1998 Community Assessment

Health Chapter -- Part B

CONTINUUM OF CARE

"A continuum of care refers to a comprehensive array of services available at any intensity or level of need required to adequately address the needs of an individual so that they may attain their maximum potential."

Strategies for Building a Stronger Community: A Community Guide

BACKGROUND AND INFLUENCING FACTORS

According to the Healthy People 2010 Objectives: Draft for Public Comment, in efforts to address difficult health and quality of life issues, the most successful communities have involved a broad and inclusive spectrum of sectors from the community. This "continuum" includes public health, business, local government, schools, civic organizations, faith organizations, voluntary health organizations, traditional health care, and a wealth of other groups and private citizens interested in improving the health of their community.

This document will focus specifically on three portions of this continuum of care: Wellness and Prevention Services, Family Planning Services, and Medical Services.

Wellness and prevention services include such activities as educating the public concerning risky behaviors and their health consequences; providing screening, testing and other health problem detection services; or making available opportunities for behavioral modification to improve lifestyles and eliminate risky health behaviors.

These activities can be provided in a variety of locations, including schools, the workplace, community centers, and other community-based environments, as well as traditional health and medical facilities, and public health settings.

Importance to Community

Modifying the behavior of community residents to improve lifestyle, diet, and physical activity habits could save uncounted millions of dollars in medical, physical rehabilitation, and mental health care costs in the future. Improving lifestyles and eliminating risky behaviors would also reduce the years of productive life lost to premature deaths due to preventable illnesses and conditions.

Costs

The costs to Travis County residents of unhealthy lifestyles are incalculable. For example, in Texas, according to Office of Smoking and Healths 1995 reports, one of every five deaths was from a smoking-related disease. These deaths represented nearly 375,000 years of potentially productive life lost. In addition, smoking-attributable costs were more than $5 billion, including direct health care costs and indirect morbidity and mortality costs.

A study completed by Travis County Emergency Medical Services of all drivers injured seriously enough to be admitted to Brackenridge Hospital provided the following information. In 1994 and 1995, 1,017 drivers were admitted to Brackenridge Hospital suffering motor vehicle accident-related injuries. Of these, nearly 46% tested positive for both alcohol and/or drugs. The average hospital bill for injured drivers with a blood alcohol level of more than 99 mg/dl was $18,500, and more than 40% of these drivers had no insurance or depended upon public funding for support. The cost of providing direct medical care alone to these drivers potentially totaled $7,400,000 for the two-year period.

These two examples alone indicate the magnitude of the community costs related to only two lifestyle habits: tobacco and alcohol/drug usage, which can be changed with the appropriate wellness, education, and prevention services in place and accessible.

Health Risk Behaviors

Health risk behaviors which may be affected by accessible wellness, education, and prevention services¾ include everything from poor nutrition to abusive family situations.

Family Planning

"Family planning remains a keystone in attaining a national goal aimed at ensuring that every pregnancy is planned."

(U.S. Dept. of Health and Human Services, Healthy People 2010 Objectives, 1998.)

Healthy People 2000 defines family planning as the process of establishing the preferred number and spacing of the children in ones family, then selecting the means by which these preferences are achieved. The Community Action Network has defined increased utilization of family planning services as a priority for Travis County.

Importance to Community

It has been estimated that 60% of all pregnancies in the United States are unintended. The United States has one of the highest rates of unintended pregnancies among industrialized nations. Those women who are able to access family planning services derive tangible benefits from this access. Half of all women who are at risk of unintended pregnancy need publicly subsidized family planning services but are not receiving these services, according to the Report to Congress on Family Planning, Fiscal Years 1994-1995.

Family planning reduces the need for abortion. There is approximately one abortion for every three live births in the United States. Each year family planning services prevent over one million unintended pregnancies, according to the Alan Guttmacher Institute.

Costs

Unintended pregnancy in the United States has serious financial, welfare, and social costs. It is estimated that the pregnancy cost for each woman who does not intend to become pregnant is approximately $3,200 annually. Furthermore, for every dollar spent on publicly funded contraceptive services, three dollars are saved in Medicaid costs for pregnancy-related health care and medical care for newborns.

Socially, the costs can be measured in unintended births, reduced educational attainment and employment opportunity, increased welfare dependency, and increased potential for child abuse and neglect. Economically, there are increased health care costs--an unintended pregnancy is expensive no matter what its outcome.

Health Risk Behaviors

With an unintended pregnancy, the mother is less likely to seek prenatal care in the first trimester and more likely not to obtain prenatal care at all. The child of an unintended pregnancy is at greater risk of being at low birth weight, dying in its first year, being abused or neglected, and receiving insufficient resources for healthy development. Infants born to teenagers, especially to mothers under age 15, are more likely to suffer from low birth weight, neonatal mortality, and sudden infant death syndrome. They may also be at greater risk for child abuse/neglect, and behavioral and educational problems at later stages.

Although unintended pregnancies occur among women of all races and socioeconomic levels, unmarried women, poor women, and African-American women are especially likely to become pregnant unintentionally. These women are also least likely to have access to family planning services and most likely to be negatively affected by an unintended pregnancy.

Sexual experience represents a critical indicator of the risk of pregnancy and sexually transmitted diseases (STDs). Youth who begin having sex at younger ages are exposed to these risks over a longer period of time. Sexual intercourse without protection puts a teen at risk for pregnancy and for contracting STDs and HIV. The vast majority of teens do not want to become pregnant.

Community-based medical services involve a spectrum of primary, urgent, emergent, acute, chronic, and long-term care for both physical and mental health services.

Importance to Community

The accessible presence of a full array of health services with capacity to meet all residents medical care needs is critical to a community the size of Travis County.

More than 1,600 physicians are in active practice in the County, distributed among a variety of specialties including primary care, and in a variety of public and private settings.

Currently, two comprehensive health care systems offer medical services in Travis County: one for-profit and one non-profit. In addition, a specialty womens hospital has recently opened, and a cardiac disease-related hospital is presently under construction.

Mental health care is available from for-profit care networks, private practice professionals, plus a variety of public and community-based organizations.

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OUTCOMES AND INDICATORS

A complete continuum of health care includes any services needed to support the health and wellness of individuals within the community. These services extend from health education and prevention services across the spectrum of primary, acute, and emergency medical care, to long-term support for chronic, debilitating, or terminal illnesses.

In addition to the management of chronic disease and acute illness, primary care includes such services as prevention and wellness, education, and immunizations. Access to these services is important in the early detection and treatment of disease. Access is often difficult if not impossible for those who are medically indigent (defined here as those who either have no health insurance or have inadequate health insurance coverage).

According to the Texas State Board of Medical Examiners, there were approximately 600 primary care physicians (PCPs) in practice in Travis County in September 1998. However, most PCPs do not serve the medically indigent, with approximately two-thirds of Austins PCPs currently not accepting new Medicaid patients. The situation is even more acute for rural areas of the county. These areas have an even greater shortage of accessible health providers.

In addition to the numerous private physician offices, Travis County residents also have access to several public clinics that provide primary health care services. A combination of city, county, state and federal funds support these clinics.

Focus in this section will be on outcomes related to insurance coverage and family planning services. Both relate to accessibility of services for residents.

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OUTCOME: Increased proportion of the population insured for medical care

A significant number of Americans lack health insurance. The Census Bureau estimates that 71.5 million Americans went without health insurance for at least one month in the 36-month period between 1993 and 1995. Of these, 9.1 million were uninsured for the full 36-month period. Since health insurance is associated with life circumstances such as employment, retirement, or participation in government programs, health insurance status does change over time for some portions of the U.S. population. Because of these factors, certain segments of the population¾ men, Hispanics, young adults between 18 and 24, the foreign-born, people with a high school diploma or less, residents of central cities or non-metropolitan areas, the poor and the near-poor, part-time/temporary workers, and the unemployed are more likely to go without coverage for at least some part of the year.

Although among the general population aged 18-64 workers are more likely to be insured than non-workers, among the poor, non-workers are more likely to be insured than workers. About half of poor full-time workers were uninsured in 1997 (49.2%).

In 1993, according to the Census Bureau, 21.9% of the overall U.S. population lacked continuous health insurance coverage. In that same year the report Options for Improving Access for the Medically Indigent Persons in the Austin/Travis County Area, prepared for the Health Care Task Force by Lewin-VHI Inc., estimated that 116,016 persons or 20.1% of Austin/Travis County residents lacked health insurance coverage. Another 27,552 individuals or 4.8% of the Austin/Travis population were estimated to be underinsured based on the ratio of their medical expenses to their income. Hispanics made up a third of uninsured Austin/Travis County residents, while Blacks accounted for 10%. About 24% of the uninsured were under age 18, while another 20% were aged 18-24.

Since 1993, Health Partnership 2000 has sponsored a biennial telephone community survey patterned after the national and state-level Behavioral Risk Factor Survey System (BRFSS). As part of the survey, respondents are questioned about the health insurance status of the adult members of their household. In 1993, 19.8% of Travis County residents reported that not all of the adult members of their household had health insurance.

The Census Bureau estimates that 41.7 million Americans or 15.6% of the population went without health insurance in 1995. In that same year, according to the March 1996 Current Population Survey, 24.5% of Texas residents were without health insurance. Of those Texans without health insurance in 1995, nearly 25% were employed. The 1995 Health Partnership 2000 Community Survey shows that 17.9% of Travis County residents reported that not all the adults in their household had health insurance.

In 1997, 43.4 million persons or 16.1% of the U.S. population were without health insurance coverage during the entire calendar year. When we extrapolate this proportion to the 1997 Travis County population projection, this means that 101,900 county residents went without insurance in that year. The 1998 HP 2000 Community Survey reports that 13.9% of Travis County respondents indicated that not all of the adults in their household had health insurance coverage.

Children's Health Insurance: The 1993 HP 2000 survey showed that 12.6% of Travis County respondents reported that not all of the children in their household were covered by health insurance. This proportion fell to 11.2% in 1995. By comparison, 13.8% of all U.S. children are estimated by the Census Bureau to have been uninsured in 1995.

Accessibility of Health Services: The City of Austin and Travis County Medical Assistance Program (MAP) provides financial support and case management for eligible County residents for primary care. These residents may also need coordinated access to the emergency and acute care medical systems.

According to MAP, in 1996-97, the majority of MAP visits were to three Federally Qualified Health Centers (FQHCs): East Austin (21.5%), South Austin (26.2%), and Northeast Austin (17.8%). For most of that same year, Rosewood-Zaragosa Health Center, which serves the second largest number of clients, was closed for renovation. These four clinics primarily serve the areas identified by the 1993 Lewin-HVI study as vulnerable areas based on income and health status.

Figure 4.4.21

FY 1996-1997 Unduplicated Client Demographics

Source: Austin/Travis County Health and Human Services Department, Medical Assistance Program.

Medicaid, using state and federal funds, provides medical financial assistance to another segment of the Travis County population. In 1996, Texas Department of Health reported there were 69,444 eligible Medicaid recipients in Travis County. Of these, Medicaid had provided services to 53,494 persons, including children.

Figure 4.4.22

Medicaid Clients Served -- Travis County, 1996

Source: Texas Department of Health

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OUTCOME: Increased family planning services utilization

The Institute of Medicine (IOM) estimates that 60% of all pregnancies in the United States are unintended. Unintended pregnancies are defined as those that, at the time of conception, are unwanted or mistimed. One-half of unintended pregnancies result in births; half are terminated by abortion.

Available statistics indicate that in 1994, the proportion of unintended pregnancies was 82% for females under age 15, 83% for females aged 15 to 17, and 75% for females aged 18 to 19. Notwithstanding this fact, the majority of unintended pregnancies occur among adult women. In addition, the percentage of births from unintended pregnancies may be increasing. Thus, unintended pregnancy is an issue for women of all ages, regardless of marital status. Information concerning actual utilization of family planning services is not readily available.

Family planning services reduce the need for abortion, and prevent over one million unintended pregnancies each year, according to the Alan Guttmacher Institute. A variety of surrogate measures may be examined to provide a partial understanding of the issue of unplanned pregnancy and family planning services. These surrogate measures include the teen-age pregnancy rate and documented abortions.

Pregnancy rates for Travis County teen-age mothers (age 13-17) have declined from an average of roughly 49.4 pregnancies per 1,000 between 1992 and 1995, to 46.1 per 1,000 in 1996. Travis County has consistently had a higher teen-age pregnancy rate compared to other counties in Texas.

Figure 4.4.23
Pregnancy Rates (Aged 13-17 Years) - Travis County Residents, 1992 - 1996

Source: Texas Department of Health, Vital Statistics.

The abortion rate for Travis County women has fluctuated between 12% and 14% since 1992. In 1996, the rate was 13.4%.

Figure 4.4.24
Abortions by Race -- Travis County Residents, 1992 - 1996

Source: Texas Department of Health, Vital Statistics.

White women account for approximately half of the abortions in Travis County. This proportion has declined since 1992, from 51.9% to 44.7% in 1996. The percentage of total annual abortions among Black and Hispanic women has increased since 1992.

Figure 4.4.25
Abortions by Race Percentage Distribution -- Travis County Residents, 1992 - 1996

Source: Texas Department of Health, Vital Statistics.

Over the past five years in Travis County, the total number of abortions has remained fairly steady ranging from 4,051 in 1992 to 4,198 in 1996. The proportions of women (ages 15-44) obtaining abortions for the same years, however, shifted with a decrease from 51.9% to 44.7% for White women, and increases from 18.9 % to 20.4% for Black women and 23.7% to 28.0% for Hispanic women.

Abortion rates among the ethnic groups vary widely as follows for 1996; 44.1 per 1,000 for Black women, 28.9 for Hispanic women and 15.9 for White women. Abortions by age groupings have shifted little in the past five years. In 1996, teenage women under 19 obtained 17% of all abortions, while the age groupings 20 to 24 and 25 to 29 obtained 37.4% and 24.0%, respectively.

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D. OTHER KEY OUTCOMES AND STATUS

The Community Guide identified other outcomes related to health that were not addressed in the assessment. In addition, other health issues and recommendations for future assessments were developed and are listed below.

The following health outcomes are measurable but were beyond the scope of the current assessment:

• Improved age-adjusted health status
• Improved age-adjusted mortality rates
• Improved functional status
• Improved measures of basic sanitation: air, water, and food quality
• Increased early diagnosis of disease
• Reduced emergency room visit rates related to unintentional injuries

System Capacity Indicators:

• Improved knowledge and skills related to health
• Increased access to continuum of care as reported by persons with or without the ability
  to pay
• Increased percentage of population with a primary source of medical care
• Increased ability of providers to refer clients to needed health services
• Increased use of case management services
• Reduced waiting time for appointments
• Measurable improved changes in the wellness/prevention system capacity

Health Behavior Indicators:

• Reduced rate of adolescent pregnancies
• Decreased prevalence of self-reported unhealthy behavior
• Increased appropriate use of primary care and hospital emergency services
• Increased use of sexual health services by young men
• Increased age-appropriate health screenings

Recommendations were made for additional outcomes and indicators to be used in future comprehensive assessments. They include the following:

• Increased Adult Immunization Rates: Adult immunization rates for such conditions such as pneumococcal pneumonia and influenza should be examined in addition to childhood immunizations. Immunizations are the best preventive health measure against communicable diseases for which there are vaccines.
• Decreased Cancer Rates: Currently lung and breast cancers are the only types analyzed. Other important cancers that are growing concerns for Travis County are cancers of the prostate, skin, and colon.
• Decreased Intentional Injury Rates: Morbidity rates need to be determined for intentional injuries. Suicide and homicide are a small part of the public health picture. Further information is needed on domestic violence, assault, and other intentional injuries as well as the overlap between public safety and public health issues.
• Decreased Sexually Transmitted Disease (STD) Rates: The most prevalent STD in Travis County is infection with chlamydia trachomatis. Other STDs of concern are gonorrhea, syphilis, and human papillomavirus. Of new STD infections in Travis County, more than 50% are occurring in persons under age 25. There appears to be a rise in both chlamydia and gonorrhea cases in Travis County in 1998, according to the Austin/Travis County STD Program.
• Decreased Rate of Tuberculosis: From 1990 to 1996, there were a total of 27 deaths from tuberculosis in Travis County. There was a decline in the number of reported cases between 1993 and 1997 (from 104 cases in 1993 to 75 cases in 1997). Year 2000 national targets for tuberculosis are 3.5 total cases per 100,000 population, 10.0 cases per 100,000 African Americans and 5.0 cases per 100,000 Hispanic population. The risk of developing the disease is highest in children under three years old, lowest in later childhood, and high again among adolescents, young adults, the very old, and the immunosuppressed. TB infection has the potential for increase as a result of changes in demographic patterns, including immigration from countries with a high incidence of TB.
• Decreased infant mortality rate with special emphasis on decreasing the mortality rate of African American infants: Infant mortality in Travis County has been consistently lower than the state's rate. Travis County's rate has decreased from 6.2 per 1,000 births in 1992 to 5.9 in 1996. The African American infant mortality rate for 1995-1996 was 10.0 per 1,000 live births, almost twice as high as the total rate for Travis County.

Additional issues were suggested that should be included in future assessments. These include:

• Access to Care: Improving access to health services by decreasing barriers of affordability, cultural sensitivity, transportation and hours of operation.
• Environmental Health: By further addressing air, water, and food quality as well as animal/vector control efforts, a more complete picture of Austin/Travis County and the health of its residents will be developed.
• Vulnerable Populations: Developing indicators that focus on identified vulnerable population groups of Austin/Travis County with a differential experience of health issues. These might include the elderly and rural residents of Travis County.
• Case Management: Effective case management helps ensure a holistic approach to health care through monitoring and evaluation of patients and their needs.
• Intervention and Prevention: Intervention and prevention efforts that should be addressed include age-appropriate screenings (pap smears, mammograms, testing for sickle-cell anemia in African-American infants, influenza and pneumococcal pneumonia vaccinations in the elderly, colon and prostate cancer screenings, etc.), school health programs, and other systematic efforts.
• Emerging Diseases:
  • Hepatitis C: Hepatitis C is an important emerging disease whose estimated prevalence is four times the prevalence of HIV infection.
  • Cryptosporidiosis: The Brushy Creek Municipal Utility District recently experienced an outbreak of this disease, which is caused by a parasite that manifests in contaminated water. Cryptosporidiosis infects the digestive tract and can be fatal to immuno-compromised patients.
• Expanding magnitude of outcomes to include age- and gender-specific health experiences.
• Expanding the focus of children's health beyond infancy and childhood immunization rates.
• Separating adult and children's health sections to allow more analysis and concentration in each area.

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E. TERMS, CONCEPTS AND DEFINITIONS

Accidental Poisonings: Exposure to a toxic substance. Includes accidental drug overdose, ingestion of drugs in error, and drugs taken inadvertently (ICD-9 codes 860-869). Also includes accidents with the use of drugs and biologicals in medical and surgical procedures (ICD-9 codes 850-858).

AIDS: Acquired immunodeficiency syndrome, caused by the human immunodeficiency virus (HIV), is a specific group of conditions that result from the suppression of the body's natural immune response to an antigen (ICD-9 codes 042-044).

Cerebrovascular Disease: Bleeding which occurs into brain or spinal cord tissues (ICD-9 codes 430-438).

Chronic Obstructive Lung Disease: Chronic blockages in breathing organs (ICD-9 codes 490-496).

Colorectal Cancer: A malignant growth of the colon, rectum, and/or the anus (ICD-9 codes 153,154).

Communicable Disease: Those diseases that can be transmitted directly or indirectly from an infected individual, animal, or reservoir, to a susceptible host.

Diabetes: A disease of the endocrine system that impacts the ability of the body to metabolize carbohydrates (ICD-9 code 250).

Drowning: Suffocating in water or other liquid. Consists of ICD-9 code 830 (accidental submersion during water transport) and 910 (accidental drowning or submersion).

Epigram: A computer program provided by the Texas Department of Health for analyzing Texas population and mortality data.

Falls: To drop without restraint (ICD-9 codes 880-888). Each code specifies the object that was fallen off of or the action that caused it.

Female Breast Cancer: A malignant growth of a woman's breasts (ICD-9 codes 174,175).

General Fertility Rate: The total number of births in a calendar year per 1000 women of reproductive age (15 through 44).

HP 2000: (Healthy People 2000: National Health Promotion and Disease Objectives) - A national initiative that identifies 319 unduplicated objectives to improve the health of citizens of the United States. (Also Health Partnership 2000, an Austin collaboration of health care providers)

Heart Disease: Comprised of ICD-9 codes 393-398, 402, 404-429, this grouping reflects deaths from acute myocardial infarction, the sudden insufficiency of blood supply to an area of the heart muscle. This grouping also includes coronary arteriosclerosis, a chronic condition characterized by thickening/loss of coronary artery elasticity.

Hepatitis B: Inflammation of the liver caused by blood- and body fluid-borne infections spread primarily through high-risk behaviors (ICD-9 code 070).

Incidence Rate: The number of new cases of an illness occurring in a population over a period of time. The numerator is the number of new cases occurring in a given time period and the denominator is the population at risk during the same time period.

Infant Mortality Rate: Deaths of individuals less than one year of age per 1,000 live births.

Low Birth Weight: A birth weight of less than 2,500 grams or 5 pounds, 9 ounces.

Lung Cancer: A malignant growth of the trachea, bronchus, or lung (ICD-9 code 162).

Measles: A vaccine preventable, acute viral illness characterized by a 2 to 4 day period of high-grade fever and cough followed by a generalized rash which lasts 5 to 6 days. Disease transmission occurs primarily from person-to-person through respiratory droplets (ICD-9 code 055).

Morbidity Rate: The rate of incidence of a disease.

Mortality Rates: The frequency of a death in a specified period of time divided by the population at risk for the event.

Motor Vehicle Related Accidents: (ICD-9 codes 810-825) An accident involving a device used for conveying persons or goods from one place to another in which a fatality occurs.

Neonatal Period: The first 28 days of life.

Pregnancy Rate: The number of pregnancies (live births, fetal deaths, and induced abortions) in a given calendar year per 1,000 females age 15 through 44.

Prevalence Rate: The amount of a given disease or other condition in a given population at a designated point in time.

Prevention: Actions or activities that protect and promote safety, health, and healthy behaviors and reduce or control risks for disease, disability and dysfunction. Three types of prevention include: primary¾prevention activities carried out before an illness/condition manifests; secondary¾once illness manifests, prevention activities prevent reoccurrence or exacerbation of the illness/condition; tertiary¾prevention activities prevent further deterioration from the illness/condition.

Risk Factor: Biological, psychological, or social conditions which might influence or increase the likelihood of an individual's developing, maintaining or increasing harmful behaviors or becoming more susceptible to conditions that reduce standards of health and wellbeing.

Suffocation: To die from the lack of air or oxygen. Consists of ICD-9 codes 911 (by food), 912 (by an inhaled or ingested object other than food), and 913 (by an external object).

Syphilis (Primary and Secondary): A sexually transmitted disease characterized by lesions that may involve any organ or tissue. Untreated syphilis progresses into a chronic disease with long periods of latency (ICD-9 codes 090-097). Primary and secondary syphilis are more contagious stages of the disease.

Trauma Registry: A system for collection of data on patients who receive hospital care for injuries (trauma). Trauma is a serious injury or shock to the body, as from violence or accident.

Tuberculosis (TB): An airborne communicable disease spread primarily by microscopic airborne bacteria particles expelled by an infected person (ICD-9 codes 010-018).

Years of Potential Life Lost (YPLL): A statistical measure used to enumerate premature death. Calculated by subtracting an individual's age at death from a predetermined life expectancy (generally 75 years of age).

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