Last fall, the Hospital Association of San Diego & Imperial Counties (HASD&IC) released its tri-annual Community Health Needs Assessment (CHNA) report – the first since the onset of the COVID-19 pandemic.
Predictably, the report paints a picture of our region’s healthcare needs that include growing gaps in access to care, workforce challenges and disparities in health outcomes for disadvantaged groups which all accelerated during the pandemic.
The report paints some bright spots as well, including a community of hospitals and social groups that came together and worked collaboratively to pull through the most widespread public health crisis in a century.
A Challenging Process
HASD&IC Vice President of Public Policy Lindsey Wade said this was the fourth needs assessment she helped facilitate. The process was different than years past in that HASD&IC conducted all the interviews and gathered the data itself for the report.
“When you’re the person that’s hearing it, it’s a different responsibility to really share everything you’ve heard,” she said, adding that the 2022 CHNA’s respondents offered less solutions to solving challenges than in previous reports. She pointed out that a Spanish-speaking focus group of patients in North County responded “nothing” when asked what was working in healthcare at that moment.
On whether the needs were more challenging this time around, Wade said “yes and no.”
“Everything that had been a challenge prior to the pandemic was, for the most part, worse,” she said, adding that the pandemic added to people’s “exhaustion” – especially the workforce responses which were often along the lines of “heartbreaking and frustrating and overwhelmed.”
“Even if there were more resources, there just wasn’t the workforce to do what needed to be done, so I think that was an extra weight that everyone we talked to was carrying,” Wade said.
Other changes to the normally “boring” process of putting together the report were brought on by the pandemic, such as figuring out what to do with the initial data collected before the pandemic shut everything down.
“We basically just wanted to throw it in the trash because everything changed right after that,” Wade said.
Disparities and Access Issues
Although the pandemic may have changed the severity of responses, the results for top healthcare needs were still like years past.
“The results point out both longstanding areas of medical and social needs, as well as some areas that emerged because of COVID,” said Anette Blatt, director of community benefit at Scripps Health. “The findings are similar to those from previous reports, although many of the previously known gaps have grown wider, especially for underserved populations.”
Erica Salcuni, MPH, manager of Community Benefit/Health Improvement at Sharp HealthCare, said the findings in the report emphasized the pandemic’s impact on the health disparities and structural challenges witnessed in previous years.
“Even before the pandemic, many of our fellow San Diegans were in a vulnerable state and struggled to access basic needs and health care services,” she said. “Today, many of these previously known gaps have grown wider, especially for underserved and vulnerable populations.”
Salcuni also pointed out that the report’s findings show that health conditions and social conditions are becoming “increasingly hard to separate” when “prioritizing and identifying the most pressing needs” of the community.
Lindsey Wright, community health manager for Kaiser Permanente San Diego, also pointed out that health and social disparities in San Diego were “a common underlying theme” in the report.
“The health of San Diegans who were vulnerable before the pandemic, such as people experiencing homelessness, isolated seniors, LGBTQ+ youth, and children with special needs, deteriorated more acutely as they faced barriers and challenges brought on by the pandemic,” Wright said.
Those disparities for vulnerable and underserved populations are in large part caused by the report’s top listed need – access to healthcare. The report found that 59% of participants identified access to health care as a top concern and long waits for an appointment (31%) as the top reason for difficulties in accessing health care.
Blatt attributed some of the access issues to the COVID-19 pandemic causing widespread disruption in the health care system.
“This included postponed procedures, long wait times for appointments, and people sometimes delaying medically necessary care due to fear of exposure to the virus,” she said. “Access to care challenges such as making appointments with primary care providers, obtaining referrals for specialized care, and restrictions and confusion related to insurance coverage were among the top challenges San Diegans faced in accessing health care services.”
The most common types of care people surveyed in the report found difficult to access was dental care, urgent care, counseling/therapy, psychiatry, and mental/behavioral health.
Mental Health ‘Overwhelming People’
The need to increase access to mental health services was not a surprise, Wade said. In 2016, the first year the CHNA used focus groups in its survey, mental health was already a “big priority” and since then the CHNA has included more conversations and a behavioral health analysis specific to mental health concerns.
“It’s been building in the community with all these events colliding – the workforce shortages, the burnout, the increased stress and the lack of resources that were already there like a broken foundation for behavioral health and then you’re just adding weight on top of it and it starts to break even more,” Wade said, referring to the added pressures of the pandemic. “This time, housing and behavioral health took all the air out of the room in almost any conversation because they’re just the things that are overwhelming people.”
The relation of mental health to other socio-economic factors in San Diego – cost of childcare, housing concerns, chronic health issues, food insecurity – was a common theme in the CHNA report’s research and subsequent analysis, Salcuni said.
“A lot of the deficits experienced by residents are inter-related,” she added. “The size, scale, and severity of our behavioral health challenges, particularly for children and youth, were more prominent than ever before. Access to healthcare including behavioral health care, in spite of insurance options, continues to be limited for under-insured populations.”
A major challenge in meeting the region’s mental health needs was resources, especially workforce personnel. As Wright pointed out: “The mental and behavioral health workforce has dwindled significantly during the COVID-19 pandemic, while demand grew.”
Aaron Byzak, chief external affairs officer at Tri-City Medical Center, said that in addition to exacerbating existing issues with access to care, the pandemic “also added tremendous pressures on youth, especially in the area of mental and behavioral health.”
CHNA’s findings on mental health needs of children and young people, in this report and previous ones, has already spurred action at Rady Children’s Hospital to address the need. In 2016, Rady Children’s implemented a Depression and Suicide Screening Initiative that utilizes a brief questionnaire to identify youth with depression and thoughts of suicide regardless of whether they are seen in an ambulatory clinic, the emergency department, or admitted as an inpatient.
“This comprehensive approach has proactively identified a significant number of young people struggling with depression or considering suicide,” said Nicholas Holmes, MD, senior vice president and chief operating officer at Rady Children’s Hospital-San Diego.
Rady Children’s is also providing access to assessment, crisis intervention and resources with its Behavioral Health Urgent Care (BHUC), which opened in 2016. Located in the Mid-City region, the BHUC addresses the need for immediate access to mental health services for families concerned about their child or adolescent’s urgent mental health or behavioral symptoms.
In 2020, Rady Children’s also opened the Copley Psychiatric Emergency Department – a fully-functioning, six-bed Psychiatric Emergency Department dedicated to responding to mental and behavioral health emergencies of children and adolescents.
“As part of a free-standing Children’s Hospital, the psychiatric emergency department is one of the first of its kind in the nation,” Holmes said.
Rady Children’s is also working with the County of San Diego to construct a behavioral health pavilion in Kearny Mesa.
“The pavilion will fill a major gap and help support families in the region by expanding the number of available inpatient beds and providing crisis stabilization for kids who are struggling with severe mental health concerns,” Holmes said.
Rady Children’s is not alone in addressing the needs spelled out in the CHNA report. Nonprofit hospitals in California are required to not only conduct a needs assessment, but must also continually update implementation plans to address the needs that come out of the report.
In addition to the region’s nonprofit hospitals, Wade said this year the CHNA also included all of the region’s hospitals and clinics, including private hospitals, psychiatric hospitals and those governed by healthcare districts. All the hospitals can access the report and use it to make decisions that will help address the community’s healthcare needs.
HASD&IC also uses the CHNA findings and incorporates them into its own work.
“Around access to care, we spend a lot of time working directory with our hospitals on issues about MediCal eligibility and enrollment and around how we support patients who don’t have coverage or don’t have enough coverage,” Wade said, adding that HASD&IC takes a different approach than other regional hospital associations in that it works collaboratively with nonprofits like the Legal Aid Society on billing issues or San Diego Hunger Coalition on food insecurity issues. “We realized that our patients with MediCal either do have CalFresh or should have CalFresh so we take a more holistic approach.”
The CHNA also helps HASD&IC facilitate “high level” discussions on topics like health disparities with CEOs of hospitals, Wade said. “So even if we are not providing major programs, it’s really important that there’s an awareness across the community about what those challenges are.”
Awareness of healthcare issues, through the CHNA and internal assessments of community health needs, has spurred action by hospitals throughout the region.
“At Tri-City Healthcare District, our entire community outreach program, which we call the COASTAL Commitment, which stands for Community Outreach and Support Through Active Leadership, is built to address the findings of the Community Health Needs Assessment, with focus on priority health needs and social issues impacting health,” Byzak said. “Our program has nearly 90 partner organizations in our coastal North County region and seeks to address, to the extent possible, those identified issues that are most prevalent in the communities we serve.”
Byzak added that based on internal needs assessments and reports like the CHNA, Tri-City prioritizes the efforts and partnerships that will have “the most direct impact on affected individuals and populations and that demonstrate high return on investment, which for us means that we are helping move people towards health and wellness.”
Scripps Hospital also relies on the CHNA report for guidance in its activities to support community needs.
“Scripps is committed to increasing access to health care services, fostering multicultural diversity and promoting equity in health care through direct programs and partnerships with community-based organizations. These were important themes in the CHNA report,” Blatt said, and pointed to Scripps programs to educate people on the importance of early detection and treatment of cancer; the hospital’s involvement with a mobile health and resource fair that provides heart, neurocognitive and breast cancer screenings; and its “culturally sensitive diabetes education and self-management” program, Project Dulce.
Sharp relies on the data in the CHNA report to drive investments and collaboration amongst its service lines – including cancer care, diabetes and cardiovascular health management, behavioral health, prenatal/maternity services, senior resource services – to drive the strategies and focus within its hospital-specific implementation plans.
“As cardiovascular disease continues to be one of the most pervasive and deadly chronic conditions affecting San Diegans, Sharp is collaborating with other providers to make systemic and environmental improvements to cardiovascular care in the county’s most under-resourced communities beginning in 2023,” Salcuni said. “Each Sharp hospital adopted implementation plans based upon the CHNA findings which lay the groundwork for Sharp’s continued investment in programs that address previously-known and emerging issue areas through 2026.”
In addition to specific plans for care, Sharp is also undertaking a “system-wide shift” in how it engages with local schools, churches, nonprofit organizations, businesses and other stakeholders to focus on CHNA-specific findings, Salcuni added.
To address health needs in the community, Wright said Kaiser Permanente “routinely and proactively” screens its patients for social factors influencing their health; connects them to resources as needed; and makes adjustments to care “to ensure they receive the support they need.”
“This practice is a critical component of our commitment to provide high-quality, equitable, and comprehensive care that addresses our members’ total health. We are dedicated to care-coordination through social health screening, connection, and follow up as part of enterprise care coordination approach,” she said, and pointed to a partnership with 2-1-1 San Diego’s Community Information Exchange that allows Kaiser to send direct social health referrals to more than 50 nonprofit organizations throughout the county.
To continue to address the community needs reported in the CHNA, hospitals will need to address an issue of their own laid out in the report’s findings – workforce shortages.
According to data included in the report, from the end of 2019 to the second quarter of 2021, the staff vacancy rate at California hospitals jumped 98% and 78% of hospitals reported increased turnover. “Hospitals have workforce pipeline programs that reflect a lot of the need identified in the report, but nobody can do it alone,” Wade said, adding that even before the pandemic there was a “long-term pipeline concern” due to the age of nurses and retirements.
“I think the pandemic amplified some of the challenges in that space,” Wade added.
Salcuni agreed that workforce shortages were already “a looming challenge in healthcare” pre-pandemic and that “after a grueling, unending battle on the frontlines, many healthcare workers left the field forever.”
In addition to straining the workforce, the pandemic also put other strains on hospitals.
Health systems are facing real financial strains from the lingering disruption of services – and resulting lower revenue – caused by COVID, Blatt said, adding that in addition to pandemic financial pressures, hospitals are also facing expenses like costs to rebuild facilities to comply with upcoming earthquake standard deadlines.
“While Scripps is committed to continuing its 100-plus year legacy of caring for this community, more than ever we need the support of this region’s leaders and other organizations to help address the myriad issues that influence the health of San Diegans,” she said.
Community Engagement Needed
Despite the seemingly overwhelming challenges facing healthcare in San Diego, the CHNA report also highlighted the region’s unique resilience in facing down the pandemic. More than 80% of respondents in the surveys were optimistic about the future based on the region’s generosity, leadership and collaboration.
“The hospitals in San Diego – I don’t know that it was the same in other places – were just so intensely, deeply collaborative during the pandemic, shifting patients, trading supplies – it was just a nonstop community feeling,” Wade said.
Facing healthcare needs going forward, hospitals are counting on community engagement and financial help from local businesses.
“One of our goals with the COASTAL Commitment is to show our friends in the business community that we can make a tremendous collective impact through not just financial support, but also through contributions of time and talent,” Byzak said.
One way Tri-City is working with the business community is though its SOCAL (Student Opportunities for Career Awareness and Learning) workforce development initiative – a program that is “revolutionizing the way businesses in our region engage youth and adults alike to inform and inspire them about education and career opportunities in emerging industries — this helps elevate the community while also creating a pathway to impactful jobs at local businesses,” he added.
Blatt said hospitals like Scripps rely on active engagement in health care initiatives and collaboration with the business sector because “health care providers cannot address the needs of the underserved members of the community on our own.”
“It would also go a long way if businesses all offered health care benefits to their employees, including preventative care, wellness offerings and behavioral health services,” she added.
Wright also highlighted the impact businesses have in addressing health needs by providing individuals with “jobs, living wages, healthcare benefits, a sense of purpose, and opportunities to improve their economic circumstances over time.”
“People with steady employment are less likely to have an income below the poverty line and are more likely to be healthier than people with unstable employment,” she said. “Furthermore, individuals who do not have enough resources to meet basic needs such as safe housing and sufficient food are more likely to experience toxic stress and increased mortality.”
Salcuni pointed out that the business community was generous throughout the height of the pandemic in 2020 and 2021 and that continued support “remains important as we work toward addressing the long- and short-term impacts of the pandemic.”
She added that businesses can continue helping address health care needs by sponsoring or hosting community health events that provide access to health and wellness resources; creating partnerships with health systems to build a dynamic and diverse future healthcare workforce; and supporting nonprofit organizations that address the community health needs through contributions and volunteer efforts.
“[These] all go a long way to help vulnerable individuals and families in San Diego,” she said.