GRAND RAPIDS HEALTH CARE ACCESS PROGRAM (GRHCAP) Clinic Access and Utilization in Kent County, Michigan Fred J. De Jong, MAPA, MSW, Ph.D., ACSW, Professor of Research and Statistics, Calvin College, Federal Evaluator, GRHCAP Lauren B. Vander Plas, BSW Program, Calvin College, Mapping Specialist, GRHCAP September 5, 2007 For inquiries, contact Dr. F. De Jong, fdejong@calvin.edu * ACKNOWLEDGEMENTS This mapping project owes its success to many instrumental people involved in its conception and production. We would like to especially thank Dr. Neil Carlson, Center for Social Research, Calvin College, for his invaluable technical assistance role with software access and training, research design, data management, and map production. Mr. Rich Zandstra played an important and necessary role as consortium liaison. We thank Rich for persistently gathering the data from Consortium member organizations, as well as your presence and insight throughout the project. We acknowledge Mr. Jim Smedes, Kent County Health Department, as author of the original Kent County mapping report and for his insights in the research design and technical aspect of map creation. This project was under the leadership of Cherry Street Health Services. We want to thank Executive Director Chris Shea and Director of Operations Kathy Sather for their leadership as well as their oversight and understanding throughout the duration of this project. 1 TABLE OF CONTENTS Acknowledgements………………………………………………....………………page 1 Map Index……………….…………………………………………. ………………page 3 GRHCAP Mapping Project ……………………………………………………… page 4 Introduction and Background Methodology List of Organization Participants Measures Clinic Utilization and Catchment Area……………………………………………page 8 Clinic Utilization by Sub-Populations……………………………………………. page 12 Low-Income Population African American Population Hispanic Population Aged (65 and older) Population Diagnoses Served by Clinics.....................................................................................page 26 Distance to Closest Clinic versus Patient Preferred Clinic in Kent County……page 32 Appendices…………………………………………………………………………. page 36 Appendix A: Mapping Data Distribution Guidelines Appendix B: GRHCAP Clinic Mapping Project Data Collection Guide Appendix C: Excerpt from “Target Areas, Low-Income Analysis, Population Change and Medical Shortage Area”, Clinic Mapping Project Report,, Task Force on Health Care for People of Color, Kent County Health Department, November 2005 2 MAPS INDEX Kent County Clinics’ Location, 2005………………………………………………. page 7 Clinic Utilization in Kent County, 2005……………………………………………. page 10 Clinic Catchment Areas, 2005……………………………………………………… page 11 Kent County Population with Household Income of $20,000 or less……………….page 14 Low-Income Patient Utilization of Kent County Clinics, 2005……………………..page 15 Kent County African American Population…………………………………………page 18 African American Patient Utilization of Kent County Clinics, 2005………………. page 19 Kent County Hispanic Population………………………………………………….. page 20 Hispanic Patient Utilization of Kent County Clinics, 2005………………………… page 21 Kent County Aged Population……………………………………………………… page 24 Aged Patient Utilization of Kent County Clinics, 2005……………………………. page 25 Kent County Clinic Utilization by Patients with Asthma, 2005……………………. page 28 Kent County Clinic Utilization by Patients with Depression, 2005…………………page 29 Kent County Clinic Utilization by Patients with Diabetes, 2005……………………page 30 Kent County Clinic Utilization by Patients with Hypertension, 2005……………… page 31 Average Distance Traveled to Clinic, 2005………………………………………… page 34 Additional Distance Traveled to Patient Preferred Clinic: Kent County, 2005…….. page 35 3 Clinic Access and Utilization in Kent County, Michigan GRHCAP Mapping Project Introduction and Background The Clinic Access and Utilization Mapping Project is a product of long term collaboration beginning in 2002 between major stakeholders in the Grand Rapids, Michigan, health care delivery system. The Consortium’s goals address unmet needs of the underserved population for health related needs. The consortium also advocates for and supported the formation of a county health coverage plan (Kent Health Plan), an access project focusing primarily on residents of the designated Medically Underserved Population (Project Access), the creation of a standing county Task Force on Health Care for People of Color as well as multi-agency/manufacturer initiative to improve access to affordable and free pharmaceuticals. A federal award in 2005 from the Health and Rehabilitation Service Administration (HHS) for a Healthy Community Access Program provided resources and staff for multiple initiatives over a three year period, one of which is the Mapping Project. This second mapping report updates much of the first set of maps with more recent patient utilization data, an current list of participating clinics, the addition of 4 targeted diagnoses first identified in the GRHCAP proposal, a count of patient visits by selected diagnoses and an analysis of distance traveled to patients’ clinic of choice. Methodology In the summer of 2007, researchers associated with Calvin College received patient level data from Metropolitan Hospital, Saint Mary’s HealthLink health centers, Spectrum Health and Cherry Street Health Services for each of their participating clinics. Twenty-two clinics participated in the study. Only one clinic (Sparta) is located outside of the Grand Rapids City limits. See Map of Kent County Clinic locations on page 8. The data request process entailed requests to each health system to contribute 11 variables regarding all clinic patients in 2005. These data included patient id number, address, age, date of birth, race, payer type, visit count, and number of visits for asthma, depression, diabetes, and hypertension. Originally the data were not contributed in a uniform format by which we could join the datasets. Several decision rules provide guidance when merging health system data sets. • First, data which included duplicate patient IDs numbers were eliminated. • Some duplicates clients between multiple clinics are unavoidable. Each organization uses their own id numbers. If a patient saw two clinics from two different organizations, the patient would be duplicated within the dataset, creating some table percentages in this report to exceed 100%. • If a person went to two different clinics within the same system, we recorded the clinic included in the patient’s last duplicate record within the dataset. 4 • If the patient had two different payer types within the same record or within duplicate records, priority was given to commerical, then non-commerical, followed by Medicare. Clinic patient addresses were than geocoded upon the merging of the contributed data sets from the GRHCAP. Gecoding is a process by which address level data is assigned coordinates by which to map the data. REGIS, the regional geographic information systems most updated street level data, was used to match addresses to geographic coordinates, which was supplemented by a similar process using Tele Atlas, a software service from a commercial geocoding company. The original data set consisted of 64,657 clients. However some of these addresses were missing information and unable to geocode. Of those with proper addresses (N=63850), the match rate for geocoding was 98%, an excellent result, producing a sample size for mapping of 62570. A large number of these addresses were excluded due to being located outside of Kent County, reducing the sample size for the project is 57,255. After patient addresses were geocoded to include coordinates, these data was then used to place addresses into census block groups. Census block groups are a geographic system used by the United State Census Bureua, which they define as “A subdivision of a census tract (or, prior to 2000, a block numbering area), a block group is the smallest geographic unit for which the Census Bureau tabulates sample data. A block group consists of all the blocks within a census tract with the same beginning number.” No unit of data collection below Census block groups were used in order to protect patient privacy. Data from Geolytics Census Projections 2007 was used for comparing patient data to population data. Our analysis uses percent of total population for a given research question to display clinic utilization. We chose this metric instead of absolute numbers to show a greater sense of the impact clinics’ are having on the particular sub-populations living in particular areas. Also general maps are used to give background to high concentration area in which to guide the readers interpretation of the clinic utilization maps. 5 List of Organizational Participants Metropolitation Hospital • Breton Health Center Cherry Street Health Services: • Belknap Commons Health Center • Burton Health Center • Cherry Street Medical • Cherry Street Optical • Creston Health Center • Ferguson Adult Health Center • Grand Rapids Pediatrics • Ottawa Hills Health Center • The Salvation Army Booth Family Services • Westside Health Center • Union High School Health Center • Traveling School Medical Program Saint Mary’s Healthlinks Health Centers • Heartside Health Center • McAuley Health Center • Browning Claytor Health Center • Catherine’s Care Center • Clinica Santa Maria • Sparta Health Center • Wege Family Practice • Wege Internal Medicine Spectrum Health • Residency Practice • Internal Medicine • OB/Gyn 6 Kent County Clinics' Location, 2005 Sparta North Kent County Mark Division 13 Mile Greater Grand Rapids Ann Knapp Pla inf ie ld Creston Catherines Care Center Leonard Maryland Union HS Coi t e M on ro City of Grand Rapids 296 Leonard Pine Covell W alk er 3 Mile 2 Miles Alpine Richmond 96 Fuller 1 Turner 0.5 side Hill Alpine State 12 Mile Bristol Walker 0 Riv er Sparta Health Fuller Orchard 3 Mile Leffingwell Gardner Dean Lake 13 Mile Westside Bu tte rw or th O Brien Clinica Santa Maria 131 o Colrain Alger Ne lso n 32nd 0 36th 0.45 0.9 Elmwood Breton Oke mo s Kalamazoo Byron Center Metro Spectrum Ottawa Hills Plymouth Prairie Clyde Park CSHS Burton Eastern Organizations Burton Burlingame Porter Burton Adams Boston Madison Lee Browning Claytor Breton Wyoming ag Chi c East Grand Rapids Hall Division Gr an d vil le Freeman Franklin Robinson Lak e Fuller Fr on t Ionia College Belknap Commons 196 Spectrum Residency Bridge GR Peds Michigan & InternalMed OB/GYN Lake Michigan Pearl Fulton Ferguson McAuley Salvation Army Cherry St Heartside Wealthy Wege 1.8 32nd Kentwood 2.7 Miles StMarys Medical Shortage Area Data Source: GRHCAP Clinic Utilzation Data 2005 & Geolytics Population Projections 2007 DeJong & VanderPlas, Calvin College, 2007 7 Mapping Section #1: Clinic Utilization and Catchment Area The high level of utilization of the clinics indicates excellent access for the general population to the clinics. The total number of patients within the mapping dataset is 57,255, which is 9.5% of the projected 604,370 population of Kent County for 2005. The first map in this section, Clinic Utilization in Kent County, shows the proportion of patients from a particular block group with the total population of the block group. These percentages range from .5% to 50% of block group total population. Although a small proportion of patients will be double counted if they use more than one clinic, the total number served is very near to the total low-income population in Kent County. Table 1 shows the numbers of Kent County patients for each clinic. Among the 22 reporting clinics, Cherry Street Health Clinic and Wege Family Practice report the highest utilization at over 7,000 patients each in 2005. Clinic Catchment Area The map entitled, Clinic Catchment Area illustrates the area from which each clinic draws 60% of its patients, which is the same proportion used in the original mapping study. The larger the shaded area the greater the dispersion of a clinic’s patients. The catchment area was found by using ArcGIS select by location method in which locations are selected from a particular range, the range continued to increase until it met the threshold of 60%. 8 Table 1: Kent County Patients by Clinic, 2005 Clinics Cherry Street Health Services Belknap Commons HC Total Patients 24340 1026 Burton HC 1039 Cherry St HC 7304 Creston HC 240 Ferguson Adult HC 1463 Grand Rapids Pediatrics 4397 Ottawa Hills HC 285 Salvation Army 628 School Medical Program 1524 Union High School HC 747 Westside HC 5687 Saint Mary’s HealthLinks 22578 Browning Claytor HC 1853 Catherine's Care Center 1867 Clinica Santa Maria 4237 Heartside HC 1077 McAuley HC 451 Sparta HC 2392 Wege Family Practice 7094 Wege Internal Medicine 3607 Spectrum Health 5181 Internal Medicine 1947 Residency Practice 619 OB/GYN 2615 Metropolitan 5156 Breton HC 5156 Grand Total 57255 9 Kent County Clinic Utilization in Kent County, 2005 Patients Per Total Population Percent 0.5% - 2.5% 2.6% - 5% 5.1% - 7.5% 7.6% - 10% 10.1% - 15% 15.1% - 20% 20.1% - 25% 25.1% - 51% Clinics Medical Shortage Area City of Grand Rapids 0 2 4 0 0.5 1 8 Miles 12 Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 10 Catchment Area By Clinic Cherry Street Creston Ferguson Salvation Army Ottawa Westside Union Burton Breton Clinica Santa Maria Wege Family Practice Saint Mary's Spectrum Catchment Cherry St Catchment Metro City of Grand Rapids Clinic Grand Rapids Pediatrics Belknap Catherine's Care Center Heartside Sparta Browning Claytor Wege Internal Medicine Spectrum Internal Med Spectrum OB/GYN McAuley Spectrum Residency Data Source: GRHCAP Clinic Utilzation Data 2005 & Geolytics Population Projections 2007 DeJong & VanderPlas, Calvin College, 2007 11 Mapping Section #2: Clinic Utilization by Sub-Populations Clinic Utilization by Low-Income Population Kent County’s clinics largely serve patients with household incomes at or below the poverty threshold. The 22 clinics differ in the manner of accounting for household income among patients. Consequently, the only way to report patient income status across all clinics is to use a broad category of payer type called “non-commercial”. Non-commercial payer types include self-pay, charity care, Kent Health Plan and Medicaid, which in the clinic context constitutes lowincome clinic patients. Table 2 shows the number of patients utilizing the various payer types. The majority of patients (57%) use non-commercial payer types. Graph 1 also shows the breakdown of low-income utilization at the various clinic systems. For purposes of mapping, a patient may only have one payer source. The decision rule is that those patients seen at multiple clinics within an organization or those using multiple types of pay, commercial insurance was given priority followed by non-commercial and ending with those paying with Medicare. Census counts of those with commercial insurance, Medicaid, and other payer types are not readily available to the public. Therefore the mapping project used the Census population’s projections data available, using household income to define low-income population. A household income of $20,000 or less was used the measure of low-income: a number just lower than the $20,650 poverty line for a family of four (U.S. Department of Health & Human Services, 2007). The map entitled Kent County Population with household income of $20,000 or less gives a background understanding to where high and low percentages of the low-income population reside within Kent County. The map of Low Income Utilization of Kent County then shows the proportion of low-income clinic patients to the low-income population. Graph 1: Low Income Clinic Utilization by System, 2005 Low Income Clinic Utilization By System, 2005 N=32,428 Cherry Street Health Services 33% Metropolitan Hospital 50% Spectrum Health Saint Mary's HealthLink 11% 6% 12 Table 2: Low-income Patient Clinic Utilization: Primary Payer Type by Clinic, 2005 Clinics Cherry Street Health Services Belknap Commons HC % of Clinic Total Noncommercial** 6721 27.61% 196 19.10% Commercial % of Clinic Total Grand Total 1285 5.28% 24340 121 11.79% 1026 % of Clinic Total Medicare 16320 67.05% 709 69.10% Burton HC 272 26.18% 764 73.53% 3 0.29% 1039 Cherry St HC 1410 19.30% 5497 75.26% 394 5.39% 7304 Creston HC 61 25.42% 179 74.58% 0 0.00% 240 Ferguson Adult HC 312 21.33% 819 55.98% 331 22.62% 1463 Grand Rapids Pediatrics 2521 57.33% 1869 42.51% 3 0.07% 4397 285 Ottawa Hills HC 99 34.74% 186 65.26% 0 0.00% Salvation Army 48 7.64% 577 91.88% 3 0.48% 628 School Medical Program 189 12.40% 1332 87.40% 2 0.13% 1524 Union High School HC 217 29.05% 527 70.55% 3 0.40% 747 Westside HC 1396 24.55% 3861 67.89% 425 7.47% 5687 2910 56.44% 1824 35.38% 422 8.18% 5156 2910 56.44% 1824 35.38% 422 8.18% 5156 862 16.64% 3486 67.28% 833 16.08% 5181 Internal Medicine 115 5.91% 1260 64.71% 572 29.38% 1947 Residency Practice 378 61.07% 82 13.25% 159 25.69% 619 OB/GYN 369 14.11% 2144 81.99% 102 3.90% 2615 Metropolitan Hospital Breton HC SpectrumHealth Saint Mary’s HealthLink 10399 46.06% 10798 47.83% 516 2.29% 22578 Browning Claytor HC 503 27.15% 1147 61.90% 45 2.43% 1853 Catherine's Care Center 1614 86.45% 204 10.93% 29 1.55% 1867 Clinica Santa Maria 547 12.91% 3604 85.06% 21 0.50% 4237 Heartside HC 17 1.58% 909 84.40% 34 3.16% 1077 McAuley HC 201 44.57% 233 51.66% 9 2.00% 451 Sparta HC 1059 44.27% 1074 44.90% 40 1.67% 2392 7094 Wege Family Practice 3969 55.95% 2771 39.06% 160 2.26% Wege Internal Medicine 2489 69.00% 856 23.73% 178 4.93% 3607 20892 36.49% 32428 56.64% 3056 5.34% 57255 Grand Total **Non-commercial includes Medicaid, Charity Care, Self-Pay or Kent County Health Plan 13 Kent County Population with Household Income of $20,000 or less Kent County Low-Income Population Per Total Population Percent 0% - 1% 1.01% - 2% 2.01% - 4% 4.01% - 8% 8.01% - 10% 10.01% - 15% 15.01% - 20% 20.01% - 41% Clinics Medical Shortage Area 0 2 4 0 0.5 1 8 Miles 12 City of Grand Rapids Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 14 Low Income Patient Utilization of Kent County Clinics, 2005 Kent County Low-Income Patients Per Low-Income Population PercentofPoorPatsofPop 3.33% - 15% 15.01% - 30% 30.01% - 45% 45.01% - 60% 60.01% - 75% 75.01% - 90% 90.01% - 150% 150.01% - 764.71% Clinics Medical Shortage Area City of Grand Rapids 0 2 4 0 0.5 1 8 Miles 12 Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 15 Clinic Utilization by African American and Hispanic Populations The Mapping Project’s initial impetus from the Task Force for Health Care for People of Color focused on the unmet health-related needs of underserved populations. The original mapping project emphasized the access and utilization rates to health clinics of Kent County’s African American and Hispanic residents, since these two groups constitute the largest, minority groups in the county and disproportionately present the underserved and uninsured population. Race was coded into seven groups: non-Hispanic white, African American or Black, Hispanic, American Indian or Alaskan Native, Asian Native Hawaiian, or Other. The mapping project only used those who self-identified as African American/Black or Hispanic. Geolytics Census data also provided projected numbers of African American and Hispanics living in each block group. As seen in Table 3, of the patients seen at all clinics 36% are African American and 57% are Hispanic patients. In comparing the patients to the general population, the African American patients(N=14,019) make up 25% of the projected 57,689 Kent County African American population. Similarly, the Hispanic patients (N=15,276) make up 27% of the 57,643 projected Hispanic population for Kent County. Again, the maps showing the Kent County African American and Hispanic Populations give background to the maps of clinic utilization by these different groups. Graph 2-3: Clinic Utilization by African Americans and Hispanics by System, 2005 African American Clinic Utilization by System, 2005 Hispanic Clinic Utilization by System, 2005 N=14,019 N=15,276 Cherry Street Health Services 25% 13% 12% 50% Metropolitan Hospital 38% 53% Spectrum Health Cherry Street Health Services Metropolitan Hospital Spectrum Health Saint Mary's HealthLink 6% 16 3% Table 3: Client Race by Clinic, 2005 Clinics 6965 % of Clinic Total 28.62% 8010 % of Clinic Total 32.91% 7533 % of Clinic Total 30.95% 1832 % of Clinic Total 7.53% Belknap Commons HC 346 33.72% 97 9.45% 502 48.93% 81 7.89% Burton HC 102 9.82% 847 81.52% 72 6.93% 18 1.73% 1039 2426 33.21% 2858 39.13% 1351 18.50% 669 9.16% 7304 Cherry Street Health Services Cherry St HC African American Hispanic White Other Total Count 1026 24340 Creston HC 112 46.67% 7 2.92% 41 17.08% 80 33.33% 240 Ferguson Adult HC 643 43.95% 163 11.14% 576 39.37% 81 5.54% 1463 4397 Grand Rapids Pediatrics 992 22.56% 670 15.24% 2535 57.65% 200 4.55% Ottawa Hills HC 221 77.54% 20 7.02% 10 3.51% 34 11.93% 285 Salvation Army 252 40.13% 65 10.35% 194 30.89% 117 18.63% 628 1524 School Medical Program 624 40.94% 590 38.71% 219 14.37% 91 5.97% Union High School HC 159 21.29% 169 22.62% 369 49.40% 50 6.69% 747 1088 19.13% 2524 44.38% 1664 29.26% 411 7.23% 5687 Westside HC Metropolitan Hospital 1648 31.96% 464 9.00% 2376 46.08% 668 12.96% 5156 1648 31.96% 464 9.00% 2376 46.08% 668 12.96% 5156 1909 36.85% 931 17.97% 2200 42.46% 141 2.72% 5181 Internal Medicine 751 38.57% 204 10.48% 956 49.10% 36 1.85% 1947 Residency Practice 181 29.24% 95 15.35% 318 51.37% 25 4.04% 619 OB/GYN 977 37.36% 632 24.17% 926 35.41% 80 3.06% 2615 Breton HC Spectrum Health Saint Mary’s Healthlinks 3497 15.49% 5871 26.00% 7614 33.72% 5596 24.79% 22578 Browning Claytor HC 1090 58.82% 129 6.96% 307 16.57% 327 17.65% 1853 Catherine's Care Center 46 2.46% 39 2.09% 283 15.16% 1499 80.29% 1867 Clinica Santa Maria 26 0.61% 4059 95.80% 57 1.35% 95 2.24% 4237 1077 Heartside HC 473 43.92% 91 8.45% 475 44.10% 38 3.53% McAuley HC 112 24.83% 44 9.76% 238 52.77% 57 12.64% 451 11 0.46% 964 40.30% 1004 41.97% 413 17.27% 2392 1383 19.50% 432 6.09% 3632 51.20% 1647 23.22% 7094 356 9.87% 113 3.13% 1618 44.86% 1520 42.14% 3607 14019 24.49% 15276 26.68% 19723 34.45% 8237 14.39% 57255 Sparta HC Wege Family Practice Wege Internal Medicine Grand Total 17 Kent County African American Population Kent County African American Population Per Total Population Percent 0% 0.01% - 1% 1.01% - 2% 2.01% - 5% 5.01% - 7% 7.01% - 10% 10.01% - 25% 25.01% - 92.71% Clinics Medical Shortage Area 0 2 4 0 0.5 1 8 Miles 12 City of Grand Rapids Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 18 African American Patient Utilization of Kent County Clinics, 2005 Kent County African American Patients Per African American Population Percent 0% - 5% 5.01% - 10% 10.01% - 20% 20.01% - 30% 30.01% - 40% 40.01% - 50% 50.01% - 60% 60.01% - 800% Clinics Medical Shortage Area City of Grand Rapids 0 2 4 0 0.5 1 8 Miles 12 Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 19 Kent County Kent County Hispanic Population Hispanic Population Per Total Population 0.42% - 1% 1.01% - 3% 3.01% - 5% 5.01% - 10% 10.01% - 20% 20.01% - 30% 30.01% - 40% 40.01% - 96% Clinics Medical Shortage Area City of Grand Rapids 0 2 4 0 0.5 1 8 Miles 12 Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2006 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 20 Hispanic Patient Utilization of Kent County Clinics, 2005 Kent County Hispanic Patients Per Hispanic Population Percent 0% - 5% 5.1% - 10% 10.1% - 15% 15.1% - 20% 20.1% - 30% 30.1% - 40% 40.1% - 50% 50.1% - 177.6% Clinics Medical Shortage Area City of Grand Rapids 0 2 4 0 0.5 1 8 Miles 12 Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 21 Clinic Utilization by Aged Chronic health conditions and acute care episodes prompt many low income older persons to use Kent County’s clinics. Low income aged persons with modest fixed incomes can find themselves ineligible for Medicaid while they live in their own homes and experience outpatient expenses outside of Medicare’s coverage. Unaddressed health care needs can become disabling and lead to added pain, decreased function and eventually institutionalization. Mapping the aged for the first time in this project recognizes this important need and target population for clinic services. Each participating clinic contributed a data set including patient age. These ages were then put into 4 different categories: 0 to 15 years old, 16 to 44 years old, 45 to 64 years old, 65 and older. Table 4 shows patient age by clinic in 2005. Saint Mary’s and Cherry Street Health Services clinic systems provide care to the largest numbers of elderly. The map entitled Kent County Aged Population shows the percentage of those 65 years and old living in a particular area. Geolytics Census projection data provided the population of those 65 years and older in each block group. The map entitled Aged Patient Utilization of Kent County Clinics, 2005 shows the ratio of Aged Patients to the Aged Population of Kent County. 22 Table 4: Patient Age by Clinic, 2005 Clinics 9887 % of Clinic Total 40.62% 9444 % of Clinic Total 38.80% 3974 % of Clinic Total 16.33% 1035 % of Clinic Total 4.25% Belknap Commons HC 103 10.04% 491 47.86% 374 36.45% 58 5.65% 1026 Burton HC 680 65.45% 294 28.30% 57 5.49% 8 0.77% 1039 7304 Cherry Street Health Services Cherry St HC 0 to 14 15 to 44 45 to 64 65 and older Grand Total 24340 2186 29.93% 3122 42.74% 1615 22.11% 381 5.22% Creston HC 2 0.83% 237 98.75% 1 0.42% 0 0.00% 240 Ferguson Adult HC 0 0.00% 521 35.61% 713 48.74% 229 15.65% 1463 3592 81.69% 805 18.31% 0 0.00% 0 0.00% 4397 0 0.00% 282 98.95% 3 1.05% 0 0.00% 285 266 42.36% 362 57.64% 0 0.00% 0 0.00% 628 1338 87.80% 41 2.69% 134 8.79% 11 0.72% 1524 Grand Rapids Pediatrics Ottawa Hills HC Salvation Army School Medical Program 14 1.87% 551 73.76% 171 22.89% 11 1.47% 747 Westside HC Union High School HC 1706 30.00% 2738 48.14% 906 15.93% 337 5.93% 5687 Metropolitan Hospital 1114 21.61% 2173 42.15% 1258 24.40% 611 11.85% 5156 Breton HC 1114 21.61% 2173 42.15% 1258 24.40% 611 11.85% 5156 13 0.25% 3667 70.78% 1139 21.98% 362 6.99% 5181 1947 Spectrum Health Internal Medicine 0 0.00% 949 48.74% 762 39.14% 236 12.12% Residency Practice 1 0.16% 254 41.03% 245 39.58% 119 19.22% 619 12 0.46% 2464 94.23% 132 5.05% 7 0.27% 2615 4758 21.07% 8570 37.96% 6063 26.85% 3187 14.12% 22578 425 22.94% 852 45.98% 465 25.09% 111 5.99% 1853 1 0.05% 747 40.01% 800 42.85% 319 17.09% 1867 2077 49.02% 1608 37.95% 417 9.84% 135 3.19% 4237 OB/GYN Saint Mary's Healthlink Browning Claytor HC Catherine's Care Center Clinica Santa Maria Heartside HC 0 0.00% 500 46.43% 555 51.53% 22 2.04% 1077 McAuley HC 12 2.66% 254 56.32% 180 39.91% 5 1.11% 451 Sparta HC Wege Family Practice Wege Internal Medicine Grand Total 753 31.48% 957 40.01% 447 18.69% 235 9.82% 2392 1490 21.00% 2891 40.75% 1801 25.39% 912 12.86% 7094 0 0.00% 761 21.10% 1398 38.76% 1448 40.14% 3607 15772 27.55% 23854 41.66% 12434 21.72% 5195 9.07% 57255 23 Kent County Aged Population (65 years and older) Kent County Aged Population Per Total Population Percent 2.57% - 5% 5.01% - 7.5% 7.51% - 10% 10.01% - 12.5% 12.51% - 15% 15.01% - 18% 18.01% - 20% 20.01% - 40.12% Clinics Medical Shortage Area 0 2 4 0 0.5 1 8 Miles 12 City of Grand Rapids Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 24 Aged Patient Utilization of Kent County Clinics, 2005 Kent County Aged Patients Per Aged Population Percent 0% - 3% 3.01% - 5% 5.01% - 8% 8.01% - 12% 12.01% - 18% 18.01% - 25% 25.01% - 40% 40.01% - 60% Clinics Medical Shortage Area City of Grand Rapids 0 2 4 0 0.5 1 8 Miles 12 Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 25 Mapping Section #3 Diagnoses Served by Clinic, 2005 Part of the federal HRSA award to the GRHCAP concentrated evaluation on four diagnoses common for clinic visits: asthma, depression, diabetes, and hypertension. All four diagnoses have established regimens for care and treatment, posing clear quality benchmarks for clinic use. Mapping visits by diagnosis supplements this effort, demonstrating where patients with these diagnoses live and at which clinics they seek treatment. Providers were asked to give numbers of total visits per patient as well as numbers of four prominent diagnoses. However, some data sets were given with just the first four diagnoses of a visit. From this list we were then able to code for those which were of the diagnoses we requested and then use these numbers in order to calculate the total number of visits for each diagnoses by patient. Similar to low-income measures, census data on various diagnoses is not available to the public, therefore in our analysis we were unable to use a population comparison group for the ratio. We instead used the proportion of total visits for diagnoses by block group over the total number of visits for that block group, this ratio provides a picture of those places which are drawing large percentages of a particular diagnoses. Graph 4: Percent of Diagnoses Visits by System, 2005 Percent of Diagnoses Visits by System, 2006 Percent of Total Visits 14.00% 12.00% 10.00% 8.00% Asthma 6.00% Depression 4.00% Diabetes 2.00% Hypertension 0.00% Cherry Street Metropolitan Health Services Hospital Spectrum Health Saint Mary's HealthLink Graph 4 illustrates the broad distribution of clinic visits for these 4 diagnoses. The frequency of visits for each diagnoses is quite consistent across clinic systems. Hypertension and diabetes compete for the largest proportion of clinic visits, while asthma and depression alternate as third and fourth ranked in proportion of clinic visits. Table 4 gives the number of visits by clinic for each diagnosis, also the table gives the total visits for each of the clinics. Each of the maps shows the ratio patients with a particular diagnosis over totals patients. 26 Table 5: Patient Visits by Diagnosis by Clinic, 2005 Clinics Cherry Street Health Services Asthma Visits % of Clinic Total Depression Visits % of Clinic Total Diabetes Visits % of Clinic Total Hypertension Visits % of Clinic Total Total Clinic Visits 3356 3.84% 1965 2.25% 7934 9.08% 10094 11.55% 87381 Belknap Commons HC 67 2.50% 104 3.88% 343 12.79% 293 10.93% 2681 Burton HC 236 6.15% 100 2.61% 129 3.36% 43 1.12% 3837 Cherry St HC 849 3.02% 514 1.83% 3488 12.41% 4100 14.59% 28108 Creston HC 28 4.44% 41 6.50% 2 0.32% 0 0.00% 631 Ferguson Adult HC 450 5.25% 318 3.71% 2239 26.14% 3376 39.41% 8567 Grand Rapids Pediatrics 916 6.19% 15 0.10% 20 0.14% 35 0.24% 14793 Ottawa Hills HC 49 5.72% 17 1.99% 8 0.93% 5 0.58% 856 2605 Salvation Army 50 1.92% 30 1.15% 9 0.35% 23 0.88% School Medical Program 26 1.16% 0 0.00% 0 0.00% 2 0.09% 2241 Union High School HC 123 6.74% 31 1.70% 1 0.05% 1 0.05% 1826 Westside HC 562 2.65% 795 3.74% 1695 7.98% 2216 10.44% 21236 275 1.37% 166 0.83% 1701 8.48% 1468 7.32% 20065 Metropolitan Hospital Breton HC 275 1.37% 166 0.83% 1701 8.48% 1468 7.32% 20065 219 1.00% 420 1.92% 1131 5.18% 1292 5.92% 21836 Internal Medicine 155 2.01% 300 3.89% 925 12.00% 975 12.64% 7711 Residency Practice 24 1.06% 47 2.08% 144 6.37% 277 12.25% 2262 OB/GYN 40 0.34% 73 0.62% 62 0.52% 40 0.34% 11863 Saint Mary's Healthlinks 1049 1.49% 929 1.32% 7196 10.22% 5154 7.32% 70388 Browning Claytor HC 77 1.39% 71 1.28% 281 5.08% 447 8.08% 5530 Catherine's Care Center 0 0.00% 6 0.12% 2391 48.28% 104 2.10% 4952 Clinica Santa Maria 123 0.96% 39 0.30% 660 5.13% 342 2.66% 12864 Heartside HC 85 2.96% 57 1.98% 309 10.76% 352 12.26% 2872 McAuley HC 0 0.00% 0 0.00% 0 0.00% 0 0.00% 1561 Spectrum Health Sparta HC 38 0.59% 78 1.20% 301 4.64% 141 2.17% 6490 Wege Family Practice 287 1.31% 444 2.03% 1375 6.27% 1340 6.11% 21915 439 3.09% 234 1.65% 1879 13.23% 2428 17.09% 14204 4899 2.45% 3480 1.74% 17962 9.00% 18008 9.02% 199670 Wege Internal Medicine Grand Total 27 Kent County Clinic Utilization by Patients with Asthma, 2005 Kent County Patients with Asthma Per Total Patients Percent 0% 0.1% - 1% 1.1% - 1.5% 1.6% - 2% 2.1% - 2.5% 2.6% - 3% 3.1% - 5% 5.1% - 16.1% Clinics Medical Shortage Area City of Grand Rapids 0 2 4 0 0.5 1 8 Miles 12 Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 28 Kent County Clinic Utilization by Patients with Depression, 2005 Kent County Patients with Depression Per Total Patients Percent 0% 0.1% - 0.5% 0.6% - 1% 1.1% - 1.5% 1.6% - 2% 2.1% - 2.5% 2.6% - 3% 3.1% - 8.6% Clinics Medical Shortage Area City of Grand Rapids 0 2 4 0 0.5 1 8 Miles 12 Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 29 Kent County Utilization by Patients with Diabetes, 2005 Kent County Patients with Diabetes Per Total Patients Percent 0% 0.1% - 2% 2.1% - 4% 4.1% - 6% 6.1% - 8% 8.1% - 10% 10.1% - 12% 12.1% - 25.8% Clinics Medical Shortage Area City of Grand Rapids 0 2 4 0 0.5 1 8 Miles 12 Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 30 Kent County Clinic Utilization by Patients with Hypertension, 2005 Kent County Patients with Hypertension Per Total Patients Percent 0% - 2% 2.1% - 4% 4.1% - 6% 6.1% - 8% 8.1% - 10% 10.1% - 12% 12.1% - 15% 15.1% - 33.1% Clinics Medical Shortage Area City of Grand Rapids 0 2 4 0 0.5 1 8 Miles 12 Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 31 Mapping Section #4 Distance to Closest Clinic versus Patient Preferred Clinic in Kent County, 2005 Distance and means of transportation influence access to outpatient health care. The GRHCAP Consortium, following the leadership of Kent County Health Department, is addressing issues of public transportation to health care providers. The Mapping Project illustrates the numbers of people whose access to needed care could be affected by distance. The distance to a clinic was calculated using ArcGIS mapping program, which calculated the Euclidian distance (straight line) between two points. After patient addresses were geocoded, two calculations were made. First, the program calculates the distance in miles from a patient’s home address to the clinic he/she visited. Second, the program calculates the distance in miles from a patient’s home address to the clinic in closest distance was calculated. The distance does not take into account streets and speed limits, but it does show on average how far patients’ are traveling to clinics. Table 6 shows the average distance that patient live from the clinic they visit. The first map entitled Average Distance to Kent County Clinics, 2005 shows the average distance patients live from a clinic. The map entitled Additional Distance traveled to Patient Preferred Clinic: Kent County, 2005 shows the average difference in distance been the clinic the patient visited and the clinic closest. Mean additional distance traveled to preferred clinic rather than to the closest clinic concentrates in the northwest corner of the county, in the southwest corner of the county and west of Grand Rapids. In the northwest corner of the county, the closest clinic is Sparta, which is not the preferred clinic for some. On the west side, rural residents who are not Hispanic may be by passing Clinica Santa Maria. 32 Table 6: Average Euclidean Distance to Clinic Clinics Cherry Street Health Services Belknap Commons HC Burton HC Cherry St HC Creston HC Ferguson Adult HC Grand Rapids Pediatrics Ottawa Hills HC Salvation Army Union High School HC Westside HC Metropolitan Hospital Breton HC Spectrum Health Internal Medicine Residency Practice OB/GYN Saint Mary’s Healthlinks Browning Claytor HC Catherine's Care Center Clinica Santa Maria Heartside HC McAuley HC Sparta HC Wege Family Practice Wege Internal Medicine Grand Total 33 Average Distance to Clinic 4.19 4.55 1.43 3.79 2.52 4.16 6.26 2.40 3.98 3.86 3.77 5.47 5.47 4.44 4.33 5.13 4.37 5.23 2.73 8.44 2.52 2.05 4.75 9.93 5.18 6.01 4.75 Kent County Average Distance to Kent County Clinics, 2005 Average Distance to Clinic Miles 0.6 - 1.0 1.1 - 2.0 2.1 - 5.0 5.1 - 7.5 7.6 - 10.0 10.1 - 15.0 15.1 - 20.0 20.1 - 29.4 Clinics Medical Shortage Area City of Grand Rapids 0 2 4 0 0.5 1 8 Miles 12 Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 34 Additional Distance to Patient Preferred Clinic: Kent County, 2005 Kent County Average Difference in Distance Between Clinic Visited and Closest Clinic Miles 0.00 - 1.00 1.01 - 1.50 1.51 - 2.00 2.01 - 2.50 2.51 - 3.00 3.01 - 3.50 3.51 - 4.50 4.51 - 7.67 Clinics Medical Shortage Area 0 2 4 0 0.5 1 8 Miles 12 City of Grand Rapids Grand Rapids 96 296 196 131 2 3 Miles Data Sources: GRHCAP Clinic Utilization Data 2005 & Geolytics Population Projections 2007 DeJong & Vander Plas, Calvin College, 2007 35 Appendix A: Mapping Data Distribution Guidelines 36 Appendix A Mapping data Distribution Guidelines Data Users 1. Maps and analysis of the consolidated clinics’ population will be available, in the form of a report, to consortium members. Permission to release or otherwise publicize the report and/or results of the analysis of consolidated data is covered under guideline 3, below. 2. Maps and analysis of individual clinic data will be available in the report to consortium members according to clinic affiliation. 3. Consortium members and non members who request the use of any and all mapping data pertaining to clinics for which they have no affiliation or for data from the consolidated clinic population will require the approval of all consortium members to use such mapping data. All requests must specify in detail the intended use of the data. Data Type 4. Released maps will not contain any personal patient data. 5. Minimum unit of analysis for released data sets is census block group. Data Requests 6. Review of requests and decisions to release data by GRHCAP Consortium Board or its delegate. 7. KCHD will assess a fee to cover costs for non-consortium requests and requests from Consortium members for additional map or report reproductions. Teresa Branson, KCHD Jim Dischinger-Smedes KCHD Fred DeJong, Ph.D., Evaluator Richard Zandstra, GRHCAP 37 Appendix B: GRHCAP Clinic Mapping Project Data Collection Guide 38 Appendix B: GRHCAP Clinic Mapping Project Data Collection Guide Mapping Project Client-level data to be collected in order to complete the maps and analysis is enumerated in row 10, with a sample record in row 11. Codes for variables (optional) are number 1-19. The data fields for House Number, Street Name, Street Direction, and Street Type is an optional address form that splits the combined street address into separate fields. Income is also an optional field. If data from different clinics is submitted in one file, make sure there are separate workbooks, or preferably, a clinic code. Field List: Bold font=Necessary data Normal Font=Optional data FIELDS SAMPLE RECORD Address City 700 Fuller Ave NE Grand Rapids Zip Code 49503 Race 1 Gender 1 FIELDS cont. SAMPLE RECORD cont. Age 28 DOB 2/11/1966 Payer Type 1 Clinic Code SMHC-Clinicia 2005 Visits 3 FIELDS cont. SAMPLE RECORD cont. Asthma visits 1 Depression visits Diabetes visits 2 2 Hypertension Visits 2 FIELDS cont. SAMPLE RECORD cont. House Number 700 Street Name Fuller Street Direction NE Street Type Ave Income 29000 Variable Coding 1 2 3 4 Address City Zip Code Race/Ethnicity 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Race/Ethnicity cont. Gender Age Date of Birth Payer Type Clinic Code or Name 2005 visits Asthma visits* Depression visits* Diabetes visits* Hypertension visits* House Number Street Name Street Type Street Direction Income Full street address 5 digit Non-hispanic white=1 Asian=5 Female=1 In years mm/dd/yyyy Commercial=1 Black or African American=2 Hispanic=3 American Indian/ Alaska Native=4 Native Hawaiian=6 Other=7 Male=2 Medicaid, charity care, self-pay, KHP=2 Medicare=3 Number of asthma visits Number of depression visits Number of diabetes visits Number of hypertension visits Optional Optional Optional Optional Optional *This does not need to be the primary diagnosis to be counted as a visit Notes: 1. Records: There is no client name entered, but the records are for unique clients. There will be duplicate addresses (spouses, siblings, etc.). 2. Address: Most recent address 39 3. 2005 Visits: All visits, regardless of address change 4. Optional address variables: Break the address down helps in the quality control of address placement. 40 Appendix C: Excerpt from “Target Areas, Low-Income Analysis, Population Change and Medical Shortage Area”, Clinic Mapping Project Report,, Task Force on Health Care for People of Color, Kent County Health Department, November 2005 The full report can be accessed online at: http://www.accesskent.com/Health/HealthDepartment/Publications/taskforce/Appe ndix_A_Clinic_Mapping_Project_Report_2005.pdf or by contacting Jim Smedes at the Kent County Health Department jim.smedes@kentcounty.org 41