Sutter Health
Sutter Lakeside Hospital
2013 – 2015 Implementation Strategy
Responding to the 2013 Community Health Needs Assessment
5176 Hill Road East
Lakeport, CA 95453
http://www.sutterlakeside.org
Table of Contents
Table of Contents ............................................................................................................... 2
Introduction ........................................................................................................................ 3
About Sutter Health ........................................................................................................... 3
2013 Community Health Needs Assessment Summary .................................................. 4
Definition of Community Served by the Hospital ....................................................... 4
Significant Health Needs Identified ........................................................................... 5
2013 – 2015 Implementation Strategy ............................................................................... 8
Promotion and support of healthy choices/healthy behaviors.................................... 9
Promotion and support of emotional and mental health and well-being................... 11
Prevention and treatment of use/misuse of legal and illegal substances, including
prescription drugs and medications ........................................................................ 12
Promotion of collaborative relationships and coordinated services among Lake County
health and human services providers ..................................................................... 13
Needs Sutter Lakeside Hospital Plans Not to Address ................................................. 15
Approval by Governing Board ........................................................................................ 16
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
Introduction
This implementation strategy describes how Sutter Lakeside Hospital, a Sutter Health affiliate, plans to
address significant needs identified in the Community Health Needs Assessment (CHNA) published by
the hospital on September 13, 2013. The document describes how the hospital plans to address
identified needs in calendar (tax) years 2013 through 2015.
The 2013 CHNA and this implementation strategy were undertaken by the hospital to understand and
address community health needs, and in accordance with proposed Internal Revenue Service (IRS)
regulations pursuant to the Patient Protection and Affordable Care Act of 2010.
This implementation strategy addresses the significant community health needs described in the CHNA
that the hospital plans to address in whole or in part. The hospital reserves the right to amend this
implementation strategy as circumstances warrant. For example, certain needs may become more
pronounced and merit enhancements to the described strategic initiatives. Alternately, other
organizations in the community may decide to address certain community health needs, and the hospital
may amend its strategies and refocus on other identified significant health needs. Beyond the initiatives
and programs described herein, the hospital is addressing some of these needs simply by providing
health care to the community, regardless of ability to pay.
About Sutter Health
Sutter Lakeside Hospital is affiliated with Sutter Health, a not-for-profit network of hospitals, physicians,
employees and volunteers who care for more than 100 Northern California towns and cities. Together,
we’re creating a more integrated, seamless and affordable approach to caring for patients.
The hospital’s mission is: We improve health and help people feel better by giving excellent, efficient
health care service.
At Sutter Health, we believe there should be no barriers to receiving top-quality medical care. We strive
to provide access to excellent health care services for Northern Californians, regardless of ability to pay.
As part of our not-for-profit mission, Sutter Health invests millions of dollars back into the communities we
serve – and beyond. Through these investments and community partnerships, we’re providing and
preserving vital programs and services, thereby improving the health and well-being of the communities
we serve.
In 2012, our network of physician organizations, hospitals and other health care providers invested $795
million (compared to $756 million in 2011) in health care services for low-income people, community
health improvement services, and other community benefits.
For more facts and information about Sutter Lakeside Hospital, please visit http://www.sutterlakeside.org.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
2013 Community Health Needs Assessment Summary
The Lake County community health needs assessment provides the foundation for policymakers,
community organizations and advocates to more strategically plan services and make needed
improvements in Lake County; it also informs funders about directing investments toward areas and
populations of highest need. The assessment process included extensively reviewing existing data, and
conducting surveys, focus groups and interviews to obtain the community’s perspectives about health
needs and potential solutions for responding.
In 2012-2013, a Collaborative that included the two Lake County hospitals, St. Helena Clear Lake and
Sutter Lakeside, joined by public health and other local organizations, retained BARBARA AVED
ASSOCIATES (BAA) to update the community health needs assessment BAA conducted in 2010. The
purpose of the study was to examine relevant community health indicators, identify the highest unmet
needs and prioritize areas for improving community health. The assessment meets the provisions in the
Patient Protection and Affordable Care Act (ACA) for community health needs assessments and guides
the hospitals in updating their Community Benefits Plans to meet SB 697 requirements.
The full 2013 Community Health Needs Assessment report conducted by Sutter Lakeside Hospital is
available at http://www.sutterlakeside.org/about/SutterLakesideHospital-CHNA.pdf.
Definition of Community
Served by the Hospital
Lake County is located in Northern California just two hours by car from
the San Francisco Bay Area, the Sacramento Valley, or the Pacific Coast.
The county's economy is based largely on tourism and recreation, due to
the accessibility and popularity of its several lakes and accompanying
recreational areas. It is predominantly rural, about 100 miles long by
about 50 miles wide, and includes the largest natural lake entirely within
California borders. Lake County is mostly agricultural, with tourist
facilities and some light industry. Major crops include pears, walnuts and,
increasingly, wine grapes. Dotted with vineyards and wineries, orchards
and farm stands, and small towns, the county is home to Clear Lake,
California’s largest natural freshwater lake, known as "The Bass Capital of
the West," and Mt. Konocti, which towers over Clear Lake.
Within Lake County there are two incorporated cities, the county seat of
Lakeport and the City of Clearlake, the largest city, and the communities
of Blue Lakes, Clearlake Oaks, Cobb, Finley, Glenhaven, Hidden Valley
Lake, Kelseyville, Loch Lomond, Lower Lake, Lucerne, Nice, Middletown,
Spring Valley, Anderson Springs, Upper Lake, and Witter Springs.
Lake County is bordered by Mendocino and Sonoma Counties on the
west; Glenn, Colusa and Yolo Counties on the east; and Napa County on
the south. The two main transportation corridors through the county are
State Routes 29 and 20. State Route 29 connects Napa County with
Lakeport and State Route 20 traverses California and provides
connections to Highway 101 and Interstate 5.
According to California labor market data about county-to-county
commute patterns (which have not been updated since 2000), the total
number of workers that live and work in Lake is 15,566 persons: the total
for workers commuting in was 1,046, and 4,320 workers commuted out.
About 67% of people who live in Lake County also work within the county.
While the population size of Lake County was estimated at 64,394
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
residents in July 2012, the population can swell with daytime work
commuters and seasonal tourists.
Significant Health Needs
Identified
The following significant health needs were identified by the 2013 CHNA.
Significant Community Health Need
Intends to
Address
Promotion and support of healthy choices/healthy behaviors
This report and many population studies have identified major risk factors and
implications for preventing or reducing them. The risk factors most amenable to
being modified, treated or controlled include tobacco use, high blood pressure,
physical inactivity and obesity. Recommended strategies to improve community
health related to this priority area include:
Developing and maintaining community and school gardens and expanding the
capacity of local food banks to offer high-quality, fresh produce.
Offering nutrition education and cooking classes that are affordable, culturally
acceptable and accessible when people are off from work.
Forming walking and bicycling groups (with free or reduced-cost bike helmets).
Yes
Implementing activities that emphasize self-responsibility and selfmanagement of conditions.
While health-related organizations are expected to be key players in community
health improvement, some of the solutions for preventive health – as well as other
priority areas – should come from the non-health community as well. For example,
reaching out more to involve the faith community – and understanding the
supportive role spirituality can play in promoting physical and mental well-being –
should occur, and could bring in new partners and new venues for providing health
education messages and activities.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
Significant Community Health Need
Intends to
Address
Promotion and support of emotional and mental health and well-being
Finding ways to expand community-based mental health efforts is essential as this
needs assessment identified a relatively high level of anxiety and hopelessness in
the community input process. Many people were struggling with failing or failed
relationships, domestic violence, drug addiction, problematic child behavior or just
trying to cope with persistent poverty. Having access to therapeutic interventions
could help significantly. Some recommendations to respond include:
Support affordable one-to-one counseling and support group services,
including evening hours, through resources like community clinics, school health
centers, and family resource centers in Lake County towns as well as cities.
Yes
Organizing and supporting less formal venues for people to vent, express
concerns, share ideas and generally be supportive to one another in a setting with a
trained facilitator would be valuable.
Training and utilizing "natural helpers" (e.g., hair dressers, bartenders) who
frequently listen to people's personal problems and are generally trusted by their
customers is a way of providing an effective helping community.
Prevention and treatment of use/misuse of legal and illegal substances,
including prescription drugs and medications
Alcohol and drug use can be a significant contributor to many of the problems noted
in this report where Lake County rates are high or exceed statewide averages such
as motor vehicle accident fatalities, chronic liver disease and cirrhosis, and family
violence. Effectively addressing the high rates of smoking – and students' reported
ages at first trying cigarettes – have long-term implications for improving health as
well as reducing health care costs in Lake County. Recommended strategies
related to this priority area include:
Implementing a social marketing campaign to change socio-cultural norms and
Yes
tie the effects of illegal drug use to high unemployment and economic
consequences. One important message – echoed by several key interviewees in
this needs assessment – should be, "If you can't pass a drug test, you can't hold a
job or be hired in the first place."
Implementing alternatives to substance abuse that are attractive, fun and
affordable such as crafting, community (healthy) cooking contests, and bike and
swimming races could have the added benefit of increasing activity as well as
improving emotional well-being.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
Significant Community Health Need
Intends to
Address
Promotion of collaborative relationships and coordinated services among Lake
County health and human services providers
Visions for community support for addressing the priority areas and "turning the dial
in a more positive direction" for many of the identified community health indicators
requires identifying suitable leadership, raising awareness of stakeholders and
involving them, and agreeing in what areas and how each group will cooperate.
Recommendations for the Collaborative include:
Plan and implement a major roll-out of findings from this report. Widely share
the report with the community at large, in addition to health leaders and other
policymakers, to raise awareness of the issues, engage new partners and
stakeholders and build support for community involvement.
Yes
Continue to meet – inviting new members, especially nontraditional entities – at
least quarterly to maintain the momentum from this successful collaboration
process and operationalize this report, i.e., select strategies, identify needed
actions, agree on areas of leadership and responsibility, raise funds if needed and
implement action steps.
Track progress in implementing the priorities so that efforts can be measured
in subsequent needs assessments.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
2013 – 2015 Implementation Strategy
This implementation strategy describes how Sutter Lakeside Hospital plans to address significant health
needs identified in its 2013 Community Health Needs Assessment and consistent with its charitable
mission. The strategy describes:



Actions the hospital intends to take, including programs and resources it plans to commit;
Anticipated impacts of these actions and a plan to evaluate impact; and
Any planned collaboration between the hospital and other organizations.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
Promotion and support of healthy choices/healthy behaviors
Name of Program, Initiative
or Activity
Food Bank Collection program
Description
SLH provides a food bank donation site with a wagon in the hospital’s
front lobby. Collections are delivered to local food bank.
Anticipated Impact and Plan
to Evaluate
The Food Bank Collection is anticipated to expand the capacity of local
food banks by increasing donations. The hospital will evaluate the
impact of the Food Bank Collection program by assessing the
community’s access to food in its next Community Health Needs
Assessment.
Name of Program, Initiative
or Activity
Food Bank Donations
Description
Sutter Lakeside Hospital matches the annual donation given by Sutter
Health to our local food bank.
Anticipated Impact and Plan
to Evaluate
The Food Bank Donation is anticipated to expand the capacity of local
food banks by increasing donations. The Task Force serves
approximately 1,500 families with this donation. The hospital will
evaluate the impact of the Food Bank Donations program by assessing
the community’s access to food in its next Community Health Needs
Assessment.
Name of Program, Initiative
or Activity
Lake County Co-Op
Description
Sutter Lakeside Hospital provides a drop-off site for employees who
order local organic food online.
Anticipated Impact and Plan
to Evaluate
The Lake County Co-Op drop-off site is anticipated to promote healthy
eating by employees and their families. The hospital will evaluate the
impact of the Lake County Co-Op program by assessing the level of
participation of employees.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
Name of Program, Initiative
or Activity
Arthritis exercise classes
Description
SLH Physical Therapy department provides an arthritis foundation
sponsored exercise class.
Anticipated Impact and Plan
to Evaluate
The programs are anticipated to improve the health of participants. The
hospital will evaluate the impact of the groups by assessing the number
of participants.
Name of Program, Initiative
or Activity
Patient dietary counseling
Description
Sutter Lakeside Hospital provides inpatient and outpatient dietary
counseling to patients.
Anticipated Impact and Plan
to Evaluate
Dietary counseling is anticipated to promote healthy eating by patients
and increase awareness of overall health. The hospital will evaluate the
impact of the patient dietary counseling program by assessing the
number of patients counseled.
Name of Program, Initiative
or Activity
Community Clinic
Description
Sutter Lakeside Hospital is in the process of obtaining licensing to open
a new Community Clinic adjacent to the hospital in 2014.
Anticipated Impact and Plan
to Evaluate
The Sutter Lakeside Community Clinic is anticipated to directly recruit
and retain primary care providers. The hospital will evaluate the impact
of the clinic based on the number of providers recruited to the area and
how long they stay.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
Promotion and support of emotional and mental health and wellbeing
Name of Program, Initiative
or Activity
Lake County Mental Health System
Description
Collaboration of County, 1st Responders, Law Enforcement, and Health
Care to address County Mental Health needs.
Anticipated Impact and Plan
to Evaluate
This program is anticipated to improve care and placement of people
with mental health needs. Areas targeted are: transportation, safety,
medical screening, facility availability, and organic brain injury. The
hospital will evaluate the impact of the Lake County Mental Health
System program by assessing the community’s access to mental health
care in its next Community Health Needs Assessment and tracking the
transfer time of patients in need of psychiatric care.
Name of Program, Initiative
or Activity
Stroke Support Group
Description
Support group for stroke sufferers facilitated by Medical Social Worker.
Anticipated Impact and Plan
to Evaluate
Improved emotional health and well-being of stroke sufferers. The
hospital will evaluate the impact of the group by assessing the number of
meetings.
Name of Program, Initiative
or Activity
Pet Therapy
Description
Pet Therapy volunteers and animals round on patients.
Anticipated Impact and Plan
to Evaluate
Improved emotional health and well-being of patients. The hospital will
evaluate the impact of the program by assessing the patient satisfaction
scores as they relate to recommending the hospital.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
Prevention and treatment of use/misuse of legal and illegal
substances, including prescription drugs and medications
Name of Program, Initiative
or Activity
Rational Care Pain Plans
Description
Valley Emergency Physicians program used in ED for patients on pain
medication to spell out an agreement on pain management. Mid-level
providers in the ED document acute pain patients and strive to work with
the patient and the patient’s primary provider on documenting the pain
plan including ED pain management.
Anticipated Impact and Plan
to Evaluate
Anticipated impact is better coordinated care of patients on prolonged
pain medication between the patient, primary care provider, and ED
care. Evaluation will be based on reassessment of patients,
effectiveness of alternative pain management, and collaborative care
needs with primary care provider.
Name of Program, Initiative
or Activity
Non-Smoking Facility
Description
Sutter Lakeside Hospital is a non-smoking facility.
Anticipated Impact and Plan
to Evaluate
Being a non-smoking facility is anticipated to promote healthy behaviors
by employees and patients. The hospital will evaluate the impact of the
program by assessing the rates of smoking in its next Community Health
Needs Assessment.
Name of Program, Initiative
or Activity
Anesthesia audits
Description
Pharmacy performs utilization reviews to monitor for appropriate dosing
and usage of scheduled narcotics.
Anticipated Impact and Plan
to Evaluate
Anticipated impact is to identify and eliminate abusive prescribing and
administering practices. Evaluation will be based on appropriateness of
scheduled narcotics dispensing.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
Promotion of collaborative relationships and coordinated
services among Lake County health and human services
providers
Name of Program, Initiative
or Activity
Lake County Mental Health System
Description
Collaboration of County, 1st Responders, Law Enforcement, and Health
Care to address County Mental Health needs.
Anticipated Impact and Plan
to Evaluate
This program is anticipated to improve care and placement of people
with mental health needs. Areas targeted are: transportation, safety,
medical screening, facility availability, and organic brain injury.
Name of Program, Initiative
or Activity
Rational Care Pain Plans
Description
Valley Emergency Physicians program used in ED for patients on pain
medication to spell out an agreement on pain management. Mid-level
providers in the ED document acute pain patients and strive to work with
the patient and the patient’s primary provider on documenting the pain
plan including ED pain management.
Anticipated Impact and Plan
to Evaluate
Anticipated impact is better coordinated care of patients on prolonged
pain medication between the patient, primary care provider, and ED
care. Evaluation will be based on reassessment of patients,
effectiveness of alternative pain management, and collaborative care
needs with primary care provider.
Name of Program, Initiative
or Activity
County Health collaboration on communicable diseases
Description
Collaboration between hospital Infection Control department and Lake
County Health Department for the prevention and reporting of
communicable diseases.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
Anticipated Impact and Plan
to Evaluate
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Anticipated impact is improved quality of life by monitoring and
eliminating certain diseases, and helping detect potential outbreaks.
Evaluation will be based an annual risk assessment by the hospital.
Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
Needs Sutter Lakeside Hospital Plans Not to Address
Although no hospital can address all aspects of the health needs present in its community, Sutter
Lakeside Hospital plans to address all four of the priorities identified in the 2013 Community Health
Needs Assessment. Sutter Lakeside Hospital is committed to serving the community by adhering to its
mission, using its skills and capabilities, and remaining a strong organization so that it can continue to
provide a wide range of community benefits.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015
Approval by Governing Board
This implementation strategy was approved by the Governing Board of Sutter West Bay Hospitals on
November 21, 2013.
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Sutter Lakeside Hospital, Implementation Strategy 2013 - 2015