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Prepared for Sparrow Health System Sparrow Specialty Hospital: Community Health Needs Assessment Prepared by Public Policy Associates, Incorporated February 2013

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Page 1: Sparrow Specialty Hospital: Community Health Needs Assessment Sparrow/Sparrow Speci… · Grand Rapids are common as a result of a limited number of local pediatric sub specialists

Prepared for Sparrow Health System 

 

          

Sparrow Specialty Hospital: Community Health Needs Assessment   

     

Prepared by Public Policy Associates, Incorporated  February 2013 

  

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      Public Policy Associates, Incorporated is a public policy research, development, and 

evaluation firm headquartered in Lansing, Michigan.  The firm serves clients nationally in the public, private, and nonprofit sectors by conducting research, analysis, and 

evaluation that supports informed strategic decision making.               

 

119 Pere Marquette Drive, Suite 1C, Lansing, MI 48912‐1231, (517) 485‐4477, Fax 485‐4488, www.publicpolicy.com 

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Table of Contents     Executive Summary ......................................................................................................................1

Priority Health Needs Identified by the Healthy! Capital Counties Collaborative ..... 1

Priority Health Care Needs Identified by Sparrow Health System Through Supplemental Research ......................................................................................................... 1

Priority Health Issues to Be Addressed by Sparrow Specialty Hospital ....................... 3

 Introduction ...................................................................................................................................5

Purpose of this Report ........................................................................................................... 5

Data Gathering ....................................................................................................................... 5

Report Content ....................................................................................................................... 6

 Sparrow Specialty Hospital Area Profile ...................................................................................7

 Community Health Indicators ..................................................................................................21

Children in Poverty ............................................................................................................. 23

Single Parent Households ................................................................................................... 24

Housing Costs ...................................................................................................................... 25

Education .............................................................................................................................. 26

Community Safety ............................................................................................................... 27

Environmental Quality ........................................................................................................ 28

Obesity Among Adults ....................................................................................................... 29

Obesity Among Young People ........................................................................................... 30

Tobacco Use Among Adults ............................................................................................... 31

Tobacco Use Among Youth ................................................................................................ 32

Alcohol Use Among Adults ............................................................................................... 33

Alcohol Use Among Adolescents ...................................................................................... 34

Access to Physicians ............................................................................................................ 35

Preventable Hospitalizations ............................................................................................. 36

Medicaid Enrollment ........................................................................................................... 37

Health Insurance Coverage ................................................................................................ 38

Disease Prevention: Immunization ................................................................................... 39

Mental Health (Adults) ....................................................................................................... 40

Mental Health (Youth) ........................................................................................................ 41

Perceived Health Status ...................................................................................................... 42

Infant Mortality .................................................................................................................... 43

Low‐Weight Births ............................................................................................................... 44

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Premature Deaths................................................................................................................. 45

Cardiovascular Disease ....................................................................................................... 46

Accidental Deaths ................................................................................................................ 47

 Community Health Assets .........................................................................................................49

Hospitals ................................................................................................................................ 49

Federally Qualified Health Clinics .................................................................................... 50

Extended Care Facilities ...................................................................................................... 50

Physicians and Nurses ........................................................................................................ 51

 Findings ........................................................................................................................................53

Socioeconomic Indicators ................................................................................................... 53

Health Behaviors .................................................................................................................. 54

Access to Care ....................................................................................................................... 55

Children’s Health ................................................................................................................. 56

Health Outcomes.................................................................................................................. 57

 Community Health Issues .........................................................................................................59

 Methods ..................................................................................................................... Appendix A Interview and Focus Group Participants............................................................... Appendix B 

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Acknowledgements ____________________   This report was prepared with the assistance of a large number of individuals throughout Clinton, Eaton, and Ingham counties who provided their time and assistance in helping us to identify the most important health needs, issues, and concerns throughout this region.  Included among them are health care consumers, health care professionals, community leaders, government officials, working people, retirees, educators, community organization staff, and others.  This assessment would not have been possible without their participation as interviewees and focus group participants.    We would also like to thank the Healthy! Capital Counties collaborative—especially the staffs and leaders of the Ingham County Health Department, Barry‐Eaton Health Department, and the Mid‐Michigan District Health Department—for conducting the underlying community health needs assessment work upon which this report is based.  Their knowledge and experience as public health officials provided a level of professionalism to their model for assessing community health needs and, subsequently, their identification and assessment of the importance of numerous proposed strategies for improving the health and well‐being of all residents throughout the Greater Lansing area.   Sincerely,   Kira Carter‐Robinson, CEO      Dennis Swan, President and CEO Sparrow Specialty Hospital      Sparrow Health System  

 

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  Assessing community health needs and  adopting a strategy to address those  needs provides hospitals with a valuable  opportunity to work together with  community partners to identify strategies  for improving health, quality of life, and the  community’s vitality.1  Robert Wood Johnson Foundation, 2012 

 

                                                    

1 Robert Wood Johnson Foundation, “What’s new with community benefit?” Issue Brief (October 2012), 1. http://www.rwjf.org/healthpolicy.

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  1

 

Executive Summary     Sparrow Specialty Hospital provides extended, inpatient  acute care services to patients throughout Clinton, Eaton, and Ingham counties and in nearby areas of Gratiot, Ionia, and Shiawassee counties.  This assessment is mainly concerned with this hospital’s primary service area: Clinton, Eaton, and Ingham counties.    

Priority Health Needs Identified by the Healthy! Capital Counties Collaborative  The community health needs assessment conducted by this collaboration of four area hospitals (including Sparrow Health System) and three area community health departments identified five priority health needs for the Greater Lansing community:  

Children’s health 

Obesity 

Health care access 

Connection to resources / health literacy 

Safety and social connection 

  

Priority Health Care Needs Identified by Sparrow Health System Through Supplemental Research   Although Sparrow Specialty Hospital is a long‐term acute care facility, the information reported by those who were interviewed or participated in focus group discussions for this assessment were asked to provided information about the broad health care status, issues, and needs of the entire area rather than just those needs associated with long‐term acute care services.  Some of the findings of this assessment correspond closely to the health needs and concerns identified by those who participated in the assessment 

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for Sparrow Health System’s main hospital in Lansing.  Key health care needs include the following.    

Obesity.  Interviewees and focus group participants indicated a need to  reduce obesity in children and adults in order reduce the likelihood of diabetes and other chronic diseases in the future.  This is closely associated with the need to promote healthy lifestyles through better eating patterns, greater amounts of physical activity, and the reduction of “screen time” for video games and television, especially among children.  

  Pediatric Sub‐Specialty Physician Care.  Access to pediatric sub‐specialty consultations and direct services are not as widely available in the Greater Lansing area as parents and others would like.  Referrals to physicians in Ann Arbor or Grand Rapids are common as a result of a limited number of local pediatric sub specialists and delays in getting an appointment with a local specialist.   

Access to Primary Care Services.  Almost 30 percent of Ingham County residents and 25 percent of residents throughout the Greater Lansing area lack a primary care physician.  Low‐income working people with insurance report difficulty in getting access to primary care when needed, and both community leaders and community residents, alike, decry the use of hospital emergency services for less serious issues that might otherwise be addressed in a physician’s office or urgent care setting.    

Mental Health Services.  More extensive mental health services are needed in the Greater Lansing area, including local drug addiction treatment, post‐discharge psychiatric treatment, and the mental health needs of the area’s aging population.  There are also unmet mental health needs among the Lansing area’s growing refugee, immigrant, and international student populations. 

  Diabetes Education and Services.  Assessment participants indicated that diabetes is sufficiently widespread that special attention is needed to provide area diabetics with as much information and support as possible to control this disease and to slow or prevent the onset of its complications and life‐shortening consequences.  Participants pointed out that diabetes is a particular concern within the area’s African American community and, thus, warrants special management attention.    

Chronic Diseases.  Additional screening, testing, diagnosis and treatment of chronic diseases (e.g., cardiovascular and pulmonary disease and cancer) are important issues in the Sparrow Specialty Hospital service area.  Although chronic disease 

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  3

 

screenings are widely available in the region, these services are not necessarily adequate to the community’s needs due to the area’s aging population and the lack of health care insurance among low income segments of the population.   

 

Priority Health Issues to Be Addressed by Sparrow Specialty Hospital  Based on the needs identified in the Healthy! Capital Counties collaborative and supplemental research conducted by Sparrow Health System, Sparrow Specialty Hospital will address the following priority health issues in an Implementation Strategy:  

Healthy lifestyles  Diabetes   

   

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Introduction ___________________________   

Purpose of this Report  As a community‐based hospital, the mission of Sparrow Specialty Hospital is “to improve the health of the people in our communities by providing quality, compassionate care to everyone, every time.”2  The purpose of this report is to assess the health status and health issue concerns within this community in order for Sparrow Specialty Hospital staff to identify and understand the community’s most pressing health care needs and to suggest activities and services to address these needs and concerns. The results of this assessment will provide the basis for developing a  set of specific actions that Sparrow Specialty Hospital, in collaboration with other community partners, can undertake to resolve these issues and concerns and, ultimately, improve the health status of the community at large and the health of its individual residents.  This project is an outgrowth of the Healthy! Capital Counties Collaborative health needs assessment project that was conducted over the past eighteen months by a consortium of hospitals and county/district health departments in the Mid‐Michigan area.  Sparrow Health System is a leading participant in the Healthy! Capital Counties Collaborative, and much of the information and procedures used by the coalition to prepare a community health assessment for Clinton, Eaton, and Ingham  Counties, Michigan, has served as a model for this assessment.   This report is designed to be used by Sparrow Specialty Hospital along with public and private organizations throughout the three counties as a benchmark for improving the health and well‐being of every resident.    

Data Gathering  The information presented in this community health needs assessment (CHNA) has been gathered from two different sources.  Statistical information about the population of the community served by Sparrow Specialty Hospital, the social and economic 

                                                  

2 Sparrow Health System. Accessed December 19, 2012. http://www.sparrow.org/missionvision/.

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characteristics of the community, and the health care experiences and characteristics of the residents of the community are derived from a variety of standard sources of information including the Centers for Disease Control and Prevention (CDC), the Michigan Department of Community Health (MDCH), and the Bureau of the Census.  This statistical information has been supplemented by interviews and focus groups conducted with residents of community served by Sparrow Specialty Hospital.  This qualitative information provides balance to the study from insights and perceptions of the community’s residents, including their perceptions of what they believe are the most important health care issues within the community, why they may be important, and their suggestions as to what should be done about these concerns.  Although the identity of these information contributors is confidential, a list of the types of people who participated is provided in Appendix B. 

  

Report Content  This assessment contains the following information: 

Profile of the population, socioeconomic, and health status characteristics of the community served by Sparrow Specialty Hospital 

Thirty one‐page Community Indicator reports that provide specific data for the three counties, nearby counties, and the State of Michigan for comparison.  These indicator pages also provide some additional details on the indicators, the source of information, and comments about the issues that the indicator reflects that have been gleaned from interview and focus groups participants 

A brief list of health resources within the Sparrow Specialty Hospital service area 

Findings that identify the most important health care concerns and issues within the community based on the data presented 

    

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Sparrow Specialty Hospital Area Profile   Lansing area community residents and leaders interviewed for the Sparrow Health System Community Health Needs Assessment reported their perception that the health status of community residents in this region is “Fair to Good.”    

 

This response is in contrast to the perceptions of individuals’ own health status as reported in the 2010 Behavioral Risk Factor Survey for this area.  In that study 57 percent of area residents indicated that their own health was excellent or very good; 16 percent reported their own health as fair or poor.  Despite these findings, there are considerable health care issues and health care needs evident throughout much of the Sparrow Specialty Hospital service area as revealed through the statistical profiles provided in the following pages and through the comments provided through interviews with community leaders and focus groups conducted with area residents. 

3.33

3.8

3.75

3.59

1 2 3 4 5 6

Sparrow Lansing

Sparrow Clinton

Sparrow Specialty

Overall

Community Leadersʹ Perceived Area Health Status, 2012  (1=Very Poor, 6=Excellent)

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Ingham County Profile Ingham County is the largest county within the 6‐county Sparrow Health System service area with a population of almost 300,000 residents.  Sparrow Specialty Hospital is located in the City of Lansing (population 114,297) and it is the largest city in Ingham County and the 6‐county region.  Ingham County has a younger than average population due to the presence of Michigan State University with approximately 40,000 students, as well as several other academic institutions.  More than 30% of the population is college educated.  Approximately one of every four Ingham County residents is a member of a minority group, and there is considerable poverty in the county.  More than 20% of all county children live in poverty, and more than one‐third of households spend more than 30% of their income on housing.  Infant mortality in the City of Lansing exceeds that for the entire state.  Almost one in four adults in the county is obese, and more than one in five adults is a smoker. 

Population Characteristics – Ingham County

76.2%

11.8%

5.2%4.0%

0.6%

2.3%

Ingham County Population by Race, 2010

White

African‐American

Asian

Multi‐racial

AmericanIndian/ AlaskanNativeOther

• Population size:  280,895 • Age breakout:

0 – 4:  5.7%  5 – 14:  11.5%  15 – 44:  48.2%  45 – 64:  24.0%  65 – 74:  5.5%  75 and over:  4.8% 

• Median age: 31.4 years• Racial composition:

White:  76.2%  African American:  11.8%  Asian: 5.2%  American Indian/Alaska Native:  0.6%  Multi‐racial: 4.0%  Other:  2.3%  Native Hawaiian/Pac. Islander:  None 

• Ethnic composition:  Hispanic: 7.3% Non‐Hispanic: 92.7% 

Source: Bureau of the Census, 2010 Census of Population

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Social and Economic Indicators – Ingham County

Indicator Definition Percentage Relationship to

Michigan Income Children below 18 in poverty 22.4% Family Single parent households 9.4%

Education

Population age 25+ with a high school degree 90.7% Population age 25+ with a Bachelor’s degree or higher 35.5%

Safety Rate of violent crimes per 100,000 person 438.7

Affordable Housing Percentage of households that spend more than 30% of income on housing

37.1%

Environment Population density per square mile

505.1 people per mile2 Higher Density

More favorable than the statewide average About average Less favorable than the statewide average Source: Bureau of the Census, American Community Survey, 2006-2010; 2010 Census of Population; Michigan State Police,2010. Over one‐third of Ingham County residents 25 or older have a bachelor’s degree or higher, which is well above both the statewide and six‐county service area averages.  The county also has the highest population density in the capital area.  The poverty indicators for Ingham County mask differences within the county.  Low income and economically vulnerable families are most highly concentrated within the City of Lansing.  Higher income households are more characteristic of surrounding suburban areas.  Otherwise, Ingham County is very similar to the state in terms of the other social and economic indicators.      

Source: American Community Survey, 2006-2010 Source: Michigan Department of Community Health, 2012

Lansing71%

Balance of County29%

Residence of Children At or Below the Poverty Level in Ingham County, 2010 (N = 12,418 children at or below poverty)

6.26

8.21

3.13

7.47

0

1

2

3

4

5

6

7

8

9

InghamCounty

Lansing City(Ingham Co.

part)

Balance ofInghamCounty

State ofMichigan

Average Annual  Infant Mortality per 1,000 Live Births, 2006‐2010

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Health Indicators – Ingham County

Indicator Definition Results

Comparison With

Michigan

Child Health Rate of preventable asthma hospitalizations per 10,000 children

25.4 per 10,000

Quality of Life Perceived health status as “fair” or “poor” 16.0%

Adult Health Rate of preventable diabetes-related hospitalizations among adults

15.7 per 10,000

Premature Deaths Percentage of deaths prior to age 75 44.0% Maternal and Child Health

Low birth weight and very low birth weight babies

81.3 per 1,000 live births

Safety Policies/ Practices

Deaths due to accidental injury per 10,000 residents

29.5 per 10,000

More favorable than the statewide average About average Less favorable than the statewide average Source: Michigan Department of Community Health, 2012. While several of the preventable health indicators (diabetes‐related hospitalizations and the rate of low or very low birth weight babies in Ingham County) are about equivalent to the rates found for the entire state, asthma hospitalizations among children in the county are worse than the statewide rate.  While the definitive cause of this ambulatory‐sensitive set of admissions cannot be discerned from these data, this indicator is generally associated with poverty, poor household living conditions, and limited access to primary care services among the affected children.  In contrast, ambulatory sensitive admissions of adults for diabetes are at roughly the statewide rate in Ingham County.  Premature deaths are reported at a  more favorable (e.g., lower) percentage than for Michigan overall. 

   

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Behavior, Physical Condition, and Access to Care Indicators – Ingham County

Indicator Definition Percentage Comparison

With Michigan

Obesity Percentage of adults who are obese 24.1%

Percentage of adolescents who are obese 16.7%

Tobacco Use

Percentage of adults who currently smoke 21.4% Percentage of adolescents who smoked in the past month 10.0%

Alcohol Use

Percentage of adults who binge drank in past month 16.7% Percentage of adolescents who binge drank in past month 10.9%

Access to Care

Percentage of residents lacking a primary care physician 29.1% Percentage of population enrolled in Medicaid 11.9% Ratio of population per primary care physician

762 per physician

Prevention Percentage of children 19 to 35 months old with recommended vaccinations 76.0%

Mental Health Percentage of adults who report their mental health is “not good” 12.1%

Better than statewide average About average Worse than statewide average

Source: Michigan Behavioral Risk Factor Survey, 2008-2010

33.9% 36.2% 32.3% 35.8% 30.1%47.6%

25.0% 22.0%

49.5%30.7%

24.1%

29.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Clinton Eaton Gratiot Ionia Ingham Shiawassee

Prevelence of Overweight and Obese Adults in the SHS Service Area as Indicated by Body‐Mass Index (BMI) 

Obese Adults Overweight Adults

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Clinton County ProfileClinton County is located adjacent to the northwest border of Ingham County and the City of Lansing.  Total population is 75, 382 residents, according to the  2010 Census of Population.  The areas bordering Ingham County are primarily bedroom communities for employees of General Motors, Michigan State Government, Michigan State University and other Lansing area businesses and industries.     The rest of the county is mainly agricultural with some manufacturing in the City of St. Johns.  Sparrow Clinton Hospital is located in St. Johns, Michigan, the county’s major urban center.  Clinton County is fundamentally a middle income community with some pockets of rural poverty scattered across the area. Population Characteristics – Clinton County

92.9%

2.1%

2.0%1.5% 0.4%

1.2%

Clinton County Population by Race, 2010

White

African‐American

Multi‐racial

Asian

AmericanIndian/AlaskanNativeOther

 

• Population size: 75,382 • Age breakout:

0 – 4:  5.9%  5 – 14:  14.2%  15 – 44:  38.9%  45 – 64:  27.8%  65 – 74:  7.3%  75 and over:  5.7% 

• Median age: 38.4 years• Racial composition:

White:  92.9%  African American:  2.1%  Asian: 1.5%  American Indian/Alaska Native:  0.4%  Multi‐racial: 2.0%  Other:  1.2%  Native Hawaiian/Pac. Islander:  None 

• Ethnic composition: Hispanic: 3.9%  Non‐Hispanic: 96.1%

Source: Bureau of the Census, 2010 Census of Population

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Social and Economic Indicators – Clinton County

Indicator Definition Percentage Relationship to

Michigan Income Children below 18 in poverty 6.8% Family Single parent households 7.7%

Education

Population age 25+ with a high school degree 93.0% Population age 25+ with a Bachelor’s degree or higher 27.2%

Safety Rate of violent crimes per 100,000 person 60.9

Affordable Housing Percentage of households that spend more than 30% of income on housing

29.1%

Environment Population density per square mile

133.1 people per mile2 Lower Density

More favorable than the statewide average About average Less favorable than the statewide average Source: Bureau of the Census, American Community Survey, 2006-2010; 2010 Census of Population; Michigan State Police, 2010.  Health care concerns that are directly related to poverty, particularly among children, are  less evident in Clinton County than elsewhere in the region or state as the indicators of household poverty are either no worse or are better than average.  Fewer than 10% of Clinton County children live in poverty, which is much lower than both the statewide and six‐county service area averages.  Compared to the statewide average, a smaller proportion of county of residents spend 30% or more of income on housing.  The proportion of single parent households in Clinton County is similar to the statewide average.    Compared to the region and state, Clinton County is relatively safe; the rate of violent crime is lower in Clinton County than in any other county in the Sparrow service area.  Nine out of ten residents have a high school degree and just over one‐quarter have a bachelor’s degree or higher.  

   

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Health Indicators – Clinton County

Indicator Definition Results

Comparison With

Michigan

Child Health Rate of preventable asthma hospitalizations per 10,000 children

12.3 per 10,000

Quality of Life Perceived health status as “fair” or “poor” 17.0%

Adult Health Rate of preventable diabetes-related hospitalizations among adults

10.3 per 10,000

Premature Deaths Percentage of deaths prior to age 75 39.0% Maternal and Child Health

Low birth weight and very low birth weight babies

69.1 per 1,000 live births

Safety Policies/ Practices

Deaths due to accidental injury per 10,000 residents

20.5 per 10,000

More favorable than the statewide average About average Less favorable than the statewide average Source: Michigan Department of Community Health, 2012. Clinton County has fewer premature deaths than the other five counties in the Sparrow service area.  The county also has a relatively low rate of low birth weight babies and preventable diabetes‐related hospitalizations among adults, and deaths due to accidental injury.  Clinton County is on par with the statewide average for the rate of preventable asthma hospitalizations and the residents’ perceived health status.  Less than one‐fifth of the county’s residents have a poor perceived health status.   

   

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Behavior, Physical Condition, and Access to Care Indicators – Clinton County

Indicator Definition Percentage Comparison With

Michigan

Obesity Percentage of adults who are obese 25.0%

Percentage of adolescents who are obese 10.0%

Tobacco Use

Percentage of adults who currently smoke 16.4% Percentage of adolescents who smoked in the past month 13.5%

Alcohol Use

Percentage of adults who binge drank in past month 17.9% Percentage of adolescents who binge drank in past month 12.8%

Access to Care

Percentage of residents lacking a primary care physician 14.8% Percentage of population enrolled in Medicaid 6.2% Ratio of population per primary care physician

2,494 per physician

Prevention Percentage of children 19 to 35 months old with recommended vaccinations 77.0%

Mental Health Percentage of adults who report their mental health is “not good” 6.9%

More favorable than the statewide average About average Less favorable than the statewide average Source: Michigan Department of Community Health, Michigan Behavioral Risk Factor Survey, 2008-2010; Health Resources and Services Administration, Area Resource File, 2010.

  

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Eaton County Profile Eaton County is located immediately to the west of Ingham County and the City of Lansing.  It includes suburban areas adjacent the City of Lansing (a portion of which is located in Eaton County), a manufacturing center for the automobile industry, and an extensively developed agricultural area.  Charlotte is the county’s largest community, and it is the location of Hayes Green Beech Memorial Hospital.  Other key communities are Eaton Rapids, where Eaton Rapids Medical Center is located, and Grand Ledge, which is mainly a bedroom community for Lansing.  Both of these hospitals are critical access hospitals. As of 2010, the population of the county was 107,759 residents, as reported in the 2010 Census of Population.  Eaton County has a relatively small minority population that is mainly concentrated in the eastern edge of the county which is part of the City of Lansing.  Population Characteristics – Eaton County

87.8%

6.3%

1.7%0.4% 2.6%

1.2%

Eaton County Population by Race

White

African‐American

Asian

AmericanIndian/AlaskanNativeMulti‐racial

Other

• Population size:  107,759 • Age breakout:

0 – 4:  5.7%  5 – 14:  13.2%  15 – 44:  37.5%  45 – 64:  29.6%  65 – 74:  7.8%  75 and over:  6.2% 

• Median age: 40.3 years• Race and ethnic composition: 

White:  87.8%  African American:  6.3%  Asian: 1.7 %  American Indian/Alaska Native:  0.4%  Multi‐racial: 2.6%  Other:  1.2%  Native Hawaiian/Pacific Islander: None 

• Ethnic Composition:  Hispanic: 4.7%  Non‐Hispanic: 95.3% 

Source: Bureau of the Census, 2010 Census of Population

   

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Social and Economic Indicators – Eaton County

Indicator Definition Percentage Relationship to

Michigan Income Children below 18 in poverty 12.1% Family Single parent households 8.7%

Education

Population age 25+ with a high school degree 92.4% Population age 25+ with a Bachelor’s degree or higher 24.3%

Safety Rate of violent crimes per 100,000 person 159.5

Affordable Housing Percentage of households that spend more than 30% of income on housing

29.4%

Environment Population density per square mile

187.3 people per mile2 Higher Density

More favorable than the statewide average About average Less favorable than the statewide average Source: Bureau of the Census, American Community Survey, 2006-2010; 2010 Census of Population; Michigan State Police,2010.  Social and economic indicators for Eaton County are all about average or somewhat better than the statewide average.  Eaton County has fewer children living in poverty and fewer households spending 30% or more of their income on housing, as compared to the statewide average.  The proportion of single‐parent households in Eaton County is similar to the statewide average.  The county has a relatively low rate of violent crime.    Nine out of ten residents have a high school degree and about one‐quarter have bachelor’s degrees or more education.    

   

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Health Indicators – Eaton County

Indicator Definition Results

Comparison With

Michigan

Child Health Rate of preventable asthma hospitalizations per 10,000 children

17.9 per 10,000

Quality of Life Perceived health status as “fair” or “poor” 16.0%

Adult Health Rate of preventable diabetes-related hospitalizations among adults

10.8 per 10,000

Premature Deaths Percentage of deaths prior to age 75 43.0% Maternal and Child Health

Low birth weight and very low birth weight babies

70 per 1,000 live births

Safety Policies/ Practices

Deaths due to accidental injury per 10,000 residents

34.2 per 10,000

More favorable than the statewide average About average Less favorable than the statewide average Source: Michigan Department of Community Health, 2012.  Eaton County residents are comparable to the statewide averages for three of the indicators above, and they exhibit characteristics that are more favorable than the statewide average for the remaining three reported here.  Eaton County has lower rates of preventable diabetes‐related hospitalizations and low birth weight babies as compared to the statewide average, as well as a lower than average percentage of premature deaths.  In contrast, Eaton County is roughly similar to the statewide averages for the rate of preventable asthma hospitalizations, the residents’ perceived health status, and deaths due to accidental injury.

   

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Behavior, Physical Condition, and Access to Care Indicators – Eaton County

Indicator Definition Percentage Comparison

With Michigan

Obesity Percentage of adults who are obese 22.0% Percentage of adolescents who are obese 14.7%

Tobacco Use

Percentage of adults who currently smoke 28.8% Percentage of adolescents who smoked in the past month 13.2%

Alcohol Use

Percentage of adults who binge drank in past month 20.7% Percentage of adolescents who binge drank in past month 16.1%

Access to Care

Percentage of residents lacking a primary care physician 21.6% Percentage of population enrolled in Medicaid 8.3% Ratio of population per primary care physician

1907 per physician

Prevention Percentage of children 19 to 35 months old with recommended vaccinations 79.0%

Mental Health Percentage of adults who report their mental health is “not good” 14.5%

More favorable than the statewide average About average Less favorable than the statewide average Source: Michigan Department of Community Health, Michigan Behavioral Risk Factor Survey, 2008-2010; Health Resources and Services Administration, Area Resource File, 2010.

Unlike the social, economic, and health indicators presented in the preceding tables, health behaviors and access to care are more varied.  The percentages of adults who smoke and binge drink  are greater in Eaton County than statewide.  In contrast, Eaton County residents  have more favorable rates  of obesity (although this is still too high).  The proportion of residents who lack a primary care physician and the ratio of residents to each primary care physician are both worse than the statewide average or the ratio in adjacent Ingham County.  This is likely due, in part, to the easy availability of Ingham County physicians in Lansing and East Lansing to those who reside in the Eaton County suburbs of Lansing.  

For younger people, the proportion who are obese is about average, and both smoking and binge drinking rates are  more favorable  (i.e., lower) than the averages for adolescents throughout Michigan 

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Community Health Indicators ___________   The indicators listed in Table 1, below, are presented in the following pages.  They are grouped within the following categories:   

Social, Economic, and Environmental Indicators:  Children in Poverty; Single Parent Households; Education; Community Safety; Housing Costs; Nitrate Levels in Well Water (environmental quality)  

Health Behavior Indicators:  Adult Obesity; Youth Obesity; Adult Tobacco Usage; Youth Tobacco Usage; Adult Alcohol Consumption; Youth Alcohol Consumption  

Clinical Care Indicators:  Access to Physicians; Preventable Hospitalizations (Ambulatory‐Sensitive Admissions); Medicaid Enrollment; Health Insurance Coverage; Childhood Immunization 

  Mental Health Indicators:  Adult Mental Health; Youth Mental Health  

Morbidity and Mortality Indicators:  Perceived Health Status; Infant Mortality; Low Birth‐weight Babies; Premature Deaths; Cardiovascular Disease; Accidental Deaths 

   

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 Table 1: Indicator Data Sources

Indicator Data Source Year Children in Poverty Bureau of the Census, American Community Survey 2006-2010Single Parent Households Bureau of the Census, American Community Survey 2006-2010Housing Costs Bureau of the Census, American Community Survey 2006-2010Education Bureau of the Census, American Community Survey 2006-2010Community Safety Michigan State Police, Michigan Incident Crime Reporting 2010Environmental Quality Michigan Department of Environmental Quality 1988-2011

Obesity Among Adults Capital Area Behavioral Risk Factor Survey 2008-2010

Michigan Behavioral Risk Factor Survey 2008-2010Bureau of the Census, American Community Survey 2006-2010

Obesity Among Young People

Michigan Department of Education, Michigan Profile for Health Youth (MiPHY) 2012

Michigan Department of Community Health, Michigan Youth Risk Behavior Survey 2009

Tobacco Use Among Adults Capital Area Behavioral Risk Factor Survey 2008-2010Michigan Behavioral Risk Factor Survey 2008-2010

Tobacco Use Among Youth

Michigan Department of Education, Michigan Profile for Health Youth (MiPHY) 2012

Michigan Department of Community Health, Michigan Youth Risk Behavior Survey 2009

Alcohol Use Among Adults Capital Area Behavioral Risk Factor Survey 2008-2010

Michigan Behavioral Risk Factor Survey 2010Bureau of the Census, American Community Survey 2006-2010

Alcohol Use Among Adolescents

Michigan Department of Education, Michigan Profile for Health Youth (MiPHY) 2012

Access to Physicians Health Resources and Services Administration, Area Resource File 2009-2010American Association of Medical Colleges 2011

Preventable Hospitalizations Michigan Department of Community Health, Michigan Resident Inpatient Files 2010

Medicaid Enrollment Michigan Department of Community Health 2012

Health Insurance Coverage Bureau of the Census, Small Area Health Insurance Estimates, American Community Survey 2009

Disease Prevention: Immunization

Michigan Department of Community Health, Michigan Care Improvement Registry 2012

Mental Health (Adults) Capital Area Behavioral Risk Factor Survey 2008-2010Michigan Behavioral Risk Factor Survey 2010

Mental Health (Youth)

Michigan Department of Education, Michigan Profile for Health Youth (MiPHY) 2012

Michigan Department of Community Health, Michigan Youth Risk Behavior Survey 2011

Perceived Health Status Capital Area Behavioral Risk Factor Survey 2008-2010

Infant Mortality Michigan Department of Community Health, Michigan Infant Mortality Tables 2006-2010

Low-Weight Births Michigan Department of Community Health 2000-2010

Premature Deaths Michigan Department of Community Health, Michigan Resident Death File 2010

Cardiovascular Disease Michigan Department of Community Health, Michigan Resident Death File 2010

Accidental Deaths Michigan Department of Community Health, Michigan Resident Death File 2010

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Children in Poverty 

+-

19.0%

21.0%

23.0%

22.4%

12.1%

6.8%

16.7%

17.7%

19.8%

0.0% 10.0% 20.0% 30.0%

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area

Six‐County SHS ServiceArea

Michigan

Percentage of Children In Poverty, 2010

Source: American Community Survey, 2006‐2010

Measure.  Children in poverty is the percentage of children living in households with incomes below the 2010 Federal Poverty Threshold as determined annually by the Census Bureau.  For 2010, the poverty threshold ranged from $15,030 for a family with one adult below age 65 and one child to as much as $43,845 for a family with two adults and seven or more children.   Data source & year.  These data are from the Census Bureau’s American Community Survey for the period 2006 – 2010.  Multi‐year estimates are used to estimate data for smaller areas such as cities and counties.  Importance of this measure.  The percentage of children in poverty has been shown to be closely associated with a variety of poor health behaviors, negative health effects, and negative outcomes including higher incidence of disease and premature death.  The overall percentages of children in 

poverty are lower for both the Lansing tri‐county area and the entire 6‐county SHS service area than for the entire state.  The percentage of children in poverty exceeds the statewide average in Ingham, Gratiot, and Ionia counties.  Of more than 12,000 children in poverty in Ingham County, 71% reside in the City of Lansing.

“Kids are the poorest population in the US.  They have the least voice and the people who care for them are 

paid the least.” Source: American Community Survey, 2006‐2010 

Lansing71%

Balance of 

County29%

Residence of Children At or Below the Poverty Level in Ingham County, 2010 

(N = 12,418 children at or below poverty)

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Single Parent Households 

 

10.3%

10.8%

10.3%

9.4%

8.7%

7.7%

9.0%

9.4%

9.5%

0% 5% 10% 15%

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area

Six‐County SHS ServiceArea

Michigan

Percentage of Single Parent Households

Measure.  This measure reflects the percentage of households in which a single parent is raising at least one child. Data source & year.  These data are from the Census Bureau’s American Community Survey for the period 2006 – 2010.   Importance of this measure.  Children in single‐parent households are at a higher risk for adverse health effects, such as emotional and behavioral problems, compared to their peers.  Children in such households are more likely to develop depression, smoke, and abuse alcohol and other substances.  Consequently, these children experience increased risk of morbidity and mortality of all causes.  Similarly, single parents suffer from lower perceived health and higher risk of mortality.  

Source: Health Matters in San Francisco. http://www.healthmattersinsf.org/

Both the Tri‐county area and the six‐county service area have slightly lower percentages of single parent households than the state as a whole.  Locally, the rate is highest in Ionia County at 10.8 percent and lowest in Clinton County at 7.7 percent.  Both Gratiot and Shiawassee counties also have percentages higher than the statewide average at 10.3 percent.  

Source: American Community Survey, 2006‐2010. 

25%

41%

8%

73%

34%

0% 20% 40% 60% 80%

White (non‐Hispanic)

Hispanic

Asian/Pacific Islander

African American

All

Perecentage of Michigan Children in Single Parent Households by Race, 2010

4.1%

6.2%5.2%

5.9% 5.8%6.6%

0.0%

2.0%

4.0%

6.0%

8.0%

Clin

ton

Eaton

Gratio

t

Ionia

Ingh

am

Shiawassee

Percentage of Children Living in Households Headed by a Grandparent

Source: American Community Survey, 2006‐2010.Source: Annie E. Casey Foundation, Kids Count data, 2012.

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  25

 

Housing Costs 

   

32.6%

34.5%

30.8%

37.1%

29.4%

29.1%

34.0%

33.7%

34.8%

0% 10% 20% 30% 40%

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area

Six‐County Region

Michigan

Percentage of Households with Housing Costs Greater than 30% of 

Income, 2010

Measure.  This measure is the percentage of households that spend more than 30 percent of their total household income on housing. Data source & year.  U.S. Census Bureau, American Community Survey 2006‐2010. Importance of this measure.  The percentage of income that a family spends on housing is directly related to the amount of income available for other expenses such as health insurance, transportation, heat, child care, and food items.   high in sugars and fats.   

 Both the tri‐county region and the six‐county service areas have similar portions of households with high housing costs relative to income as compared with the statewide average.  Clinton and Eaton counties have a lower percentage of households in this category which may be attributed to higher average incomes in these areas.     

Source: U.S. Census Bureau, American Community Survey 2006‐2010, Table S2503.

    

“A lot of people have left their community to find jobs or 

affordable housing due to these economic times.” 

 “The way the economy is right now you have to choose between your health and paying your 

living expenses.”  

“A lot of people lost their house because they can’t cover the expensive hospital bills.” 

 

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26   Sparrow Specialty Hospital | February 2013 

 

Education 

   

14.9%

13.1%

13.5%

35.5%

24.3%

27.2%

31.2%

26.2%

25.0%

0.0% 10.0% 20.0% 30.0% 40.0%

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County LansingArea

Six‐County SHSService Area

Michigan

Percentage of Adults over 25 with a Bachelorʹs Degree or Higher

Measure.  Educational attainment is measured by the percentage of adults who are 25 years or older who have a bachelor’s degree or a higher level of education Data source & year.  These data are from the Census Bureau’s American Community Survey for the period 2006 – 2010.   Importance of this measure.  There is thought to be a strong correlation between positive health outcomes and higher levels of education.  There is also a well‐known relationship between higher education levels and greater economic opportunities which typically relate to healthier lifestyles.   

Both the tri‐county area and the six‐county service area have higher rates of adults with college degrees compared to the statewide average.  The lowest rates of educational attainment are found in Gratiot, Ionia, and Shiawassee counties where about 14 percent of people over age 25 have a bachelor’s degree or higher.  This is in sharp contrast to a much higher than average rate in Ingham County, where Michigan State University is located.

Source: American Community Survey, 2006‐2010. 

12.0%

7.0% 7.6%

12.9%

9.3%

12.9%

10.1%

0.0%

5.0%

10.0%

15.0%

Michigan

Clin

ton

Eaton

Gratio

t

Ingh

am

Ionia

Shiawassee

Adults 25 and Older With Less Than a HS Diploma

“Making the kinds of decisions that abandon or undervalue education will kill you in the end.  An uneducated 

population dies quicker.” Source: American Community Survey, 2006‐2010. 

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  27

 

Community Safety 

   

204.3

156.6

91.5

438.7

159.5

60.9

313.2

270.6

489.9

0 100 200 300 400 500 600

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area

Six County SHS Service Area

Michigan

Violent Crime per 100,000 Persons, 2010

Measure.  Community safety is represented by the rate of violent crimes per 100,000 residents per year.  Violent crimes are annual incidents of murder and non‐negligent homicide, first‐degree rape, robbery, and aggravated assault, as reported by the Michigan State Police.  These crimes are all crimes against people and, thus, represent the personal safety (or lack of safety) within each of the areas. Data source & year.  These data are reported in the 2010 Michigan Incident Crime Reporting tabulations prepared by the Michigan State Police. Importance of this measure.  In addition to reflecting the level of personal safety, crime generates stress among community residents, thus potentially undermining their psychological well‐being.  High levels of crime may also deter community residents from outdoor activities and may add stress to participation in education and community activities.   

Source: Michigan State Police. Michigan Incident Crime Reporting (MICR): 2010 All Offenses Reported by County/Agency.

While all of the counties examined show lower violent crime rates than was reported for the entire state of Michigan in 2010, Ingham County exhibited only a marginally lower rate at that time.  Almost two‐thirds of the violent crimes in Ingham County occurred within Lansing.  This indicates a higher potential level of stress that may be associated with health problems in the city. 

Lansing, 2787

Balance of County, 1537

Average Number of Violent Crimes in Lansing and the Balance of Ingham County, 2008‐2010

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28   Sparrow Specialty Hospital | February 2013 

 

Environmental Quality 

   

1.1%

5.2%

3.1%

0.7%

1.4%

0.5%

0.9%

0% 1% 2% 3% 4% 5% 6%

Shiawassee

Ionia

Gratiot

Ingham

Eaton

Clinton

Tri‐County Lansing Area

Michigan

Percentage of Well Samples with Nitrate Levels Above the Maximum 

Containment Level*

N.A.

Measure.  Water samples were tested for the level of nitrate in the water.  This measure is the percentage of well water samples that exhibit nitrate levels in water that are  above the Environmental Protection Agency standard of 10 milligrams per liter.   Data Source & Year.  Michigan Department of Environmental Quality, 1988 – 2011.  This information is drawn from periodic tests of private water wells. Importance of this Measure.  High nitrate levels in water may be related to the inappropriate or unsanitary disposal of human, animal, or industrial waste products.  High nitrate levels in water can cause serious illnesses among infants below six months of age (methemoglobinemia). High nitrate levels may also be an indicator of other contaminants in the water. (See Michigan Department of Environmental Quality. Nitrate in Drinking Water: Information for private water well owners. (Brochure), 2003.)    Source: http://www.michigan.gov/documents/deq/deq-wd-gws-ciu-nitratebrochure _270430_7.pdf 

Source: Michigan Department of Environmental Quality. 1988-2011. * These data are meaningful only for localities and households that are not served by municipal water systems that are routinely tested for contaminants.

Although water quality is an important concern among environmentalists and community health specialists, environmental quality issues such as concerns about high levels of ground water contamination, air pollution, industrial pollution, or lead in house paint were also raised during the interviews and focus groups conducted for this project. 

“Farm waste is really not an issue because the county [Clinton County] has done very well in 

addressing this.”  

“I am worried about the health effects of pesticides and steroids in food products.” 

 “Historical problems, such as abandoned 

manufacturing plants that have led to significant groundwater issues.” 

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  29

 

Obesity Among Adults 

47.6%

35.8%

32.3%

30.1%

36.2%

33.9%

32.1%

34.1%

35.1%

29.3%

30.7%

49.5%

24.1%

22.0%

25.0%

23.8%

26.7%

31.7%

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Region

6‐County Region

Michigan

Adults Who are Overweight or Obese2008‐2010

Overweight Obese

Measure.  Overweight adults are defined as having a body‐mass index (BMI) of 25.0 to 29.9.  Obese adults have a BMI of 30.0 and above.  BMI is a calculation which takes into account both height and weight.  Data source & year.  BMI was calculated from height and weight data submitted by sample participants in the Behavioral Risk Factor Surveillance System surveys conducted in Michigan between 2008 and 2010. Importance of this measure.  The relationship of obesity to a number of serious chronic diseases among adults has been well documented.  Foremost among obesity‐related maladies are diabetes, heart disease, high blood pressure, and liver disease.   

Two‐thirds of adults age 18 and over in Michigan are either overweight or obese.  Adults in the Tri‐County Lansing Area exhibit lower rates of overweight and obesity in most cases.  Adults in Gratiot and Shiawassee counties exceed both regional and statewide levels. 

Source: 2008-2020 Capital Area Behavioral Risk Factor Survey; 2008-2010 Michigan BRFSS; American Community Survey, 2006-2010.

 

“Obesity keeps increasing – if we can expand the communication and educational opportunities to make 

people aware of the problem, perhaps we can control this problem.” 

 “In our obesity prevention efforts, people agree with us mentally but in practice [they] go back to offering candy 

as rewards.”  

Among interviewees, obesity was the most frequently listed top health issue in communities serviced by Sparrow 

Health System. 

41.6%28.7%

42.6%

0%

50%

Black non‐Hispanic White non‐Hispanic

Hispanic

Obese Adults by Race and Ethnicity in Michigan,  2009

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30   Sparrow Specialty Hospital | February 2013 

 

Obesity Among Young People 

 

   

17.3%

16.8%

17.4%

15.2%

15.2%

15.7%

15.6%

15.9%

14.2%

18.2%

16.5%

12.3%

14.0%

15.2%

10.0%

13.6%

14.4%

11.9%

Gratiot County

Ionia County

Shiawassee County

Ingham County

Eaton County

Clinton County

Tri‐County Region

6‐County Region

Michigan*

Youth  Who Are Overweight or Obese2011‐2012

Overweight Obese

* 2009

Measure. Overweight youth are those who are at or above the 85th percentile and below the 95th percentile for body‐mass index (BMI) by age and sex.  Obese youth are at or above the 95th percentile for BMI by age and sex.  Data source & year.  County data were drawn from the 2012 Michigan Profile for Healthy Youth (MiPHY) survey which is conducted among a sample of students in the 7th, 9th, and 11th grades in selected schools in selected districts in each county.  Students in 31 of 72 school districts in the six‐county area participated, including those in 36 of 143 middle school buildings and 35 of 125 high school buildings.  Statewide comparative data are from the 2009 Michigan Youth Risk Behavior Survey. Importance of this measure.  Over‐weight and obese youth exhibit both current and future risk factors, including risk for heart disease, diabetes, stroke, and cancer.  Over‐ weight youth are also are at a greater risk for being socially stigmatized and having poor self‐esteem.  

Between 25% and 35% of youth in each of this region’s counties are overweight or obese, with some of the highest rates reported in the more rural areas.  In all cases, these rates exceed the statewide levels recorded in 2009.  

Source: Michigan Department of Education, 2012 Michigan Profile for Healthy Youth; Michigan Department of Community Health, 2009 Michigan Youth Risk Behavior Survey. Regional data calculated by PPA. * 2009 data.

  

“People try to fill their bellies and don’t worry about health necessarily. Families may eat better at the

beginning of the month than [at] the end due to financial limitations.”

“It’s a national disease frankly. I think

it’s going to get worse because kids don’t go out and get exercise. Schools are cutting back on gym and athletics.

It’s driven by revenue.”

Obese14%

Overweight16%

Not Overweight

70%

Overweight and Obese Youth in the Sparrow Service Area, 2011‐2012

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  31

 

Tobacco Use Among Adults  

   

18.7%

15.4%

28.8%

21.4%

28.8%

16.4%

22.3%

21.6%

18.9%

0% 5% 10% 15% 20% 25% 30% 35%

Shiawassee County*

Ionia County*

Gratiot County*

Ingham County†

Eaton County†

Clinton County†

Tri‐County Lansing Area

Six‐County SHS Service Area

Michigan

Perecentage of Current Adult SmokersMeasure.  Tobacco use among adults is measured as the percentage of the adult population that reported smoking every day or most days and has smoked at least 100 cigarettes in their lifetime.   Data source & year.  Smoking data are from the 2008‐2010 Capital Area 2008‐2010 Michigan Behavioral Risk Factor Surveys.   Importance of this measure.  Despite years of publicity regarding the health dangers associated with tobacco use, about 20 to 25 percent of the adult population continues to smoke.  Smoking has a variety of direct and indirect health consequences, including lung cancer, other pulmonary diseases, and heart disease.  Indirect consequences include both low birth weight and the possibility of disease among those exposed to second hand smoke.  As noted in the Healthy! Capital Counties CHNA Report, tobacco use may also indicate the need for smoking cessation programs or illustrate the effectiveness of existing programs.  

Tobacco use in the six‐county Sparrow Health System service area is slightly higher than the state as a whole.  Higher percentages of adults use tobacco in Eaton and Gratiot counties, while both Clinton and Ionia counties have much smaller percentages of users.    

† Source: 2008‐2010 Capital Area Behavioral Risk Factor Survey * Source: 2008‐2010 Michigan Behavioral Risk Factor Survey 

“There are programs out there to educate, but there are people who ignore it.”  

“[It] was a high priority five to ten years ago, but [it] seems to have dropped off.” 

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32   Sparrow Specialty Hospital | February 2013 

 

Tobacco Use Among Youth  

   

9.1%

9.4%

8.9%

5.4%

9.4%

4.0%

6.1%

6.7%14.0%

0% 2% 4% 6% 8% 10% 12% 14% 16%

Shiawassee

Ionia

Gratiot

Ingham

Eaton

Clinton

Tri‐County Lansing Area

Six County Region

Michigan*

Percentage of Students Who Smoked Cigarettes in the Past 30 Days

* Michigan  2010 BRFS

Measure.  Tobacco use among youth is measured as the percentage of young people who reported smoking cigarettes during the past 30 days.  Data source & year.   These data are drawn from the Michigan Department of Education, Michigan Profile for Healthy Youth (MiPHY), 2010 and the 2008‐2010 Capital Area Behavioral Risk Factor Survey.  Importance of this measure.  One of the successful outcomes of years of promoting the dangers of smoking and has been a decline in the prevalence of smoking among young people in recent years.  Despite this, some young people continue to take up smoking each year.  As is widely known, smoking has a variety of direct and indirect health consequences, including lung cancer, other pulmonary diseases, and heart disease.  Indirect consequences include both low birth weight and the possibility of disease among those exposed to second hand smoke.  As noted in the Healthy! Capital Counties CHNA Report, tobacco use may also indicate the need for smoking cessation programs or the effectiveness of existing programs.   

Source: 2008-2010 Capital Area Behavioral Risk Factor Survey; 2008-2010 Michigan Behavioral Risk Factor Survey.

“I fear for smoking.  I see way too many young people smoking.” 

“We were doing more a few years 

ago.”

Within the six‐county Sparrow Health System service area the percentage of youth that report having smoked a cigarette in the last 30 days is significantly lower than that for the state as a whole.  The highest rates of tobacco use are found in the more rural counties within the SHS service area.  The Lansing tri‐county region has a lower rate of youth tobacco use than the six‐county region overall with the highest rate found in Eaton County.  This may be indicative of the scope and reach of current and past smoking cessation efforts. 

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  33

 

Alcohol Use Among Adults 

   

19.5%

15.8%

18.7%

16.7%

20.7%

17.9%

17.8%

17.8%

19.7%

0.0% 10.0% 20.0% 30.0%

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area

Six‐County Region

Michigan*

Binge Drinking Among Adults, 2008‐2010

Measure.  Binge drinking is defined as the percentage of adult males who had 5 or more and adult females who had 4 or more drinks of alcohol in a row within a short period of time during the past 30 days. Data source & year.  These data are from the 2008‐2020 Capital Area Behavioral Risk Factor Survey; the  2008‐2010 Michigan Behavioral Risk Factor Survey; American Community Survey, 2006‐2010; and the Centers for Disease Control, Vital Signs, Binge Drinking.  Importance of this measure.  Adult binge drinking causes 80,000 deaths in the US each year and, in 2006 cost the economy $223.5 billion.  This behavior can lead to increased incidents of violence, automobile accidents, suicide, unplanned pregnancies, spread of sexually transmitted diseases, and fetal alcohol syndrome.  Community coalitions with a broad set of partners that includes educators, public safety, public health officials, and community leaders can help address this issue.  

Source: 2008‐2020 Capital Area Behavioral Risk Factor Survey; 2008‐2011 Michigan BRFSS; American Community Survey, 2006‐2010. 

“[We are] dealing with people who are addicted or drunk all the time.  How do you motivate people to get out of where 

they’re stuck?” 

19.7% 20.4%

15.6%

20.5%21.6%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Michigan White Black Other Hispanic

Binge Drinking by Race and Ethnicity in Michigan, 2011

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34   Sparrow Specialty Hospital | February 2013 

 

Alcohol Use Among Adolescents 

   

10.7%

17.4%

13.8%

10.9%

16.1%

12.8%

12.3%

12.8%

23.2%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0%

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area

Six‐County Region

Michigan

Binge Drinking Among High School Students, 2011‐2012

Measure.  Binge drinking is defined as the percentage of students who had 5 or more drinks of alcohol in a row, that is, within a couple of hours, during the past 30 days. Data source & year.  County data were drawn from the 2012 Michigan Profile for Healthy Youth (MiPHY) survey which is conducted among students in the 7th, 9th, and 11th grades in selected schools in selected districts in each county.  Regional data were calculated by the authors.  Students in 31 of 72 school districts in the six‐county area participated, including those in 36 of 143 middle school buildings and 35 of 125 high school buildings.  Statewide data are from the 2009 Michigan Youth Risk Behavior Survey. Importance of this measure.  Alcohol consumption among adolescents may have a negative effect on brain development as well as negatively effecting liver and endocrine system development.  Binge drinking can also lead to risk‐taking behaviors that might result in negative health outcomes such as sexually transmitted diseases, unplanned pregnancies, traffic‐related injuries, or alcohol poisoning. 

The data indicate that the six counties that Sparrow Health System serves all perform much better than the state as a whole on this indicator.  While the rates are higher in Eaton and Ingham counties, these areas are still below the statewide average.   

Source: American Community Survey, 2006-2010

 “I see a lot of alcohol being served in the area, including high school graduation parties, 

weddings, and party stores.”  

“There is still a lot of drinking and driving going on in this county.  People think because you’re on a country road it’s okay.” 

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Access to Physicians 

 

   

2530

2670

1323

762

1907

2494

1017

1114

1034

0 1000 2000 3000

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area

Six‐County Region

Michigan

Population per Primary Care Physician, 2009‐2010

Measure.  The measure on the top right is the number of total residents per primary care physician (including general medicine, family practice, internal medicine, pediatrics, or gynecology).  Below is the percentage of the resident population that does not have a primary care physician for routine health care needs.    Data source & year.  Data are from the U.S. Department of Health & Human Services, Health Resources and Services Administration (HRSA), Area Resource File, 2009‐2010, the American Association of Medical Colleges (AAMC), and the Behavioral Risk Factor Survey, 2008‐2010. Importance of this measure.  Primary care serves as the gateway to health through the provision of preventive care services, treatment for basic health needs, and referrals to specialized care when needed.  Lack of access to primary care may delay treatment for minor problems that, with time, may become serious concerns with life‐threatening consequences. 

While the Lansing area and the entire six‐county Sparrow Service Area have an average number of physicians available for the population served, the Lansing area and Ingham County, in particular, report more than 1 in 4 residents does not have a primary care physician. 

Source: Health Resources and Services Administration, Area Resource File, 2009-2010; American Association of Medical Colleges, 2011.

 

“Many people are reluctant to drive into Lansing, so if the required resources are not available many people go without” 

“Ingham County is not underserved as far as number of physicians to population 

ratio.” 

“The emergency room becomes their primary care vehicle since primary care is not really available without insurance.” 

Source: American Community Survey, 2006‐2010 

12.5%

25.4%

14.8%21.6%

29.1%

13.4% 14.0%

0%

10%

20%

30%

40%

Michigan

 Lan

sing

Area

Clin

ton

Cou

nty

Eaton

Cou

nty

Ingh

amCou

nty

Gratio

tCou

nty

Ionia

Cou

nty

Shiawassee

Cou

nty

Percentage Lacking Access to a Primary Care Physician, 2008‐2010

NA

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36   Sparrow Specialty Hospital | February 2013 

 

Preventable Hospitalizations 

209.6

325.8

184.2

218.3

181.1

212.1

268.4

0 50 100 150 200 250 300 350

Shiawassee

Gratiot

Ionia

Ingham

Clinton

Eaton

Michigan

Preventable Hospitalizations per 10,000 Population, 2010

Measure.  Preventable hospitalizations are those which typically do not require inpatient services for treatment.  Common preventable hospitalizations diagnoses are diabetes for adults and asthma for children.    Data source & year.  These data are from the Michigan Department of Community Health, 2010 Michigan Resident Inpatient Files.  Importance of this measure  “High rates of Ambulatory Care Sensitive hospitalizations in a community may be an indicator of a lack of or failure of prevention efforts, a primary care resource shortage, poor performance of primary health care delivery systems, or other factors that create barriers to obtaining timely and  effective care.” Michigan Department of Community Health.   http://www.mdch.state.mi.us/pha/osr/CHI/HOSP/INSTRUC2.htm   

Source: Michigan Department of Community Health, 2010 Michigan Resident Inpatient Files.

25.6

18.1

12.4

21.4

14.3

0 10 20 30

Ingham County

Eaton County

Clinton County

Tri‐County LansingArea

Michigan

Example: Preventable Hospitalizations Due to Asthma per 10,000 Children Below Age 18

“Routine physical exams.  Yes if you have insurance.  If you don’t, that’s the last thing that you’re going to do.  Of all the issues, that’s probably the biggest gap.  If we can catch some of this stuff earlier, it would be better/save money.” 

The tri‐county area has a much higher rate of preventable hospitalizations due to asthma per 10,000 children younger than 18 than does the state as a whole.  Ingham County performs much worse on this measure than does Clinton or Eaton counties.  (See chart at left.) 

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Medicaid Enrollment  

12.2%

10.7%

12.0%

11.9%

8.3%

6.2%

10.2%

10.6%

12.3%

0% 2% 4% 6% 8% 10% 12% 14%

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area

Six‐County SHS Service Area

Michigan

Percentage of Residents Enrolled in Medicaid

Measure.  This measure reflects the percentage of residents enrolled in any Medicaid Health Plan. Data source & year.  These data are August 2012 enrollment figures from the Michigan Department of Community Health.   Importance of this measure.  Because accurate measurements of uninsured individuals are not standardized, accurately measuring the percentage of Medicaid enrollees can help provide firmer estimates for health insurance coverage in the region. (http://www.chis.ucla.edu/dataquality6.html).    This indicator is also helpful in determining an area’s demand for services and providers that accept Medicaid patients.       

Both the tri‐county area and the six‐county service area have a lower percentage of residents enrolled in a Medicaid Health Plan than that state as a whole.  Clinton County enrollment is the lowest, with only 6.2% of residents enrolled in a Medicaid Health Plan. 

Source: Michigan Department of Community Health, 2012

“We’re not a physician shortage area, but we’re low on specialists in this area.  Specialists don’t see uninsured or Medicaid, so we need more access 

to that.”  

“Dental and some of the specialty care is largely restricted if you’re on Medicaid.  In our area, there is one dentist . . . who will see Medicaid [patients].  If [a] kid is in hospital, they [physicians] will see them, but 

not in office.” 

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38   Sparrow Specialty Hospital | February 2013 

 

Health Insurance Coverage 

10.3%

11.3%

14.2%

12.9%

16.4%

14.9%

13.6%

13.4%

13.9%

0.0% 5.0% 10.0% 15.0% 20.0%

 Clinton County

 Eaton County

 Ingham County

3‐county region

 Gratiot County

 Ionia County

 Shiawassee County

6‐county region

Michigan

Percentage of the Population Without Health Insurance, 2009

Measure.   This is the percentage of the entire non‐institutionalized population that reported not having any form of health insurance, including commercial insurance, Medicare, Medicaid, military services health care, or other health insurance.  Data source & year.  These data are from the Bureau of the Census, 2009 Small Area Health Insurance Estimates.  Regional estimates were calculated by the authors.   Importance of this measure.  The lack of health care insurance provides an estimate of the potential level of unmet health care needs in the community as well as the potential level of uncompensated care when uninsured individuals may need care provided by the emergency department of a local hospital. 

Source: Bureau for the Census, Small Area Health Insurance Estimates, 2009. 

4.4%

12.4%

16.1%

24.6%

0.0% 10.0% 20.0% 30.0%

Massachusetts

Michigan

U.S.

Texas

Percent Uninsured, Selected States, 2009‐2011 Average

Source: U.S. Census Bureau, Current Population Survey, 2009 to 2012 Annual Social and Economic Supplements.

Compared to the total percentage of uninsured people across the United States, Michigan has a relatively low proportion of residents without any form of health insurance.  Only 13 states have a smaller proportion of their population that is uninsured.  The rates presented above for Clinton, Eaton, and Ingham counties, in particular, compare very favorably with most of the rest of the nation. 

“People who don’t have health insurance put off getting care, and lot of small businesses don’t provide 

insurance.”  

“I see the real gaps where people don’t have insurance.  Seems to me people who have insurance can get care.  

Physicians won’t take Medicaid because the reimbursement is so poor.” 

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Disease Prevention: Immunization 

75%77%

79% 81%76%

81%78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Michigan

Clin

ton Co.

Eaton Co.

Gratio

t Co.

Ingh

am Co.

Ionia Co.

Shiawassee Co.

Percentage of Children Ages    19 to 35 Months with Recommended 

Immunizations, 2012

Measure.  This reflects the percentage of children 19 to 35 months of age who have received the recommended 4:3:1:3:3:1 series of immunizations (including immunization for polio, hepatitis B, measles, mumps, diphtheria, and several others). Data source & year.  These data are from the Michigan Department of Community Health, Michigan Care Improvement Registry, June 2012.   (http://www.mcir.org/index.html) Importance of this measure.  Vaccinations received early in life provide lifelong immunity from several deadly childhood diseases (Healthy! Capital Counties, 2012).  Protection against childhood diseases reduces deaths and improves long‐term health for individuals, and protects the community at large.  Source: MDCH, “Michigan Immunization Timely Tips.” April 2011.

 

68.3%

78.5%

72.1%

64.1%

0% 50% 100%

Michigan

Hispanic

White

AfricanAmerican

Childhood Immunization by Race and Ethnicity, 2011

Source: Michigan Department of Community Health, Michigan Care Improvement Registry, June 2012.

While these figures do not represent the immunization rates for the Greater Lansing area, the general pattern of disparity in the percentage of children immunized by race and ethnicity are likely to be found in this six‐county region. 

“I worry about the parents who don’t follow up with immunizations. I am surprised that schools don’t do a better 

job.”  

“There is a lack of outreach and education when it comes to 

immunizations” 

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40   Sparrow Specialty Hospital | February 2013 

 

Mental Health (Adults) 

   

13.4%

14.0%

6.4%

12.1%

14.5%

6.9%

11.8%

11.9%

10.7%

0% 5% 10% 15% 20%

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area

Six‐County Region

Michigan

Adults Reporting Poor Mental Health 2008‐2010

Measure.  This is the percentage of individuals age 18 and older reporting 14 or more days of poor mental health in the past 30 days.  Data source & year.  Data are from the 2008‐2010 Capital Area BRF & SC Survey; 2010 Michigan BRFSS; American Community Survey, 2006‐2010. Importance of this measure.  The relationship between mental health and physical health is important to overall well‐being.  As a determinant of quality of life, mental well‐being is positively correlated to physical well‐being.  There are multiple facets to mental health included in this measure such as stress, emotional problems, and depression.   

While both the six‐county and the tri‐county regions register a somewhat higher percentage of adults reporting poor mental health compared to the state as a whole, Clinton and Gratiot counties perform noticeably better on this measure.   

Source: 2008-2010 Capital Area BRF & SC Survey; 2010 Michigan BRFSS; American Community Survey, 2006-2010.

“We have facilities now that we did not have 10‐15 years ago, but affordability continues to be an 

issue.”  

“There is a gap in mental health services; we don’t have adequate resources in terms of practitioners 

or facilities.”  

“Mental health services are no longer represented in the 

community, especially for the uninsured.” 

10.4%11.6%

10.4%

14.7%

0.0%

5.0%

10.0%

15.0%

20.0%

White Black Other Hispanic

Adults Reporting Poor Mental Health, by Race and Ethnicity, 2010

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  41

 

Mental Health (Youth) 

 

  

   

26.9%

29.2%

29.4%

26.7%

27.7%

24.5%

26.7%

27.1%

26.0%

Shiawassee

Ionia

Gratiot

Ingham

Eaton

Clinton

Tri‐County Lansing Area

Six‐County Region

Michigan

0% 5% 10% 15% 20% 25% 30% 35%

Adolescents With Symptoms* of Depression, 2011

Measure.  This measure is the percentage of students (grades 7, 9, 11, and 12 in some cases) who report feeling sadness or hopelessness almost every day for at least 2 weeks in a row that results in not doing usual activities.  This reflects feelings of stress, depression, and other emotional problems. Data source & year.  These data are from the Michigan Profile for Healthy Youth Survey (MiPHY), 2012; Michigan Youth Risk Factor Survey, 2011. Importance of this measure.  Mental health is an important component of overall health.  Depression among youth not only may be manifest in feelings of sadness, defeat or hopelessness, but may interfere with school activities and may affect physical health as well.  

*Self-reported feelings of sadness or hopelessness for 2 weeks or more. Source: Michigan Department of Education; Michigan Department of Community Health. Michigan Profile for Healthy Youth, 2012 County Reports; CDC, National Center for Health Statistics, Michigan Youth Risk Behavior Survey, 2011. /mdoe.state.mi.us/MIPHYADMIN/reports/ CountyReport.aspx

28.8%

34.5%

24.3%

Black Hispanic White0%

10%

20%

30%

40%

Adolescents With Symptons of Depression by Race and 

Ethnicity, 2011

“[We are] seeing more kids with mental health problems, but it is very difficult to find treatment for

them.”  

Indicators of youth depression are slightly above the statewide average in mostly rural Gratiot and Ionia counties.  Hispanic and African‐American youth report higher overall rates of depression than white youth in Michigan. 

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42   Sparrow Specialty Hospital | February 2013 

 

Perceived Health Status  

 

 

  

   

3.75

3.33

3.86

3.8

3.66

0 1 2 3 4 5 6

Sparrow Specialty

Sparrow Lansing

Sparrow Ionia

Sparrow Clinton

Six‐County Area

Community Leaders  ́Perceived Area Health Status, 2012 (1 = Very Poor, 6 = 

Excellent)

   

14.0%

11.5%

16.1%

16.0%

16.0%

17.0%

16.2%

15.5%

14.2%

0% 5% 10% 15% 20%

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area

Six‐County SHS Service Area

Michigan

Percentage of Adults with a ʺFair/Poorʺ Perceived General Health Status

Measure.  Health status is the percentage of adults who self‐reported their health as “fair” or “poor” when asked “Would you say that in general your health is excellent, very good, good, fair, or poor?.”    Data source & year.  Capital Area Behavioral Risk Factor Survey 2008 – 2010; Ingham County Health Department.   Importance of this measure.  Perceived health status is indicative of quality of life, or those physical, emotional, and social items that contribute to one’s well‐being.  Self‐ perceived health status can also be an important indicator for determining health care and health‐related service demands for a community.     

http://publichealth.lacounty.gov/ha/reports/angelenos/chapter4/angel4phs.pdf

Between 14 and 16 percent of the population throughout Michigan, the six‐county SHS service area, and the Greater Lansing Area perceive their own health status as “fair” or “poor.”  Ionia County is an exception as only 11 percent report relatively poor health status. 

Interviews conducted for Sparrow Health System asked community and health care leaders to provide their perceptions of the general health status of the Greater Lansing area.  They indicated that the health of area residents is good, but not excellent. 

Source: Capital Area Behavioral Risk Factor Survey, 2008‐2010; Ingham County Health Department. 

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  43

 

Infant Mortality 

   

4.9

3.9

8.7

6.3

5.4

3.9

6.1

5.9

7.5

0 2 4 6 8 10

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area

Six‐County Regioan

Michigan

Average Annual Infant Deaths per 1,000 Live Births, 2006‐2010

Measure.  This is the average annual number of infant deaths for every 1,000 live births between 2006 and 2010. Data source & year.  Data were obtained from  the Michigan Department of Community Health, Michigan Infant Mortality Tables.; Center for Disease Control (CDC), Birth Outcomes; Center for Disease Control, Office of Minority Health and Health Disparities.   Importance of this measure.  According to the CDC, infant mortality is associated with maternal health, quality of and access to medical care, socioeconomic conditions, and public health practices.  This indicator reflects factors associated with the health of the mother before and during pregnancy and also problems of infants including congenital abnormalities, pre‐term/low birth weight, Sudden Infant Death Syndrome (SIDS), and respiratory distress syndrome.  Racial disparities also exist with infant mortality among African Americans occurring at nearly twice the national average, and according to the Indian Health Service, SIDS deaths among American Indian and Alaska Natives are 2.3 times the rate for non‐Hispanic white mothers. Centers for Disease Control.  http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/InfantMortality.htm

Source: Michigan Department of Community Health, Michigan Infant Mortality tables. http://www.mdch.state.mi.us/pha/osr/index.asp?Id=3

“We could do a better job getting people who don’t have insurance hooked up earlier.  We need more resources, 

especially at the ICHD level.  A lot of it is awareness.  Many of them have multiple other issues.  If you have insurance or money, you get great 

prenatal care.” 

With the exception of Gratiot County, all of the counties in the SHS service area perform better on this indicator than the state as a whole.  In Ingham County, the greatest percentage of infant deaths is reported in the city of Lansing. 

Lansing81%

Balance of Ingham County19%

Average Annual Infant Deaths, Lansing & Balance of Ingham County, 

2006‐2010

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44   Sparrow Specialty Hospital | February 2013 

 

Low‐Weight Births 

   

74.8

65.7

71.8

81.3

70

69.1

77.2

75.3

82.8

0 20 40 60 80 100

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Region

6‐County Region

Michigan

Low Weight Babies, Average per 1,000 Live Births

Measure.  Babies that weigh less than 2,500 grams (5 pounds, 8 ounces) at the time of birth are considered low birth weight babies.  About one in 12 babies born in the U.S. (83.3 per 1,000 live births) weigh less than 2,500 grams. Data source & year.  These data are calculated from county birth data compiled by the Michigan Department of Community Health for the year 2000 through 2010. Michigan birth data may be found at http://www.mdch.state.mi.us/pha/osr/index.asp?Id=2 Importance of this measure.  Low birth weight may be an indicator of the health status of mothers in a community.  There are several factors responsible for low birth weight, including chronic health problems among the mothers and poor pre‐natal care.  There are also several implications for low birth weight babies early in life, including breathing problems, vision problems, learning problems, hearing loss, and cerebral palsy.  Low birth weight risk can be reduced through improved pre‐natal care, better nutrition, smoking cessation, and other health improvements.     

The incidence of low birth weight babies in this region over the past 10 years compares favorably with statewide and national figures.  Low birth weight babies in both the Lansing area as well as the entire 6‐county Sparrow Health System service area are about 10 percent below the statewide rate.  The highest area rates are found in mainly urban Ingham County and mainly rural Shiawassee County. 

Source: Michigan Department of Community Health, Michigan Natality 

 

“If you have insurance or money you get great prenatal care.  There are just gaps for people who don’t have insurance or money.” 

 

“When you look at some of the statistics I would say the overall health status is fair to poor.  Particularly looking at low birth weight babies.” 

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Premature Deaths 

 

   

44%

51%

42%

44%

43%

39%

42%

56%

0% 10% 20% 30% 40% 50% 60%

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County Lansing Area*

Michigan

Percentage of Deaths Before Age 75 (Premature Death), 2010

Measure.  Death prior to age 75 is considered premature death.  Data source & year.  These data are drawn from the Michigan Department of Community Health, Michigan Resident Death File, 2010;  Importance of this measure.  The percentage of an area’s population that dies before the age of 75 is indicative of deaths that might have been prevented.  Examining the underlying reasons for “premature” deaths are likely to reveal community health issues that can be addressed and, if resolved, may lead to longer life among community residents.    

Across Michigan, 56 percent of the population dies before the age of 75.  Within the six‐county SHS service area Ionia has the highest mark at 51 percent with a low of 39 percent for Clinton County.  Using premature death as a singular surrogate for overall community health, each of the counties in the SHS service area exhibits a healthier status than generally found throughout the entire State of Michigan. 

Source:  Michigan Department of Community Health, Michigan Resident Death File, 2010; Ingham County Health Department. 

“Factors such as the percentages of adult smokers and adults with a college education are associated with premature mortality among U.S. counties.  Population health policies aimed at reducing mortality disparities require an understanding of the socioeconomic context within which modifiable variables exist.”  Cheng, Erika R., and David A. Kindig. "Disparities in Premature Mortality Between High- and Low-Income US Counties." http://www.cdc.gov/pcd/issues/2012/11_0120.htm. 

* 2012 Community Health Profile and Health Needs Assessment.  Healthy! Capital Counties. 

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46   Sparrow Specialty Hospital | February 2013 

 

Cardiovascular Disease 

   

209

182

249

195

158

171

181

207

0 100 200 300

Shiawassee County

Ionia County

Gratiot County

Ingham County

Eaton County

Clinton County

Tri‐County LansingArea*

Michigan

Deaths Due to Cardiovascular Disease  per 10,000 Residents, 2010

Measure.  Deaths due to cardiovascular disease per 10,000 residents are used to represent the impact of chronic disease in the community.  Data source & year.  Data are from the Michigan Department of Community Health, Michigan Resident Death File, 2010;   Importance of this measure.  There is a strong correlation between cardiovascular disease and chronic morbidity (illness) and mortality (death).  Cardiovascular disease includes coronary artery disease, stroke, cardiomyopathy, and heart failure.   

295.6

149.1 124.7 151.9

235.9

0

100

200

300

Black AmericanIndian/Alaska

Native

Asian/PacificIslander

Hispanic White, Non‐Hispanic

Deaths per 100,000 Residents from Heart Disease, Males, by Race and Ethnicity: 

U.S., 2008

Source: Michigan Department of Community Health, Michigan Resident Death File, 2010.

“Across Michigan, Black Men have the highest rates of cardiovascular disease deaths, followed by Black Women.  White Males have a higher rate of mortality from cardiovascular disease than White Women.”  Healthy! Capital Counties 2012 Community Health Profile & Health Needs Assessment, 47. 

* 2012 Community Health Profile and Health Needs Assessment. Healthy! Capital Counties.

The highest rate of cardiovascular disease in the six‐county SHS service area is in Gratiot County.  Shiawassee County is the second highest in the region with a rate close to the statewide average.  All of the remaining counties in the region have rates lower than the statewide average with the lowest rate found in Eaton County. 

National Center for Health Statistics.  Health, United States 2011: With Special Feature on Socioeconomic Status and Health.  Hyattsville, MD. 2012    Table 30. 

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Accidental Deaths 

   

45.5

62.1

42.4

28.1

28.7

28.3

29.3

35.3

35.4

0 10 20 30 40 50 60 70

Shiawassee County

Ionia County

Gratiot County*

Ingham County

Eaton County

Clinton County

Tri‐County Region

6‐County Region

Michigan

Age‐Adjusted Death Rate Due to Accidental Injury per 100,000 Persons, 2010

Measure.  Deaths due to accidental injury per 10,000 persons include unintentional injuries such as traffic‐related fatalities, falls, suffocation, drowning, and poisoning.  The measure excludes deaths attributed to homicide or suicide. Data source & year.  The data are reported on the Michigan Department of Community Health, Michigan Resident Death File, 2010.  Importance of this measure.  Accidental death due to poisoning and drowning are among the leading causes of death for children and young adults.  Accidental death resulting from a fall is one of the leading causes of death among people 65 and over.  According to the Healthy! Capital Counties Collaborative, poor socioeconomic environments can lead to an increase in deaths due to accidental injuries. 

The rate of death due to accidental injury is higher in Ionia and Shiawassee counties compared to both the statewide and the tri‐county areas.   

Source: Michigan Department of Community Health, Michigan Resident Death File, 2010; County Health Profiles.  www.mdch.state.mi.us/pha/osr/chi/profiles/frame.html 

13.3

37.6

5

16.1

0510152025303540

Large Metro

Central

Large Metro Fring

e

Med

ium M

etro

Small M

etro

Town/City

(Micropo

litan

)

Rural

Age‐Adjusted Motor Vehicle Death Rates per 100,000,  2007‐2009

Male Female

The graph on the right is a comparison of the rates of death due to accidental injury from traffic related incidents in the U.S. between urban and rural localities.  The trends found in the six county service area are similar to this national trend data.  Source:  CDC, Morbidity and Mortality Weekly Report. March 23, 2012 (volume 61, number 11; page 197. Source data may be found within the National Vital Statistics System. County‐level mortality file. http://www.cdc.gov/nchs/deaths.htm and http://wonder.cdc.gov/mortsql.html 

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  49

 

Community Health Assets  ______________   

Hospitals  

Sparrow Hospital.  Lansing, Michigan  General medical and surgical hospital  638 beds  32,611 admissions  506,602 outpatient visits  4,196 births  5,038 personnel 

Sparrow Specialty Hospital. Lansing, Michigan.    Acute long‐term care hospital   36 beds  325 admissions  106 personnel 

Sparrow Clinton Hospital.  St. Johns, Michigan  General medical and surgical hospital  Critical access hospital3  25 beds  822 admissions  53,171 outpatient visits  222 personnel 

McLaren Greater Lansing.  Lansing, Michigan   General medical and surgical hospital  318 beds  15,927 admissions  342,964 outpatient visits  1,269 births  1,723 personnel  

                                                  

3 Critical Access Hospitals are typically located in rural areas, at least 35 miles from the nearest hospital, and furnish 24-hour emergency care services 7 days a week. Critical Access Hospitals are limited to no more than 25 inpatient beds. Centers for Medicare & Medicaid Services (CMS). http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/CAHs.html

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50   Sparrow Specialty Hospital | February 2013 

 

Hayes Green Beach Memorial Hospital. Charlotte, Michigan  General medical and surgical hospital  Critical access hospital  25 beds  778 admissions  141,386 outpatient visits  365 personnel 

Eaton Rapids Medical Center. Eaton Rapids, Michigan  General medical and surgical hospital  Critical access hospital  20 beds  359 admission  14,727 outpatient visits  195 personnel 

 Source: American Hospital Association. 

  

Federally Qualified Health Clinics  

Ingham County Health Department, Willow Health Center  Ingham County Health Department, Otto Community Center  Ingham County Health Department, Cedar Community Health Center  Ingham County Health Department, St. Lawrence Community Health Center  Source: Michigan Primary Care Association   

Extended Care Facilities  

Clinton County  Two nursing homes, 251 total beds 

Two for profit facilities  Eaton County 

Three nursing homes, 431 total beds  One government medical care facility  Two for‐profit facilities 

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  51

 

Ingham County  Eight nursing homes, 1,054 total beds 

One government medical care facility  One nonprofit facility  Six for‐profit facilities  

Source: Michigan Department of Community Health     

Physicians and Nurses  

Table 2: Health Care Professionals in the Sparrow Health System Service Area, 2008

County

Total, Active, non-Federal

Medical Doctors'

Active Nurse Anesthetists

Active Nurse Practitioners

Active Certified

Nurse Midwives

Total Advanced Practice Nurses

Clinton County 41 3 26 1 30 Eaton County 65 7 28 0 35 Ingham County 836 9 97 10 116 Ionia County 21 6 10 4 20 Gratiot County 48 4 10 1 15 Shiawassee County 45 9 13 2 24 Area Total 1056 38 184 18 240 Source: U.S. Department of Health & Human Resources, Health Resources and Services Administration, Area Resource File, 2010.

   

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  53

 

Findings  ______________________________   

Socioeconomic Indicators  Vulnerable families and children are about as prevalent in the three‐county Sparrow Specialty Hospital service area (Clinton, Eaton, and Ingham counties) as they are throughout the entire six‐county Sparrow Health System service area and the State of Michigan.  One exception is that the percentage of children in poverty is slightly lower than the statewide average.  The Lansing service area and the six‐county service areas are considerably safer than indicated for the entire State of Michigan.  Although not illustrated here, poverty rates and associated factors are higher within the City of Lansing than elsewhere in this hospital’s primary service area.  Due to the presence of Michigan State University in the region, the Sparrow Lansing service area contains a more highly educated population than is either found in the surrounding area or for the entire state.  Indicator  Location Measure  Comparison

Children in poverty 

Michigan  19.0%   6‐County region  17.7%   

Lansing area  16.7%   

Single parent families 

Michigan  9.5%   6‐County region  9.4%   

Lansing Area  9.0%   

Housing costs more than 30% of household income 

Michigan  34.8%   6‐County region  33.7%   

Lansing Area  34.0%   

Violent crimes per 1,000 persons 

Michigan  489.9   6‐County region  270.6   

Lansing Area  313.2   

Adults with at least a Bachelor’s degree 

Michigan  25.0%   6‐County region  26.2%   

Lansing Area  31.2%    More favorable than the statewide average About average Less favorable than the statewide average

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54   Sparrow Specialty Hospital | February 2013 

 

Health Behaviors   Indicators of health behaviors in the Sparrow Specialty Hospital service area are mixed, with some indicators pointing to better than average health behaviors than elsewhere and some pointing to worse than average behaviors.  Smaller than average percentages of adults in the area are obese, but the percentage of obese adolescents in the region is higher than average.  These levels of excess weight also hold when the percentages of overweight but not obese adults and adolescents are figures in.  Similarly, smoking levels for adults are higher than average while the smoking indicator for adolescents is lower than average.  The percentage of adults who reported binge drinking  is about average; the percentage of teenagers who reported binge drinking  is lower than the state‐wide figures.  Indicator  Location Measure  Comparison

Adults who are obese 

Michigan  31.7%   6‐County Region   26.7%   

Lansing Area  23.8%   

Children who are obese 

Michigan  11.9%   6‐County Region   14.4%   

Lansing Area  13.6%   

Adults who smoke 

Michigan  18.9%   6‐County Region   21.6%   

Lansing Area  22.3%   

Students who smoked in the past 30 days 

Michigan  14.0%   6‐County Region   6.7%   

Lansing Area  6.1%   

Binge drinking among adults 

Michigan  19.7%   6‐County Region   17.8%   

Lansing Area  17.8%   

Binge drinking among high school students 

Michigan  23.2%   6‐County Region   12.8%   

Lansing Area  12.3%    More favorable than the statewide average About average Less favorable than the statewide average

 

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Sparrow Specialty Hospital | Public Policy Associates, Inc.  55

 

Access to Care  The ratios of primary care physicians to the population in both the entire Sparrow Health System service area and in the Sparrow Specialty service area are roughly comparable to the statewide ratio; access to primary care physicians in the Sparrow Specialty Hospital’s primary service area is a problem.  One of every four persons in the tri‐county area reports that they lack access to a primary care physician, and thus lack continuity of care and a gateway to other health care services that may be needed.  Residents of the Lansing area are also more likely to report that their health is poor or fair than are those outside the area.    Indicator  Location Measure  Comparison

Persons per primary care physician 

Michigan  1,034   6‐County Region  1,114   

Lansing Area  1,017   

Persons lacking access to a primary care physician 

Michigan  12.5%   6‐County Region  NA   Lansing Area  25.4%   

Medicaid enrollment 

Michigan  12.3%   6‐County Region  10.6%   

Lansing Area  10.2%   

Adults reporting poor or fair health 

Michigan  14.2%   6‐County Region  15.5%   

Lansing Area  16.2%   

Adults reporting poor mental health 

Michigan  10.7%   

6‐County Region  11.9%   

Lansing Area  11.8%    More favorable than the statewide average About average Less favorable than the statewide average

 

   

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56   Sparrow Specialty Hospital | February 2013 

 

Children’s Health  Although focus group participants and community residents interviewed throughout the Lansing area reported on the difficulties some parents have had in accessing pediatric sub‐specialty physician services for their children, early childhood indicators are  generally more favorable in the Lansing area when compared with the rest of Michigan.  Infant mortality rates are lower in the Lansing area and the incidence of low‐weight births is also lower in the Lansing area than elsewhere.  Indicator  Location Measure  Comparison

Infant deaths per 1,000 live births 

Michigan  7.5   6‐County Region   5.9   

Lansing Area  6.1   

Low birth weight babies per 1,000 live births  

Michigan  82.8   6‐County Region   75.3   

Lansing Area  77.2    More favorable than the statewide average About average Less favorable than the statewide average

 

   

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Community Health Issues _______________   Based on the findings from examination of health indicators for the Sparrow Specialty Hospital service area and comments provided by interviewees and focus group participants, the highest priority health issues for  the Sparrow Specialty Hospital area are as follows.  

Obesity:  While Sparrow Specialty Hospital is licensed as a long‐term acute care hospital, assessment informants nonetheless identified overweight and obese adults and young people as the leading health issue within the Sparrow Specialty Hospital service area.  The percentages of both adults and youth in this region that are overweight or obese are high, and the percentage for children in this area who are overweight or obese are above average.  The impact of excess weight for diabetes and other chronic diseases is a major concern and is reflected in interest in promoting more healthy lifestyles, including healthy eating habits, the need for more physical exercise, and preventive health activities in general.   

Pediatric Sub‐Specialty Physician Care.  Access to pediatric sub‐specialty physicians in the Greater Lansing area has been a community concern for at least a decade.  Sparrow Specialty Hospital does not provide any obstetrical or pediatric services, and relatively healthy birth outcomes characterize the Sparrow Specialty Hospital service area (e.g., lower than average infant mortality and low birth‐weight babies).  However, it is widely recognized that the families of babies and children in need of pediatric sub‐specialty consultations and services cannot always get to see a local sub‐specialist physician or they may have excessive waits to get an appointment.  In some cases, no sub‐specialist for their particular issue practices in this area.  As a result, families are frequently referred to physicians in Ann Arbor or Grand Rapids where greater numbers of pediatric sub‐specialists practice.  Study interviewees also report that low income families enrolled in Medicaid may have some difficulty getting to see local pediatric sub‐specialists in a timely manner due, possibly, to low Medicaid reimbursement rates.  Another concern is the aging of this area’s sub‐specialists and the lack of younger physicians in the area to take their place upon retirement.   

Access to Primary Care Services:  Numerous references were made by community and health care leaders to the valuable primary care services provided through the Ingham Health Plan and the CareFree Clinic.  Nonetheless, the current need for 

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more primary care services in the Greater Lansing area now and in the future was a common concern of those individuals who participated in this assessment.  Low‐income working people with insurance report they cannot always get to a physician when they need to.  Community leaders and community residents are also aware of the frequent use of hospital emergency services for the insured, the uninsured, and the homeless, even for minor issues that might more appropriately be addressed at a physician office, walk‐in clinic, or urgent care setting.  One interviewee noted that this problem is at least partly attributable to a lack of information about where non‐emergent care services may be obtained within the Greater Lansing area.  Lack of health care insurance and inadequate health care insurance are also problems, especially among low‐wage workers, but there is an expectation that further implementation the Affordable Care Act will resolve most of those issues.  

Mental Health Services.  Despite the presence of some short‐term psychiatric beds in Lansing area hospitals and an extensive community mental health system, access to mental health services is an important concern among community residents who participated in this assessment.  Some observers indicated that these resources are not adequate in terms of either facilities or practitioners to meet the area’s need for drug addiction treatment, post‐discharge psychiatric treatment, and the mental health needs of the area’s older residents.  The latter is a direct reference to the area’s aging population and the projected increase in Alzheimer’s disease and dementia within that segment of the population.  Older Hispanic residents were singled out as suffering from depression as a result of isolation and language barriers, and needing mental health services provided in Spanish.  University students, especially international students, need services dealing with stress and the related problem of sleep disorders.  Non‐European immigrants to the area also often need mental health services that take into account their cultural backgrounds and are sensitive to the adjustment difficulties that some immigrants experience.  

Diabetes Education and Services:  As an outgrowth of the large number of overweight and obese adults and children in the Sparrow Specialty Hospital service area, special attention was placed on providing diabetics with as much information and support to control this disease and to slow or prevent the onset of the complications and life‐shortening consequences of diabetes.  Participants pointed out that diabetes and hypertension are particular concerns within the area’s African American community.  Diabetes is a growing concern within the area’s East Indian community as well.  East Indian and Muslim community participants noted the need for greater knowledge of Asian foods and eating habits to more effectively assist diabetics from those cultures with adjusting their diets.   

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  Chronic Diseases:  Although statistical information provided through the Healthy! Capital Counties Collaborative indicate lower than average premature deaths, below average deaths from cardiovascular disease, and below average rates of unnecessary hospitalization for diabetes, interviews and focus group participants nonetheless indicated great need for more patient education about chronic diseases as well as screenings and preventive services in the Sparrow Specialty Hospital service area.  The long‐term consequences of chronic disease, such as the growing need for dialysis services, are also a serious concern among community and health care leaders.  Hypertension and diabetes are particular concerns within the area’s African American community.    

Ninety‐five percent of community and health leaders interviewed noted that disease screenings are available in the Sparrow Specialty Hospital service area, but only two‐thirds of those observers thought that these services were sufficiently adequate to address all of these needs.  One particular concern regarding chronic diseases is the need for greater attention to post‐discharge patient follow up, both in terms of medical follow up as well as assistance for the daily living needs of discharged patients—needs such as shopping, cooking, transportation, and maintaining a residence, all of which may have an important impact on healing.   

   

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Appendix A: Methods __________________   In order to meet the needs of the community served by this hospital and to meet the requirements that are required by law, Sparrow Health System engaged in a two‐phase CHNA process beginning in 2011 and continuing through 2012.  This process consisted of (1) participating as a supporting partner of the Healthy! Capital Counties’ (H!CC) region‐wide community health needs assessment, and (2) by supplementing the H!CC community health needs assessment and prioritization efforts with additional data collection, analysis, and identification of critical health care needs in the areas served by each of Sparrow Health System’s hospital.  Healthy! Capital Counties.  H!CC is a collaborative effort of four acute care community hospital organizations  and three area health departments that serve the Greater Lansing Area, as defined by Clinton, Eaton, and Ingham counties, Michigan.  The four hospital organizations are:  

Sparrow Health System, consisting of four community hospitals, three of which are located in the three‐county Greater Lansing region: 

Sparrow Hospital, Lansing, Michigan  Sparrow Specialty Hospital, Lansing, Michigan  Sparrow Clinton Hospital, St. Johns, Michigan  Sparrow Ionia Hospital, Ionia, Michigan 

McLaren Greater Lansing  Hayes Green Beach Memorial Hospital  Eaton Rapids Medical Center  

The three health departments collaborating in this effort are:  

Ingham County Health Department, serving Ingham County, Michigan  Barry‐Eaton District Health Department, serving Eaton County, Michigan  Mid‐Michigan District Health Department, serving Clinton County, Michigan  

Additional support was provided by Physician’s Health Plan of Mid‐Michigan, McLaren Health Plan, Ingham Health Plan Corporation, and the National Association of County and City Health Officials.  

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As a partner of the Healthy! Capital Counties collaborative, Sparrow Health System participated as a member of the Steering Team that was directly responsible for oversight of the CHNA conducted within the three‐county region as well as for community dialogues conducted by H!CC to identify the greatest health care needs in the region, prioritize these needs, and incorporate them into a Community Health Improvement Plan (CHIP).  Under the direct supervision of the health officers within each of the three community health departments, the H!CC CHNA was compiled from publicly‐available data resources obtained from the U.S. Bureau of the Census (American Community Survey), Michigan Department of Community Health (vital records and registries), Michigan State  Police (crime statistics), Centers for Disease Control and Prevention (Behavioral Risk Factor Surveillance Survey), and the Michigan Department of Education (Michigan Profile for Healthy Youth), among others.  These data were supplemented by nine focus groups conducted with Lansing area residents (including one conducted in Spanish) who may be considered medically underserved or, at minimum, may have greater than average health care needs.  These individuals consisted of adults without health insurance, those enrolled in Medicaid, unemployed residents, handicapped residents, and low‐wage workers.  Data collected through these efforts were compiled in a region‐wide report that was used as the basis for a series of public community dialogues in which the findings were discussed and participants were asked to assist the professional staff in identifying the area’s most important health care needs.  These needs were prioritized at a subsequent community meeting.  The collaborative’s region‐wide health improvement plan will be based on these determinations and the interests of each partner—hospitals, health departments, and others, alike—to work towards ameliorating the high priority issues.  Sparrow Health System.  As Sparrow Health System serves all or parts of six counties, including the three‐county Greater Lansing Area, it was determined by its Executive Leadership that their participation in the Healthy! Capital Counties collaborative would need to be supplemented with additional data collection efforts in order to include these additional areas—such as the community served by Sparrow Ionia Hospital—in their assessment, and because there were some additional service area populations and issues which were not addressed in the H!CC assessment process.  In response to this need for additional information, Sparrow Health System hired Public Policy Associates, Inc., to work with the H!CC team on their foundational community health needs assessment and to collect additional data to meet the health system’s additional information needs. 

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 Through these efforts, the following tasks were accomplished.  1. Professional Community Health Expertise.  By participating collaboratively with H!CC, 

the foundation for the Sparrow Health System Community Health Needs Assessments was based on the professional expertise and direction of the Health Officers and technical staff of each of the participating health departments: 

Renee Branch Canady, Ph.D., Health Officer, Ingham County Health Department, Lansing, Michigan 

Colette Scrimger, Health Officer, Barry‐Eaton District Health Department, Hastings, Michigan 

Marcus Cheatham, Health Officer, Mid‐Michigan District Health Department, Stanton, Michigan 

Lisa McCafferty, the Health Officer for the Ionia County Health Department has also been consulted for this assessment.  

2. Quantitative Data Collection.  Much of the information contained in this report are drawn from the same resources found in the H!CC CHNA report, and these data were supplied by the Ingham County Health Department to Sparrow Health System through Sparrow’s participation in this collaborative.  In a few cases, data were updated to reflect the availability of more recent data.  In addition, Sparrow Health System’s consultants compiled some additional data elements for this assessment.  Additional data elements include the following:  

Single parent households.  Bureau of the Census, American Community Survey, 2006‐2010; 

Medicaid Enrollment.  Michigan Department of Community Health, 2012;  Health Insurance Coverage (Population without Health Insurance).  Bureau of the Census, American Community Survey, 20106‐2010. 

Low Birth Weight Babies.  Michigan Department of Community Health, 2000‐2010. 

 3. Qualitative Data Collection.  In order to reach a broad cross‐section of the hospitals’ 

service areas and in order to investigate the heath care needs and concerns of identifiable sub‐groups within the region’s population, Sparrow Health System sponsored more than 30 one‐on‐one interviews and six focus groups as part of this assessment.  Interviews and focus groups were conducted between June 2012 and November 2012. 

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Interviewees and focus group participants were mainly health care consumers who have health care insurance and who serve in their respective communities as health care leaders, elected officials, health care providers, social service workers, educators, retirees, and others, as noted below.  All interviews were conducted by Public Policy Associates, Inc. staff.   Approximately twenty‐five percent of all participants who participated in these data collection efforts are members of racial or ethnic minority groups.  Racial, ethnic, and religious minority interests represented include the following:  

Muslim Community focus group  African American focus group  Medical director of an Hispanic Community organization  Representatives of the East Indian Community  International students from China, Taiwan, and Egypt 

  Other community participants include the following: 

Community health leaders, including health care administrators and hospital board members 

Health care providers, including physicians, other service providers, and long‐term care providers 

Educators, including one health care educator  Social service providers  Refugee service providers  State and local elected officials  Students   Retirees 

 All interviewees and focus group participants were explicitly asked to identify the most pressing community health needs as well as their suggestions for addressing these issues through the efforts of Sparrow Health System and/or through the efforts of Sparrow Health System in cooperation with other community partners.  Identification of the most frequently mentioned community health needs for each hospital’s service area were combined with the findings illustrated through analysis of community health indicators to compile the findings in this report.  Suggestions for addressing these needs and concerns are based on the information provided by interviewees and focus group participants and the health care concerns and issues identified through H!CC community dialogues.   

 

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4. Follow Up/Community Health Priorities.  A key follow‐up effort has been to identify how the high priority community health needs that have been identified independently through each process relate to each other, and how they collectively represent the basis upon which the most important health needs in the Sparrow Health System service area and the H!CC three‐county region will be addressed.  At the time this report was completed, an illustration of the commonalities between the two sets of priorities  was prepared and circulated to all of the hospitals and health departments participating in this collaborative effort for their planning activities. 

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Appendix B: Interview and Focus Group Participants ____________________________   As a supplement to the Healthy! Capital Counties (H!CC)Community Health Needs Assessment (CHNA), interviewees and focus group participants were solicited from a wide variety of community residents within the principal areas served by Sparrow Health System hospitals.  Among those solicited were community leaders and health care leaders;  state and local elected officials; physicians and other health care providers or workers; leaders and members of racial, ethnic, and religious minorities; educators; students; retirees; social service providers; and others.  Among minority groups with whom these issues were discussed include African Americans, members of the Muslim community from several different ethnic backgrounds, international students, and members of the East Indian community.  Health care issues within the Hispanic community were addressed by a physician that serves the Hispanic community. International students were from China and the Middle East.  The occupations or special expertise of these participants not only include expected participants such as city managers, health care administrators, and social service providers, but they also include a fitness coach, two dentists, a farmer, a former drug addict, a firefighter, a high school principal, a veterinarian, and a librarian.  Almost 70 individuals participated either as interviewees or focus group participants for this project.  The categories in which these individuals are classified are found in Table B‐1, below.  Note that some individuals are classified in more than one category.  

Table B-1: Interviewees and Focus Group Members, 2012 Category Number Community Leader 15 Educator 6 Government Official 8 Health Care Administrator 7 Health Care Consumer (not otherwise categorized) 6 Health Care Provider/Health Care Worker 10 Hospital Board Member 11 Long-Term Care Provider 4 Minority Community Leader 5 Minority Community Member 15 Physician 4

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B‐2   Sparrow Specialty Hospital | February 2013 

 

Table B-1: Interviewees and Focus Group Members, 2012 Category Number Refugee Services 2 Religious Leader 1 Religious Minority Member 8 Retiree 4 Social Services Provider 9 Student 3 Total* 118 * Some individuals are in more than one category.