.69%

805

18.31%

0

0.00%

0

0.00%

4397

0

0.00%

282

98.95%

3

1.05%

0

0.00%

285

266

42.36%

362

57.64%

0

0.00%

0

0.00%

628

1338

87.80%

41

2.69%

134

8.79%

11

0.72%

1524

Grand Rapids Pediatrics Ottawa Hills HC Salvation Army School Medical Program

14

1.87%

551

73.76%

171

22.89%

11

1.47%

747

Westside HC

Union High School HC

1706

30.00%

2738

48.14%

906

15.93%

337

5.93%

5687

Metropolitan Hospital

1114

21.61%

2173

42.15%

1258

24.40%

611

11.85%

5156

Breton HC

1114

21.61%

2173

42.15%

1258

24.40%

611

11.85%

5156

13

0.25%

3667

70.78%

1139

21.98%

362

6.99%

5181 1947

Spectrum Health Internal Medicine

0

0.00%

949

48.74%

762

39.14%

236

12.12%

Residency Practice

1

0.16%

254

41.03%

245

39.58%

119

19.22%

619

12

0.46%

2464

94.23%

132

5.05%

7

0.27%

2615

4758

21.07%

8570

37.96%

6063

26.85%

3187

14.12%

22578

425

22.94%

852

45.98%

465

25.09%

111

5.99%

1853

1

0.05%

747

40.01%

800

42.85%

319

17.09%

1867

2077

49.02%

1608

37.95%

417

9.84%

135

3.19%

4237

OB/GYN Saint Mary's Healthlink Browning Claytor HC Catherine's Care Center Clinica Santa Maria Heartside HC

0

0.00%

500

46.43%

555

51.53%

22

2.04%

1077

McAuley HC

12

2.66%

254

56.32%

180

39.91%

5

1.11%

451

Sparta HC Wege Family Practice Wege Internal Medicine Grand Total

753

31.48%

957

40.01%

447

18.69%

235

9.82%

2392

1490

21.00%

2891

40.75%

1801

25.39%

912

12.86%

7094

0

0.00%

761

21.10%

1398

38.76%

1448

40.14%

3607

15772

27.55%

23854

41.66%

12434

21.72%

5195

9.07%

57255

23

Kent County Aged Population (65 years and older)

Kent County

Aged Population Per Total Population Percent 2.57% - 5% 5.01% - 7.5% 7.51% - 10% 10.01% - 12.5% 12.51% - 15% 15.01% - 18% 18.01% - 20% 20.01% - 40.12% Clinics Medical Shortage Area

0

2

4

0

0.5

1

8

Miles 12

City of Grand Rapids

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

24

Aged Patient Utilization of Kent County Clinics, 2005

Kent County

Aged Patients Per Aged Population Percent 0% - 3% 3.01% - 5% 5.01% - 8% 8.01% - 12% 12.01% - 18% 18.01% - 25% 25.01% - 40% 40.01% - 60% Clinics Medical Shortage Area City of Grand Rapids

0

2

4

0

0.5

1

8

Miles 12

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

25

Mapping Section #3 Diagnoses Served by Clinic, 2005 Part of the federal HRSA award to the GRHCAP concentrated evaluation on four diagnoses common for clinic visits: asthma, depression, diabetes, and hypertension. All four diagnoses have established regimens for care and treatment, posing clear quality benchmarks for clinic use. Mapping visits by diagnosis supplements this effort, demonstrating where patients with these diagnoses live and at which clinics they seek treatment. Providers were asked to give numbers of total visits per patient as well as numbers of four prominent diagnoses. However, some data sets were given with just the first four diagnoses of a visit. From this list we were then able to code for those which were of the diagnoses we requested and then use these numbers in order to calculate the total number of visits for each diagnoses by patient. Similar to low-income measures, census data on various diagnoses is not available to the public, therefore in our analysis we were unable to use a population comparison group for the ratio. We instead used the proportion of total visits for diagnoses by block group over the total number of visits for that block group, this ratio provides a picture of those places which are drawing large percentages of a particular diagnoses. Graph 4: Percent of Diagnoses Visits by System, 2005 Percent of Diagnoses Visits by System, 2006 Percent of Total Visits

14.00% 12.00% 10.00% 8.00%

Asthma

6.00%

Depression

4.00%

Diabetes

2.00%

Hypertension

0.00% Cherry Street Metropolitan Health Services Hospital

Spectrum Health

Saint Mary's HealthLink

Graph 4 illustrates the broad distribution of clinic visits for these 4 diagnoses. The frequency of visits for each diagnoses is quite consistent across clinic systems. Hypertension and diabetes compete for the largest proportion of clinic visits, while asthma and depression alternate as third and fourth ranked in proportion of clinic visits. Table 4 gives the number of visits by clinic for each diagnosis, also the table gives the total visits for each of the clinics. Each of the maps shows the ratio patients with a particular diagnosis over totals patients.

26

Table 5: Patient Visits by Diagnosis by Clinic, 2005 Clinics

Cherry Street Health Services

Asthma Visits

% of Clinic Total

Depression Visits

% of Clinic Total

Diabetes Visits

% of Clinic Total

Hypertension Visits

% of Clinic Total

Total Clinic Visits

3356

3.84%

1965

2.25%

7934

9.08%

10094

11.55%

87381

Belknap Commons HC

67

2.50%

104

3.88%

343

12.79%

293

10.93%

2681

Burton HC

236

6.15%

100

2.61%

129

3.36%

43

1.12%

3837

Cherry St HC

849

3.02%

514

1.83%

3488

12.41%

4100

14.59%

28108

Creston HC

28

4.44%

41

6.50%

2

0.32%

0

0.00%

631

Ferguson Adult HC

450

5.25%

318

3.71%

2239

26.14%

3376

39.41%

8567

Grand Rapids Pediatrics

916

6.19%

15

0.10%

20

0.14%

35

0.24%

14793

Ottawa Hills HC

49

5.72%

17

1.99%

8

0.93%

5

0.58%

856 2605

Salvation Army

50

1.92%

30

1.15%

9

0.35%

23

0.88%

School Medical Program

26

1.16%

0

0.00%

0

0.00%

2

0.09%

2241

Union High School HC

123

6.74%

31

1.70%

1

0.05%

1

0.05%

1826

Westside HC

562

2.65%

795

3.74%

1695

7.98%

2216

10.44%

21236

275

1.37%

166

0.83%

1701

8.48%

1468

7.32%

20065

Metropolitan Hospital Breton HC

275

1.37%

166

0.83%

1701

8.48%

1468

7.32%

20065

219

1.00%

420

1.92%

1131

5.18%

1292

5.92%

21836

Internal Medicine

155

2.01%

300

3.89%

925

12.00%

975

12.64%

7711

Residency Practice

24

1.06%

47

2.08%

144

6.37%

277

12.25%

2262

OB/GYN

40

0.34%

73

0.62%

62

0.52%

40

0.34%

11863

Saint Mary's Healthlinks

1049

1.49%

929

1.32%

7196

10.22%

5154

7.32%

70388

Browning Claytor HC

77

1.39%

71

1.28%

281

5.08%

447

8.08%

5530

Catherine's Care Center

0

0.00%

6

0.12%

2391

48.28%

104

2.10%

4952

Clinica Santa Maria

123

0.96%

39

0.30%

660

5.13%

342

2.66%

12864

Heartside HC

85

2.96%

57

1.98%

309

10.76%

352

12.26%

2872

McAuley HC

0

0.00%

0

0.00%

0

0.00%

0

0.00%

1561

Spectrum Health

Sparta HC

38

0.59%

78

1.20%

301

4.64%

141

2.17%

6490

Wege Family Practice

287

1.31%

444

2.03%

1375

6.27%

1340

6.11%

21915

439

3.09%

234

1.65%

1879

13.23%

2428

17.09%

14204

4899

2.45%

3480

1.74%

17962

9.00%

18008

9.02%

199670

Wege Internal Medicine Grand Total

27

Kent County Clinic Utilization by Patients with Asthma, 2005

Kent County

Patients with Asthma Per Total Patients Percent 0% 0.1% - 1% 1.1% - 1.5% 1.6% - 2% 2.1% - 2.5% 2.6% - 3% 3.1% - 5% 5.1% - 16.1% Clinics Medical Shortage Area City of Grand Rapids

0

2

4

0

0.5

1

8

Miles 12

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

28

Kent County Clinic Utilization by Patients with Depression, 2005

Kent County

Patients with Depression Per Total Patients Percent 0% 0.1% - 0.5% 0.6% - 1% 1.1% - 1.5% 1.6% - 2% 2.1% - 2.5% 2.6% - 3% 3.1% - 8.6% Clinics Medical Shortage Area City of Grand Rapids

0

2

4

0

0.5

1

8

Miles 12

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

29

Kent County Utilization by Patients with Diabetes, 2005

Kent County

Patients with Diabetes Per Total Patients Percent 0% 0.1% - 2% 2.1% - 4% 4.1% - 6% 6.1% - 8% 8.1% - 10% 10.1% - 12% 12.1% - 25.8% Clinics Medical Shortage Area City of Grand Rapids

0

2

4

0

0.5

1

8

Miles 12

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

30

Kent County Clinic Utilization by Patients with Hypertension, 2005

Kent County

Patients with Hypertension Per Total Patients Percent 0% - 2% 2.1% - 4% 4.1% - 6% 6.1% - 8% 8.1% - 10% 10.1% - 12% 12.1% - 15% 15.1% - 33.1% Clinics Medical Shortage Area City of Grand Rapids

0

2

4

0

0.5

1

8

Miles 12

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

31

Mapping Section #4 Distance to Closest Clinic versus Patient Preferred Clinic in Kent County, 2005 Distance and means of transportation influence access to outpatient health care. The GRHCAP Consortium, following the leadership of Kent County Health Department, is addressing issues of public transportation to health care providers. The Mapping Project illustrates the numbers of people whose access to needed care could be affected by distance. The distance to a clinic was calculated using ArcGIS mapping program, which calculated the Euclidian distance (straight line) between two points. After patient addresses were geocoded, two calculations were made. First, the program calculates the distance in miles from a patient’s home address to the clinic he/she visited. Second, the program calculates the distance in miles from a patient’s home address to the clinic in closest distance was calculated. The distance does not take into account streets and speed limits, but it does show on average how far patients’ are traveling to clinics. Table 6 shows the average distance that patient live from the clinic they visit. The first map entitled Average Distance to Kent County Clinics, 2005 shows the average distance patients live from a clinic. The map entitled Additional Distance traveled to Patient Preferred Clinic: Kent County, 2005 shows the average difference in distance been the clinic the patient visited and the clinic closest. Mean additional distance traveled to preferred clinic rather than to the closest clinic concentrates in the northwest corner of the county, in the southwest corner of the county and west of Grand Rapids. In the northwest corner of the county, the closest clinic is Sparta, which is not the preferred clinic for some. On the west side, rural residents who are not Hispanic may be by passing Clinica Santa Maria.

32

Table 6: Average Euclidean Distance to Clinic Clinics

Cherry Street Health Services Belknap Commons HC Burton HC Cherry St HC Creston HC Ferguson Adult HC Grand Rapids Pediatrics Ottawa Hills HC Salvation Army Union High School HC Westside HC Metropolitan Hospital Breton HC Spectrum Health Internal Medicine Residency Practice OB/GYN Saint Mary’s Healthlinks Browning Claytor HC Catherine's Care Center Clinica Santa Maria Heartside HC McAuley HC Sparta HC Wege Family Practice Wege Internal Medicine Grand Total

33

Average Distance to Clinic 4.19 4.55 1.43 3.79 2.52 4.16 6.26 2.40 3.98 3.86 3.77 5.47 5.47 4.44 4.33 5.13 4.37 5.23 2.73 8.44 2.52 2.05 4.75 9.93 5.18 6.01 4.75

Kent County

Average Distance to Kent County Clinics, 2005 Average Distance to Clinic Miles 0.6 - 1.0 1.1 - 2.0 2.1 - 5.0 5.1 - 7.5 7.6 - 10.0 10.1 - 15.0 15.1 - 20.0 20.1 - 29.4 Clinics Medical Shortage Area City of Grand Rapids

0

2

4

0

0.5

1

8

Miles 12

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

34

Additional Distance to Patient Preferred Clinic: Kent County, 2005

Kent County

Average Difference in Distance Between Clinic Visited and Closest Clinic Miles 0.00 - 1.00 1.01 - 1.50 1.51 - 2.00 2.01 - 2.50 2.51 - 3.00 3.01 - 3.50 3.51 - 4.50 4.51 - 7.67 Clinics Medical Shortage Area

0

2

4

0

0.5

1

8

Miles 12

City of Grand Rapids

Grand Rapids 96

296

196

131

2

3 Miles

Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007

35

Appendix A: Mapping Data Distribution Guidelines

36

Appendix A Mapping data Distribution Guidelines

Data Users 1. Maps and analysis of the consolidated clinics’ population will be available, in the form of a report, to consortium members. Permission to release or otherwise publicize the report and/or results of the analysis of consolidated data is covered under guideline 3, below. 2. Maps and analysis of individual clinic data will be available in the report to consortium members according to clinic affiliation. 3. Consortium members and non members who request the use of any and all mapping data pertaining to clinics for which they have no affiliation or for data from the consolidated clinic population will require the approval of all consortium members to use such mapping data. All requests must specify in detail the intended use of the data. Data Type 4. Released maps will not contain any personal patient data. 5. Minimum unit of analysis for released data sets is census block group. Data Requests 6. Review of requests and decisions to release data by GRHCAP Consortium Board or its delegate. 7. KCHD will assess a fee to cover costs for non-consortium requests and requests from Consortium members for additional map or report reproductions.

Teresa Branson, KCHD Jim Dischinger-Smedes KCHD Fred DeJong, Ph.D., Evaluator Richard Zandstra, GRHCAP

37

Appendix B: GRHCAP Clinic Mapping Project Data Collection Guide

38

Appendix B: GRHCAP Clinic Mapping Project Data Collection Guide Mapping Project Client-level data to be collected in order to complete the maps and analysis is enumerated in row 10, with a sample record in row 11. Codes for variables (optional) are number 1-19. The data fields for House Number, Street Name, Street Direction, and Street Type is an optional address form that splits the combined street address into separate fields. Income is also an optional field. If data from different clinics is submitted in one file, make sure there are separate workbooks, or preferably, a clinic code. Field List: Bold font=Necessary data Normal Font=Optional data FIELDS SAMPLE RECORD

Address City 700 Fuller Ave NE Grand Rapids

Zip Code 49503

Race 1

Gender 1

FIELDS cont. SAMPLE RECORD cont.

Age 28

DOB 2/11/1966

Payer Type 1

Clinic Code SMHC-Clinicia

2005 Visits 3

FIELDS cont. SAMPLE RECORD cont.

Asthma visits 1

Depression visits Diabetes visits 2 2

Hypertension Visits 2

FIELDS cont. SAMPLE RECORD cont.

House Number 700

Street Name Fuller

Street Direction NE

Street Type Ave

Income 29000

Variable Coding 1 2 3 4

Address City Zip Code Race/Ethnicity

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Race/Ethnicity cont. Gender Age Date of Birth Payer Type Clinic Code or Name 2005 visits Asthma visits* Depression visits* Diabetes visits* Hypertension visits* House Number Street Name Street Type Street Direction Income

Full street address 5 digit Non-hispanic white=1 Asian=5 Female=1 In years mm/dd/yyyy Commercial=1

Black or African American=2 Hispanic=3 American Indian/ Alaska Native=4 Native Hawaiian=6 Other=7 Male=2 Medicaid, charity care, self-pay, KHP=2

Medicare=3

Number of asthma visits Number of depression visits Number of diabetes visits Number of hypertension visits Optional Optional Optional Optional Optional

*This does not need to be the primary diagnosis to be counted as a visit Notes: 1. Records: There is no client name entered, but the records are for unique clients. There will be duplicate addresses (spouses, siblings, etc.). 2. Address: Most recent address

39

3. 2005 Visits: All visits, regardless of address change 4. Optional address variables: Break the address down helps in the quality control of address placement.

40

Appendix C: Excerpt from “Target Areas, Low-Income Analysis, Population Change and Medical Shortage Area”, Clinic Mapping Project Report,, Task Force on Health Care for People of Color, Kent County Health Department, November 2005 The full report can be accessed online at: http://www.accesskent.com/Health/HealthDepartment/Publications/taskforce/Appe ndix_A_Clinic_Mapping_Project_Report_2005.pdf or by contacting Jim Smedes at the Kent County Health Department [email protected]

41