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Part III. A Strategic Assessment and Action Agenda

1. Assessment

Bucks County has reaped many benefits from its past collaborative initiatives. BCHIP has grown, taking on a full time executive director. It has also expanded on its original set of initiatives to include a task force on employment, a collaborative network of dental services for children of low income families, and the initial stages of a network of clinics for low income uninsured adults. Funding for three years is in place for these medical access projects through a $1.84 million grant from the Centers for Medicare and Medicaid Services. School districts have become engaged in many innovative collaborative efforts with social service agencies. Access to daycare for children has expanded, as has the range of services for seniors. United Way of Bucks County has also taken steps towards improving collaboration through its new "United Communities" initiative, aimed at strengthening and expanding services in local disadvantaged communities.

Two recurring themes are reflected in these accomplishments and in all of the information gathered for this assessment. They are reflected in the key informant groups that we conducted and in the county statistical trends that we analyzed.

First, in Bucks County there is an impressive openness and willingness of service providers to collaborate and to come up with creative solutions to the real problems faced by the individuals and families they serve.

The fruits of these efforts are borne out by the hard numbers. Since the 1994 needs assessment, data shows that age adjusted death rates (all causes, infant, cardiovascular, lung cancer, breast cancer, motor vehicles, suicide and homicide) have declined significantly. The percentage of births with no prenatal care in the first trimester has dropped from 13.5% to 8.2%. Residents smoke less, exercise more, use more screening services and report fewer problems in accessing health services. Ninety-five percent of Bucks County residents describe the quality of life in their neighborhood as good, very good or excellent, a rating significantly higher than a comparable assessment for the nation as a whole.

Second, in spite of this, Bucks County often doesn’t function as a coherent whole.

Services to individuals, families and communities are fragmented, and this fragmentation has been further exacerbated over the last decade by the rapid growth, poverty, aging, and growing ethnic diversity of the Bucks County population. Service providers and their clients have to work hard to overcome the fragmentation and complexity of the system. Fragmentation adds to the cost and reduces the effectiveness of the services provided. It persists in part because many residents cling to the belief that: (1) their part of the county is unique and has very different needs from its other parts, (2) their particular community does not have mental health, crime, drug and alcohol, domestic abuse, poverty and homeless problems and (3) their community is insulated from the problems of the larger Philadelphia metropolitan area. The statistics presented in this report refute all three of these beliefs. The lack of affordable housing and adequate public transportation, persistent problems in Bucks County, add to the seriousness of the looming health care and social service workforce shortages now beginning to impact the region as a whole. Hospital emergency rooms are overcrowded, often requiring ambulance diversions. The workforce shortages are symptoms of more complex underlying problems, which include the current medical malpractice insurance crisis, declining reimbursement for health care services, and the growth of an aging population that will increasingly tax all social and medical systems in the county. These and other factors will have long-term repercussions for our county.

The creation of a plan for more systematic and cost effective approaches for addressing the health and social problems facing Bucks County is the essential challenge we face. This needs assessment is but one more step in a process for creating even greater successes in the next decade.

2.Creating a Strategic Vision

However constructed, a plan for enhancing the quality of life of Buck County residents must increase the forces protecting people and reduce those creating poor and costly outcomes. As shown by the dominos in Figure III.1, the cumulative effect of many small but coordinated initiatives can make the dominos fall in the opposite direction towards more positive outcomes. Overall, such investments should be more than offset by savings in direct costs incurred by social welfare, criminal justice and health care systems. Direct costs are overshadowed by the hidden costs to families, employers and communities. In such a complex system, any change in one part of the system affects all the other parts.

Figure III.1

"Complex adaptive systems" such as this require but a few simple rules that, locally applied, can respond effectively to the needs of individuals while assuring coherence and synergy for the system as a whole. Bucks County residents, providers, and funding agencies need only a simple outline to help guide the rich forms of collaborative innovation of which they are all deservedly proud. Four simple rules should guide their actions.

  1. Actions should be goal directed. The goals we have adopted are the broad consensus goal of the national Healthy People 2010 initiative driven down to the local level. These goals are: (1) Extend quality of life years in the population and (2) Eliminate disparities in opportunities (access and outcomes). All activities should contribute to the accomplishment of these goals.
  2. Actions should be coherent. They should be related to the actions of others. Ideally there should be "one" of everything: one emergency service system, one leadership Chamber of Commerce program, one system of interventions for smoking prevention etc. Planning, development and support of all actions should be predicated on a conscious effort to assure this coherence throughout Bucks County.
  3. Actions should be transparent. They should be easily communicated and widely understood. Actions should provide evidence that is clear to all in terms of its implications for the accomplishment of the two basic goals.
  4. Actions should focus on lives. Services should focus on improving the experiences of the "customer" rather than addressing the needs of the agencies that serve them.

Focusing on improvement in the lives of Bucks County residents represents a fundamental change similar to what was called for in the Institute of Medicine’s recent reports on quality. In essence, the process proposed is just a logical extension of the continuous quality improvement process long used by many businesses, social service and health care providers. The process sets measurable standards for the "product," however it is defined, and reduces variation from this standard in its production. The product in this case is the life of a Bucks County resident. The standard is the quality of life years of its most fortunate residents. As illustrated in Figure III.2, reducing variation enhances the overall quality of life years and reduces the disparities.

 

Figure III. 2

3. Designing a Service Line Action Agenda

Given the goals of increased quality of life years and elimination of disparities in opportunities for Bucks County residents, the action agenda outlines the steps necessary to accomplish these goals, focusing on improving different stages in the life cycle. The action agenda was completed with the help of county leaders and with the guidance of expert panels. Our research suggested that we could best achieve these goals by focusing on these five stages (e.g. ages 0-5, 6-17, 18-39, 40-64 and 65+) in people’s lives.

We envisioned a "matrix organization" or "service line management approach" that would cut across the different functional areas or "institutional silos" providing specialized services to different age groups. As illustrated in Figure III.3, we envisioned five different "service lines" representing different stages in the life cycle of Bucks County residents.

In developing the agenda for this structure, we invited key experts to assist us. Five expert panels that included representatives from diverse organizations providing services to each of the five age groups reviewed the evidence and made recommendations. We were also careful to include in these panels representatives from the three geographic regions of the county. A total of eighty individuals participated in the second round of sessions.

The summary of the recommendations for each group addresses three questions: (1) who will be responsible for carrying out the recommendations

(2) what issues will they be responsible for addressing

(3) how will the success of their subsequent activities be assessed.

 

 

Figure III. 3

(i) Early Childhood (0-5)

Assessment

Investments in prenatal care and in the first years of life promise the greatest return in extending quality of life and reducing disparities

Low birth weight births, associated with greater developmental and medical needs, grew from 5.4% to 7. 3% in the last decade, in part as a result of the continued improvements in prenatal care. Thirty percent of women of childbearing age continue to smoke in Bucks County. Daycare, a necessity for working single parents and two-wage-earner households, has become a central part of the lives of more than half of young children in Bucks County. Key informants expressed a need for better linkages between daycare and schools, health care providers, and social service providers.

Recommendations
  1. The Bucks County Quality Child Care Coalition for Early Care and Education with whatever additional representation is appropriate to assure improved coordination with public officials, legislators, employers, parenting programs, schools, health providers, and social service providers should make recommendations about how all parties can work together to improve the child care experience for all children in Bucks County.
  2. Major issues to be considered should include:
    1. Promotion of a new vision of high quality child care as essential for assuring healthy futures for children and communities
    2. Assurance of universally accessible high quality services
      1. Child care particularly for children with special needs
      2. Medical homes for young children and particularly for high-risk babies
      3. Pediatric mental health services
      4. Full day kindergarten
    3. Effective use of outreach

      4. Use of child care sites as points of universal outreach for comprehensive services and support to families

    4. High uniform standards
      1. High quality care for the more than one third receiving care in unregulated settings
      2. A living wage, adequate professional development and respect necessary to attract and keep high quality child care workers
      3. Improved universal credentialing
      4. A process of continuous quality improvement that cuts across all child care settings
      5. School readiness requirements that are standardized across the thirteen school districts in the county
    5. Improved child care information and advocacy
      1. Easily accessible, full, objective information to assist families in choosing a child care provider
      2. Flexible work scheduling where possible and parenting programs in work settings to assist parents of young children
      3. Targeted assistance for informal, extended family and kinship care providers
      4. Increased parent engagement
      5. Increased public advocacy
  3. Methods of assessing the success of the subsequent initiatives should include:
      1. Improved access to affordable high quality daycare by low and moderate-income families
      2. Wage parity between preschool workers and elementary school teachers
      3. Reduced turnover and enhanced professional training opportunities for child care workers
      4. Quality assurance as well-ingrained a process in child care as it is in health care
      5. Reduced incidence of the spread of infectious diseases in daycare centers
      6. Improved readiness and school performance of grade school youngsters

(ii) School Age (6-18)

Assessment

The at-risk behaviors of school-age children continue to be a legitimate priority concern in Bucks County; we have some victories, and continued attention to these problems holds promise for improvement.

Collaborative programs with the criminal justice system, with conflict resolution and violence prevention groups, and with local Y’s have shown results; these programs increase the level of trust and encourage a greater openness and further collaboration. These efforts may in part account for Bucks County’s having the second lowest incarceration rate of any county in Pennsylvania. Pennsylvania as a whole has a prison incarceration rate 3.7 times as high as Bucks County. On the top of the list of concerns of adults interviewed in our household telephone survey were teen drug and alcohol abuse and teen pregnancy. According to the 2000 Pennsylvania Youth Survey covering Bucks County, these at-risk behaviors are prevalent. These and other at-risk behaviors are higher in those who lack a sense of attachment to their family, community and school.

Recommendations

  1. Create a single, visible, countywide mechanism for (1) sharing information, (2) evaluating the effectiveness of existing efforts and (3) stimulating new or more coordinated initiatives to reduce risk behavior and enhance the protective attachments of school-age children. An existing organization or combination of organizations involved with these issues, if feasible, should assume responsibility for this effort rather than creating a new structure. The task force, as it would evolve, would be composed of representatives of all the groups that work with school age children, parents and communities on these issues; it would assist in the design of the mechanism to serve these three functions and to make recommendations about the funding and staffing necessary to sustain it.

2) The major concerns of this effort include:

    1. Reducing the risks of:
      1. Drug and alcohol abuse
      2. Violence and domestic abuse
      3. Tobacco use
      4. Unsafe sexual activity
    2. Enhancing the protective mechanisms that can insulate individuals from risks including:
      1. Poverty reduction within families and communities
      2. Greater parental and community connectedness and sense of empowerment
      3. Structured after-school activities/child care
      4. Mentoring programs
      5. Strategies to enhance trust, and earlier and more seamless use of mental health and drug and alcohol treatment services

      3) Methods of assessing the success of these activities should include continued use by

      all school districts of the county of the Pennsylvania Youth Survey or subsequently

      revised standard instruments for measuring and analyzing trends in risk behavior at a

      countywide level. Measures of success should include:

    3. Reduction in reported use of tobacco, drugs, alcohol and violent behavior among junior and senior high school students and increased reported protective factors in the survey
    4. Reduction in school suspensions for violent behavior, truancy, violent crime rates, etc.

(iii) Young Adult (19-39)

Assessment:

The needs of young adults have largely been ignored, yet addressing these needs is critical to quality of life of all in Bucks County.

The need for workers in child care, residential care for the disabled, personal care for seniors and a host of technical occupations will continue to grow in the county. Yet, the assistance required for the pool of young adults so that they can help fill these positions is lacking. Young adults are transformed overnight from children for whom many protective, supportive and educational services are available into individuals who are expected to function as responsible adults on their own. The young adult population, age 19-34, was the only age cohort experiencing a decline in census numbers (20%) over the last decade. Death rates for those aged 20-24 have increased in the county and are now higher than average in Pennsylvania. Many informants saw a subgroup of the non-college-bound young adults falling through the cracks, depressed and lost, trapped in minimum wage dead-end jobs or unemployed, lacking support and guidance, often abusing drugs and alcohol and slipping into destructive criminal behavior. The hard-core part of this group, for whom earlier interventions in their lives and with their families have failed, exerts a particularly devastating impact on low-income neighborhoods and communities. Poverty creates overwhelming odds. Often the impoverished begin to receive some services only after homelessness, criminal incarceration, life threatening drug overdoses, or unwanted pregnancies.

Recommendations
  1. Create a task force to make recommendations about how the complex problem of poverty and employment at living wages for this age group can be more systematically addressed. In essence, poverty in this age group is the county’s most costly disease. It destroys lives, undermines communities, erodes the quality of care provided particularly to the very young and old and adds to the cost of the welfare, criminal justice, mental health, and drug and alcohol treatment systemS. "Disease management," a systematic, intensive, protocol-based case management process, has proven its effectiveness in reducing the cost of many chronic diseases. A similar systematic approach is called for here. The task force should be composed of key representatives of public and private agencies providing services to this population as individuals, representatives of major employers, the media, and legislators. An existing organization or combination of organizations involved with these issues, if feasible, should assume responsibility for this effort rather than creating a new structure.

2) The major issues that should be addressed include:

    1. Pre job readiness and job training.
    2. Mental health counseling and support
    3. Increasing opportunities for living wage employment, affordable housing, child care, and an improved public transportation system
    4. Behavioral risk reduction interventions (smoking, drug and alcohol use, motor vehicle accidents and violence)
    5. Transitional services for released criminal offenders

      6. 3) Success of the resulting initiatives can be shown by:

    6. Increase in the employment rate and wages of young adults without college education
    7. Reduction in reported risk behaviors in the 19-39 age group
    8. Reduced crime and incarceration rate
    9. Reduction in drug overdose emergency room visits and deaths

(iv) Middle Age (40-64)

Assessment

There is a clear need for more concerted efforts in health screening and risk reduction for Bucks County’s middle aged population.

Central Bucks has higher age-adjusted heart disease death rates; Lower Bucks has higher cancer death rates; all three areas have slightly higher death rates from stroke compared to the state average. Colorectal cancer, prostate cancer and melanoma death rates, while declining in the county as a whole, are all somewhat higher than the state age-adjusted average. Only 53% of males over the age of 50 reported having a digital rectal exam in the last two years. Binge drinking is highest among adults in the central part of Bucks County. 35% of Bucks County adults are overweight; that percentage rises to 41% in the northern part of the county. 93% of adults in Bucks County have one or more cardiovascular risk factors, including overweight, lack of exercise, smoking, high blood pressure and high cholesterol. The economic and emotional stresses faced by this "sandwich generation" that provide critically important support for aging parents, children and even grandchildren adds to the risks.

Recommendations
  1. Expand the existing Bucks County Wellness Partnership to include representatives of major employers, health insurance providers, churches, and community organizations that interface with the 40-64 year old age group and launch a major initiative to target cardiovascular risk reduction and promote cancer screening and chronic disease management in this age group.

2) The major activities should include:

a. Development of community based stress reduction strategies

b. Development of countywide navigational systems, navigators, and the

simplification of systems to assure more seamless referral and access to

preventive and chronic disease management services and support
    1. Cancer screening promotion and outreach
    2. Cardiovascular risk reduction activities (tobacco cessation, weight control, exercise programs, and cholesterol and blood pressure screening)
    3. The development and implementation of community-wide rather than health plan or institution-specific disease management protocols
    4. The development of intergenerational strategies in risk reduction

3) Methods for assessing the success of these activities should include:

    1. Reported increases in screenings and risk reduction behaviors in this age group
    2. Reductions in the death rate from cancer, stroke and heart disease in this age group
    3. Reductions in the cost of treatment of heart disease, cancer and stroke

(v) Seniors (65+)

Assessment

The rapid growth of this population not only offers a rich and insufficiently tapped resource for the county but has also has begun to strain resources for care and services, particularly for low and moderate-income seniors.

Between 1990 and 2000, the population over the age of 75 in Bucks County grew 56%, twice the rate of statewide growth. The percent of residents over 65 living with disabilities jumped from 17.5% to 34.9%. The median age of the Bucks County population grew from 33 to 38, a rate of aging twice that of the United States as a whole. Bucks County has experienced a rapid growth in retirement and assisted living development over the last decade. The need for these services continues to grow. The senior population is growing due to migration. This influx has taxed local providers and added to the difficulties in staffing for elder care. Even the relatively affluent segment of Bucks County’s over-65 population struggles to meet the rising costs of medications, affordable home and personal care services, and assisted living arrangements. Our upper- income, over-65 affluent population is not getting the flu shots and pneumonia shots they should. This is in striking contrast to the strong relationship generally observed between income and use of preventive services. Ironically, through BCHIP’s flu shot programs, the proportion of low-income seniors who reported having flu shots in the last year was higher than that of their higher income counterparts.

Recommendations

  1. An ongoing task force should monitor the growth of the elderly population and the development of retirement communities, assisted living facilities and nursing homes in the county. This task force should assess the impact and advocate solutions. The key providers of services and representatives of the senior community should serve on this task force, whose membership will shift over time as the issues that need to be addressed change and as the initiatives that are possible to address locally and that will have the most potential impact become clearer. An existing organization or combination of organizations involved with these issues, if feasible, should assume responsibility for this effort rather than creating a new structure.
  2. The major issues that should be explored by the taskforce include:

      1. Designing an ongoing information-gathering process to monitor and anticipate the impact of the changing needs of the elderly
      2. Effectively using seniors in meaningful engagement as volunteers and employees to enrich and improve the quality of life in the county
      3. Designing appropriate strategies for linking people to the services they need, including awareness campaigns through appropriate media channels.
      4. Creating coordinated local strategies for supporting aging in place in the community, including house sharing options, encouraging appropriate design of new housing, renovation to enhance safety, sustaining informal support networks, assuring adequate nutrition, medication safety, transportation, exercise and social engagement
      5. Local initiatives to assist in making personal care and prescription services more affordable to low and moderate-income seniors
      6. Developing communication and advocacy strategies for affecting larger policy changes
      7. Refining all of the above areas into a more manageable list of priorities that hold out the most promise given limited local resources
  3. The success of these efforts will be measured by the development of broadly supported activities for both fully engaging the county’s seniors as resources and addressing their needs. It will also be assessed by improving the ease by which residents can access the information and resources that they or a family member needs.

    4. Conclusion

    There will, of course, never be perfect or permanent answers to any human community’s search for ways of improving the quality of life of its members. Yet, it is that search that makes all the participants in the initiatives proposed here for Bucks County uniquely human. What they accomplish will be ultimate measure of their humanity.

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