STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 STEMC 2020 COMUNITY HEALTH NEDS ASESMENT St. Thomas East End Medical Center Corporation, Inc. STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 i STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 i S T . T HOMAS E AST E ND M EDICAL C ENTER C ORPORATION 2020 C OMUNITY H EALTH N EDS A SESMENT F INAL R EPORT Source: USVI 2020 Census : Eastern End of St. Thomas, USVI: Catchment Area for St. Thomas East End Medical Center, Corp. Submited to St. Thomas East End Medical Center Corporation, Inc. Submited by the Caribean Exploratory Research Center University of the Virgin Islands Novem ber 2020 STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 i DISCLAIMER The compilation of data and development of this Comunity Health Neds Asesment (CHNA) was suported by funding from the St. Thomas East End Medical Center Corporation (STEMC) . The content of this CHNA is solely the responsibility of the authors and does not necesarily represent the views of the funding agency . ACKNOWLEDGEMENTS The Project Team from the Caribean Exploratory Research Center (CERC) within the Schol of Nursing (SON) at the University of the Virgin Islands (UVI) wishes to acknowledge the students from UVI who made significant con t ributions to the development of th is neds asesment . The Team also acknowledges the suport and contributions of a former UVI student - recent U VI graduate Ȯ in the development of th is report. We acknowledge al who facilitated the identification and retrieval of administrative and secondary data critical to the development of this neds asesment. The colaboration betwen the CERC team and the STEMC team ensured the production of a high - quality product. P ROJECT T EAM R ESEARCH A SISTANTS * STEMC Nore n Michael Mervin Brandy, Jr. C. Patricia Pen Deborah E. Brown Shaunté M. Rawlins Lisa Corneiro Ariana Athanase LaVerne E. Ragster Ramiz Hurtault Moleto Smith Sarai Hutchinson * Note: Mervin Brandy, Jr. served as a graduate research asistant. Shaunt é Rawlins, BSN, RN is a recent UVI graduate. Al other research asistants are curently undergraduate students at UVI. Sugested citation : Michael, N., Brown, D.E. & Ragster, L.E. (2020). St. Thomas East End Medical Center Corp. 2020 Comunity Health Neds Asesment . St. Thomas, USVI: Caribean Exploratory Research Center, University of the Virgin Islands STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 i T ABLE OF CONTENTS DISCLAIMER . . . . . i ACKNOWLEDGEMENTS . . . . i TABLE OF CONTENTS . . . . i ABREVIATIONS AND ACRONYMS . . . . ix EXECUTIVE SUMARY . . . . x Aproach . . . . . x The Comunity Ȯ Demographi c Profile . . . xi The Teritory . . . . . xi The St. Thomas - St. John District . . . . xi The STEMC Catchment Area . . . . xi Key Findings . . . . . xi BRFS 2016 . . . . . xi YRBS 2017 . . . . . xi Behavioral Health Ase sment 2018 . . . xv STEMC HRSA - UDS 2016 - 2019 . . . xvi Priority Health and Programatic Isues . . . xvi Strengths, Gaps, and Oportunities . . . xvi Conclusions and Recomendations . . . xix INTRODUCTION . . . . . 1 Overview . . . . . 1 Background . . . . . 2 Purpose and Scope . . . . 2 COMUNITY DEFINED: POPULATION AND DEMOGRAPHIC PROFILE . 4 Population . . . . . 4 Primary Language Spoken at Home . . . 7 Fa mily Structure . . . . 8 Selected Economic Characteristics . . . . 8 The St. Thomas - St. John District . . . . 10 The STEMC Catchment Area . . . . 1 Other Health Services Available in the St. Thomas - St. John District . . 14 STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 i APROACH TO 2020 CHNA . . . . 16 Administrative and Secondary Data and Data Analysis . . 16 Adults . . . . . 17 Adolescents and Children . . . . 19 Comunity Engagement Activities . . . 20 FINDINGS . . . . . 21 BRFS 2016 . . . . . 21 Health Outcomes for Ad ults . . . . 2 Health - Related Quality of Life . . . . 2 Health Determinants for Adults . . . . 29 YRBS 2017 . . . . . 42 Health Behaviors and Outcomes for Adolescents . . . 42 Sexual behaviors . . . . 50 Behavioral Health Asesment: 2018 . . . 5 Health Status of Children and Youth . . . 5 Health Status of Adults . . . . 62 STEMC: U DS DATA FY2016 Ȯ FY2019 . . . 65 A Snapshot of STEMC Clients: FY2016 Ȯ FY2019 . . . 6 Health Outcomes for Clients . . . . 68 Health Determinants for Clients . . . . 73 Customer Satisfaction . . . . 76 Client Suport from the Perspective of Case Managers and Outreach Workers . 79 Determination of Client Caselo ad . . . 80 Roles and Responsibilities and Changes over the Past Two to Thre Years . 81 .©∫¨πΩ®ª∞∂µȱ∂≠ȱ"≥∞¨µª∫Ȃȱ!¨Ø®Ω∞∂π∫ȱ®π∂ºµ´ȱ,¨´∞ Management . . . . . 82 Case Management and Outreach Activities with Schol - age Children . . 83 Scop e of Responsibilities within Framework of the Adition of Behavioral Health Unit . 83 Meting Clients Neds during the COVID - 19 Pandem ic . . 84 Changes in Lifestyle Management and Welnes Linked to Case Management/Outreach Workers . . . . . 84 STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 iv What Case Managers and Outreach Workers Do Particularly Wel and Areas for Improvement . . . . . 85 Recomendations for Improving Programs and Services for STEMC Clients . 86 /π∂Æ𮥥®ª∞™ȱ$≠≠∂πª∫ȱª∂ȱ ´´π¨∫∫ȱ"≥∞¨µª∫Ȃȱ-¨¨´∫ Ȯ FY2019 . . 87 PRIORITY HEALTH AND PROGRAMATIC ISUES . . . 89 Proces to Prioritize Health and Programatic Isues . . . 89 Priority Health Isues . . . . 90 Priority Programatic Isues . . . . 90 STRENGTHS, GAPS, AND OPORTUNITIES . . . 91 Strengths . . . . . 91 Gaps . . . . . 91 Oportunities . . . . . 92 CONCLUSIONS AND RECOMENDATIONS . . . 93 RE SOURCE INVENTORY . . . . 97 Description of Existing Health Care Facilities Within the Same Comunity, Including Specialty Services . . . . 97 Aditional Resources Available to Met the Comunity Health Neds Identified . 97 DISEMINATION PLAN . . . . 9 Description an d Date of Report Release to Public . . . 9 Acesing the Report Ȯ List of Websites and Hot links . . 9 Description of Proces to Share Information with the Broad Comunity . 9 APENDICES . . . . . 10 Apendix I. STEMC Pa tient Satisfaction Survey . . . 101 Apendix I. Protocol Used for Focus Group Discusion . . 103 Apendix I. Fedback from PAC and Other Stakeholders on Neds Asesment . 104 REFERENCES . . . . . 105 STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 v L IST OF F IGURES Figure 1. Population: Teritory and Islands Ȯ 2014 and 2015 dzdzdzdzdzdzdzdz. dzdzdz. . . 4 Figure 2. USVI Population by Ethnicity: Teritory and islands, 2014 and 2015 dzdzdz. dzdz 6 Figure 3. USVI 2015 Population by Age Group : Teritory and Island s dzdzdzdzdzdz. . dz. dz 6 Figure 4. First Language Spoken at Home for Persons over 5 Years Old : Teritory and Islands, 2015 dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯdz. dzdz. . 7 Figure 5. USVI 2015 Population by Family Composition dzdzdzdzdzdzdzdzdzdzdzdz. dz. dz 8 Figure 6. USVI Household Income Levels: Teritory and Islan ds, 2015 dzdzdzdzdzdzdzdz. 9 Figure 7. Race/Ethnicity and Language Spoken at Home: STEMC Catchment Area, 2 010 . . 12 Figure 8. Poverty and Insurance Status: STEMC Catchment Area, 2010 dzdzdzdzǯdzdzǯ 1 3 Figure 9. Housing Units Damaged & Severity of Damage - STEMC Catc hment Areas dzdz13 Figure 10. Healthcare Sites: St. John, 2020 dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯǯǯ . dzǯ. 1 5 Figure 1. Healthcare Sites: St. Thomas , 2020 dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯǯ 1 5 Figure 12. General Health Status dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯ. ǯdz. dz2 3 Figure 13. Number of Days of Bad Physical Health - Past 30 Days dzdzdzdzdzdzdzǯǯ . dzdz. . 2 4 Figure 14. Number of Days of Bad Mental Health - Past 30 Days dzdzdzdzdzdzdzǯǯǯ dz. dzdz2 4 Figure 15. Number of Days Por Mental or Physical Health Restricted Usual Activities . dz2 5 Figure 16. Ever Told You had a Hea rt Atack/Myocardial Infarction, dzdzdzdzdzdzdzǯǯ . dzǯǯ 2 5 Figure 17. Had a Test for High Blod Sugar or Diabetes in the Past Thre Years dz. dzdzdzǯ2 6 Figure 18. Ever ben told you are Pre - diabetic dzdzdzdzdzdzdzǯǯdzdzdz dzdzdzdzdzǯǯ ǯǯdzdzǯǯ 2 6 Figure 19. Ever ben told you have some form of Arthritis dzdzdzdzdzdzǯdzdzdzǯǯ dzdzdzdz2 7 Figure 20. Ever ben told you had Asthma dzdzdzdzdzdzdzdzǯdzdzdzdzǯdzdzdzǯǯ dzdzdzdzǯǯ 2 7 Figure 21. Ever ben told you ha d a Depresive Disorder dzdzdzdzdzdz. ǯdzdzdzdzǯǯ dzdzdz2 7 Figure 2. Body Mas Index by Sex dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdz. . 28 Figure 23 . Last Visited a Dentist or Dental Clinic dzdzdzdzdzǯǯdzdzdzdz dzdzdzǯdzdzǯǯ dzǯdzǯǯ 2 9 Figure 2 4 . Number of Permanent Teth Removed dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯdzdzǯ 30 Figure 2 5 . Have Aces to Insurance/Healthcare Coverage dzdzdzǯǯdzdz dzdzdzdz. dzǯǯ dzdzǯǯ 31 Figure 2 6 . Insured by Medicare? dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdz. dzǯdzdzǯǯ 31 Figure 2 7 . Do you have a personal doctor/usual source of care? dzdzdzdzdzdzdzdzǯǯ dzdzdz3 2 Figure 2 8 . Last Doctor's Visit for a Routine Checkup dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯ3 2 Figure 2 9 . Deferment of Medical Visit because of Cost dzdzdzdzdzǯǯdz dzdzdzdzdzǯǯ dzdzdzǯǯ 3 3 STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 vi Figure 30 . In past 12 months, d efered tak ing p rescription m edication because of c ost dzdzdzǯdz. . 3 3 Figure 3 1 . Level of Satisfaction with Healthcare Received dzdzdzdzdzdzdz. dzdzǯǯdzdzdzdz 3 4 Figure 3 2 . Smoked at least 10 Cigaretes in Lifetime dzdzdzdzdzdzdzdzdzdzǯǯ dzdzdzdzdzǯǯ 3 5 Figure 3 3 . Days in the past 30 days had at least one alcoholic beverage dzdzdzdzdzdzdzdzǯř 5 Figure 3 4 . Average number of alcoholic drinks per day in last 30 days dzdzdzdzdzǯǯ dzdzdzř6 Figure 3 5 . Number of drinks on a single ocasion - past 3 0 days dzdzdzdzdzdzdzdzdzdzdzǯř 6 Figure 3 6 . Participated in any physical activities for exercise in past 30 days dzdzdzdzdzdzř6 Figure 3 7 . Use a seatbelt when riding or driving in a car dzdzdzdzdzdzdzdzdzdzdzdzǯdzdzǯǯř 7 Figure 3 8 . Had the flu shot or spray in the past 12 months dzdzdzdzdzdzdzdzdzdzǯǯǯ dzdzdzř8 Figure 3 9 . Ever had a Tetanus shot or Tdap vacine dzdzdzdzdzdzdzdzdzdzdzdzdzdz. dzdzǯ 3 8 Figure 40 . Ever ben tested for HIV dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯdzdzǯǯř 9 Figure 41. Ever had a Sigmoidoscopy/Colonoscopy dzdzdzdzdzdzdzdzdzdzdz. dzdzdzdzdz3 9 Figure 42. Ever had a Mamo gram dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯǯ 40 Figure 43. Ever had a Pap T est dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdz. dzǯdzǯ40 Figure 4. Ever had a PSA Test dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯǯ dzdzdzdzdzdz. dz40 Figure 45. Highest Educational Level Atained dzdzdzdzdzdzdzdzdzdzdzdzdzǯdzdzdzdzdzǯǯ 4 1 Figure 46. Employment Status dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdz4 2 Figure 47. Anual Household Income dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯǯ 4 2 Figure 48. Ever tried cigarete smoking? dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯǯdzdzǯŚ 3 Figure 49. Ever used an electronic vapor product? dzdzdzdzdzdzdzdzdzdzdzdzǯǯǯdzdzdzdzǯǯŚ 3 Figure 50. Age at which you had your first drink of alcohol dzdzdzdzdzdzdzdzǯdzdzdzdzdz4 Figure 51. -º¥©¨πȱ∂≠ȱ´®¿∫ȱ∫ªº´¨µª∫ȱπ¨∑∂πª¨´ȱªØ®ªȱªØ¨¿ȱ® . 4 Figure 52. Number of times ate fruit in past 7 days dzdzdzdzdzdzdzdzdzdzǯǯdzdzdzdzdzdzǯǯ 45 Figure 53. Number of times ate gren salad in past 7 days dzdzdzdzdzdzdzdzdzdzdzǯǯdzdzǯǯ 45 Figure 54. Hours of TV watched on an average schol day dzdzdzdzdzdzdzdzdzǯǯdzdzdzdzǯ 46 Figure 5. Number of hours a day play video/computer games or use computer for non - schol work dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯdzdzdzdzdz47 Figure 56. Number of days you were physicaly active for at least 60 minutes a day in the past 7 days dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdz. . 48 Figure 57. I fel safe at my schol dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯdzǯ4 9 Figure 58. There is gang activity at my schol dzdzdzdzdzdzdzdzdzdzdzdzǯǯdzdzdz . . dzdzdz4 9 Figure 59. I have ben bulied at my schol dzdzdzdzdzdzdzdzǯǯdz dzdzdzdzdzdzdzdzdz. dzǯǯ 50 STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 vi Figure 60. Ever had sexual intercourse dzdzdzdzdzdzdzdzǯǯǯdzdzdzdzdz dzdzdzǯdzdzdz. dzdz50 Figure 61. Age f irst had sexual intercourse dzdzdzdzdzdzdzdzdzǯǯdz dzdzdzdzdzdzdzǯǯ dzdzǯǯ 51 Figure 62. Used a condom during last sexual intercourse dzdzdzdzdzdzdzdzdzdzdzǯdzdzdz51 Figure 63. During past 12 months, felt so sad or hopeles almost every day for two weks or more in a row, you stoped doing ∫∂¥¨ȱº∫º®≥ȱ®™ª∞Ω∞ª∞¨∫ȱdzdz . dzdz. dzdzdzdzǯ52 Figure 64. During past 12 months, ever seriously considered atempting suicide? dz. dzdzǯǯ 53 Figure 65. During past 12 months, made plan about atempting suicide? dzdzdzdzdzdzdzǯǯ 53 Figure 6. Have you ever ben told you have asthma? dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯǯ 54 Figure 67. Student participants by age dzdzdzdzdzdzdzdzdzdzdzdzǯdzdzdzdzdzdzdzdzǯǯ dzǯǯ 60 Figure 68. Student participants by grade level dzdzdzdzdzdzdzdzdzdzdzdzdzǯǯ dzdzdz. dzdzǯ 60 Figure 69. Number of Clients Served: FY2016 - FY2019 dzdzdzdzdzdzdzdzdzdzdzdzdzdzdz 6 Figure 70. STE EMC Clients by Age Group: FY2016 - FY2019 dzdzdzdzdzdzdzǯǯ dzdz. dzdzǯ 67 Figure 71. STEMC Clients Served by Race - Ethnicity: FY2016 - FY2019 dzdzdzdzdzdzdzǯ 68 Figure 72. STEMC Clients Best Served in a Language other than English, FY2016 - FY2019 ǯǯǯdz 68 Figure 73 . Prevalence of Select Medical Conditions for STEMC Clients, FY2016 - FY2019 dzǯdz. 6 9 Figure 74 . Select Presenting Chronic Diseases for STEMC Clients, FY2016 - FY2019 ǯdz. 70 Figure 75 . Adult patients (18 and older) with BMI Screning and Folow - Up: FY2017 Ȯ FY201 9 . . . 71 Figure 76 . Select Services Ofered at STEMC, FY2016 - FY2019 dzdzdzdzdzdzdzdzdzǯǯ dzǯǯ 72 Figure 7 . Patients Screned for Clinical Depresion with Folow - Up Plan, if Neded: FY2017 - FY2019 dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzȱ72 Figure 7 8 . STEMC Clients by Source of Insurance Coverage, FY2016 ȮFY2019 dzdzǯǯǯ dz 73 Figure 7 9 . First Trimester Prenatal Care for Prenatal Clients, FY2016 - FY2019 dzdzdzdzdz 74 Figure 80. Number of Clients Screned for Colorectal Cancer, FY2017 - FY2019 dzdzdzdzdz 75 Figure 81. Number of Clients Screned for Cervical Cancer, FY2017 - FY2019 dzdzdzǯǯǯ dzǯǯ 75 Figure 82. Average Ratings of Key Items on Customer Satisfaction Survey, 2019 dzǯdzǯǯ dzǯ 76 Figure 83. Satisfied with overal care received at STEMC dzdzdzdzdzdzdzdzdzdzdzdzdz 7 Figure 84. Likelihod of refering friends and family to STEMC, 2019 CS dzdzdzdzǯdz 7 Figure 85. What Clients Like Least about STEMC, 2019 CS dzdzdzdzdzdzdzdzdzdzdzǯǯ 78 Figure 86. 2∂™∞®≥ȱ#¨ª¨π¥∞µ®µª∫ȱ∂≠ȱ'¨®≥ªØȱdzdzdzdzdzdzdzdzdzdzdz Figure 87. Social Determinants of Healt h - Considerations in Adresing Comunity Health and Welnes dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdz. dzdzdzdzǯdzdzdzǯ. . 9 5 STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 vi L IST OF T ABLES Table 1. Healthcare Services Available in the St. Thomas - St. John District, 2020 dzdz. . dzǯ1 4 Table 2. CTSQ Survey Participants by Age and Sex dzdzdzdzdzdzdzǯdzdzdzdzdzdz. dzdzǯǯ 5 7 Table 3. CTSQ Survey Participants ©¿ȱ&π®´¨ȱ®µ´ȱ2¨øȱdzdzdzdzdzdzdzdzdzdzdzdz 5 7 Table 4. 2ªº´¨µª∫Ȃȱ ≠≠∞𥮪∞Ω¨ȱ1¨∫∑∂µ∫¨∫ȱª∂ȱ"320ȱ Item s by Sex dzdz. dzdzdzdzdzǯǯǯ dzdzǯ5 8 Table 5. Student ∫Ȃ Afirmative Responses to CTSQ Item s by Grade dzdzdzdzdzǯ. dzǯǯǯdzǯ 5 9 Tab le 6. Student ∫Ȃ Afirmative Responses to CTSQ Item s dzdzdzdzdzdzdzǯdzdzǯdzdzǯǯǯdz 60 Table 7 . Students' Afirmative Responses to CPS Items Related to Functional Impairment dz. . 62 Table 8. Changes in Number of Clients Acesing Select Healthcare Services: FY2016 Ȯ %8ŘŖŗşȱdz dzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzdzǯdzǯǯ 7 2 STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 ix ABREVIATIONS AND ACRONYMS A BREVIATION / A CRONYM D ESCRIPTION P AGE [of 1 st mention] A ACA Afordable Care Act 2 ACF Administration for Children and Families 2 B BMI Body Mas Index 28 BRFS Behavior al Risk Factor Surveilance System 17 C CDC Centers for Disease Control and Prevention 17 CERC Caribean Exploratory Research Center 2 C 2 HNA Comprehensive Comunity Health Neds Asesment x/2 CHNA Comunity Health Neds Asesment 2 D DHS Department of Health and Human Services 2 E EHS Early Head Start 2 F FHC Frederiksted Health Care 1 FQHC Federaly Qualified Health Center 1 G GVI Government of the Virgin Islands 1 H HRSA Health Resources and Services Administration 1 HS Head Start 2 HSRP - VI Huma n Services Research Partnership - VI 2 M MAP Medical Asistance Program 16 MCH Maternal and Child Health 15 MOA Memorandum of Agrement 15 MUA Medicaly Underserved Area 15 N NAC Neds Asesment Comite 19 NCD Non - Comunicable Diseases 1 NIA National Institute on Alcohol AbuseandAlcoholsm 3 3 P PAC Project Advisory Comite 19 PH Public Housing xi/13 S SON Schol of Nursing 2 SRMC Schneider Regional Medical Center 1 STEMC St. Thomas East End Medical Center Corporation 1 T TANF Temporary Asistance for Nedy Families 2 U UDS Uniform Data Set 16 US United States 8 USVI United States Virgin Islands 1 UVI University of the Virgin Islands 2 V VICS Virgin Islands Comunity Survey x/ 3 VIDE Virgin Islands Department of Education 12 VIDHS Virgin Islands Department of Human Services 1 VIDOH Virgin Islands Department of Health 1 VIHA Virgin Islands Housing Authority 19 W WHO World Health Organization 63 Y YRBS Youth Risk Behavior Survey 17 STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 x EXECUTIVE SUMARY To ensure the provision of optimal care and services to clients, federaly qualified health centers ( FQHCs ) are required to complete comunity health neds asesments periodicaly. STEMC engaged CERC to complete a Comprehensive Comunity Health Neds Asesment ( C 2 HNA ) in 2015. The curent Comunity Health Neds Asesment (CHNA) updates the initial work and ∑π∂Ω∞´¨∫ȱ∞µ≠∂𥮪∞∂µȱªØ®ªȱæ∞≥≥ȱ∞µ≠ areas of enhancing services to clients, determining health priorities, identifying gaps that ned to be adresed, and embracing oportunities to colaborate with other providers to improve he alth outcomes for clients. The curent CHNA sought to adres seven key areas: 1. Key population information on curent residents of the USVI (based on the most curent Virgin Islands Comunity Survey [VICS]). 2. A description of the social and economic context of the USVI (adreses Economic Stability and Social and Comunity Context). 3. Information on households and families. 4. Documentation of the education, health, nutrition, and social services neds of children and families in the STEMC catchment area. 5. Docume ntation of the economic, social, educational, health, and environmental factors that impact eligible children and families in the STEMC catchment area. 6. Documentation of resources available to serve children and families in the district and catchment area s; and, 7. Delineation of the gaps, strength, and oportunities of the comunity and of STEMC. A PROACH To complete the STEMC 2020 CHNA, STEMC leadership agred that the 2020 CHNA would be grounded in administrative and secondary data . Thus , the project team completed an asesment of administrative and secondary data sources that would be most relevant for adresing the purpose and scope of the STEMC 2020 CHNA. Key data sources included the 2015 Virgin Islands Comunity Survey (VICS) , published in 2 018 ; the USVI 2016 BRFS; the 2017 YRBS study completed by CERC for the VIDOH; 2018 behavioral health asesment data colected for a comunity neds asesment completed in the aftermath of Huricanes Irma and Maria ; STEMC UDS data reports; other neds asesments completed for various programs acros the Teritory ; and enrolment and dropout data published by the V.I. Department of Education. STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 xi T HE C OMUNITY – D EMOGRAPHIC P ROFILE The information included in the Neds Asesment is intended to strengthen the understanding of the context within which STEMC operates to met the neds of vulnerable families in the St. Thomas - St. John District, broadly, but more particularly, its largest client pol, which comes from its catchment area. The Teritory Ba sed on the 2015 Virgin Islands Comunity Survey (VICS) the folowing is a snapshot ∂≠ȱªØ¨ȱ3¨ππ∞ª∂π¿Ȃ∫ȱπ¨∫∞´¨µª∫DZ Population ‹ The 3¨ππ∞ª∂π¿Ȃ∫ȱ∑π¨´∂¥∞µ®µª≥¿ȱ!≥®™≤ǰȱ¥º≥ª∞π®™∞ declining ( 10,728 in 2015 ) compared to 106,405 in 20 10 . ‹ The population has ben aging since the 2010 Census evidenced by a median age of 4.5 in 2015 compared to 39.2 in 2010. Family Structure ‹ The predominant famil y composition ( 58%) is that of a single - female head of household . ‹ Single - female headed households acount for 50% of households living below the poverty level in the USVI in 2015. Selected Economic Characteristics ‹ Fifty percent ( 50% ) of the households in the Teritory reported earning at or below the median income level of $3 3,964 . ‹ Twenty percent ( 20% ) ∂≠ȱªØ¨ȱ3¨ππ∞ª∂π¿Ȃ∫ȱ∑∂∑º≥®ª∞∂µ reported having no medical insurance. The St. Thomas - St. John District Key socio - demographic factors of note for the St. Thomas - St. John District include: ‹ St. Thomas - St. John District residents aco ºµªȱ≠∂πȱśŘƖȱ∂≠ȱªØ¨ȱ3¨ππ∞ª . ‹ Fifty - five percent ( 5% ) are f emale and residents are predominantly Black ( African Caribean or African American) . ‹ Twenty percent (20%) of residents speak a language other than English at home and 2% of residents were categorized as living below the poverty level . ‹ Twenty - five percent ( 25% ) of residents are uninsured and 60% of persons with health insurance were covered by private insurance . STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 xi The STEMC Catchment Area ‹ The eastern third of St. Thomas and the populated centers of St. John coincide with STEMC Ȃ∫ȱ™®ª™Ø¥¨µªȱ®π¨® representing densely populated low to moderate income areas. ‹ STEMC Ȃ∫ target population can best be described as the low income, medicaly underserved and unserved , and uninsured or underinsured vulnerable children and families who live below the poverty line. ‹ Maps of damages and loses to structures from the huricanes of 2017 show great impacts and chalenges in the catchment area of STEMC clients, including the destruction of a public housing comunity in Tutu, which resulted in the relocation of al residents . K EY F INDINGS BRFS 2016 B ased on the Teritory - wide 2016 BRFS , data related to o veral health status, health - related quality of life, health status and chronic conditions, social determinants of health and other key health outcomes we re captured for this report. ‹ More than one - third (37%) of Virgin Islanders describe d their overal health status as ȃ&∂∂´Ȅ and 42% described their general health status as ȃ$ø™¨≥≥¨µªȄ or ȃ5¨π¿ȱ&∂∂´Ȅ . ‹ Fifty - seven percent (57%) of participants reported that in the past 30 days, there were no days when they felt their physical healt h was not god. ‹ Almost two - thirds of the respondents (65%) indicated that there were no days, in the past 30 days, when physical or mental health ilnes restricted their usual activities. Health Status with Respect to Chronic Health Conditions ‹ Almost seve n in ten respondents have had tests for high blod sugar or diabetes within the past thre years; and 17% have ben told they have pre - diabetes. ‹ Only thre percent (3%) of the participants reported ever ben told they had a myocardial infraction . Healthcar e Aces and Quality ‹ Eighty - one percent (81%) have aces to coverage for healthcare , with one half (51%) of the respondents report ing that Medicare provides their health insurance coverage . ‹ Six in ten respondents (62%) indicated that they have a usual source of healthcare , an d 74% shared that they visited the doctor for a routine checkup within the past year . ‹ With re spect to cost, 16% of respondents reported that cost c ontributed to them havi ng to delay neded care and visits to the doctor ; and nine percent (9%) reported that there wa s a time in the past 12 months when they did not take medication due to cost. STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 xi Health Screnings ‹ Eight of every 10 participants reported that they did not receive the flu shot or flu vacine in the past 12 months; only 20% reported taking the flu shot. ‹ Les than one - half of the respondents (49%) self - reported ever ben tested for HIV . ‹ For diabetes screning, nearly s even in ten (69%) reported ever having blod sugar tests in the past thre years . ‹ Having a mamogram for b reast cancer screning, 81% reported in the afirmative to that survey question, while the findings show that nine of every ten respondents shared tha t they have had a Pap test for cervical cancer screning. ‹ With regards to colon cancer screning, only 56% of Virgin Islanders have ever had a sigmoidoscopy/colonoscopy. Other Health - related Behaviors and Outcomes ‹ Teritory - wide, aproximately one in thre adults (32.2%) were clasified as obese and just over one - third ( 36.6%) were clasified as overweight. Sixty - five percent (65%) of men were clasified as overweight ( 39.8%) or obese (25.2%). That percentage was higher for women, with 71.2% of women c lasified as overweight (34.6%) or obese (36.6%). ‹ Fifty - five percent (5%) of the respondents reported visit ing a dentist in the past 12 months , and an aditional 14% visited the dentist more than one year but les than two years ago . ‹ Alcohol and tobaco use may lead to major health risks when used alone and together. Almost one in five (19%) indicated that they have smoked as least 10 cigaretes in their lifetime and 40% of the respondents self - reported having 2 Ȯ 3 drinks per day in the past 30 days. ‹ Seventy - six percent (76%) of participants reported engaging in physical activities, beyond their regular job during the past month. ‹ Ninety - ªØπ¨¨ȱ∑¨π™¨µªȱǻşřƖǼȱ∂≠ȱπ¨∫∑∂µ´¨µª∫ȱπ¨∑∂π ®≥殿∫Ȅȱ樮πȱ®ȱ seatbelt when driving or riding in a car. YRBS 2017 Health Behaviors ‹ While very few public - schol students in the St. Thomas - St. John District reported ever having tried cigarete smoking (6.6% - high schol; 7.1% midle schol), almost one in four (24.2%) high schol students and 16.6% of midle schol students reported having ever used an electronic vapor p roduct. ‹ More than half (57.4%) of midle schol students and 40.6% of high schol students reported never having had a drink of alcohol . For those repo rting having had an drink of alcohol , about thre in 10 (30.2%) midle schol students had their first drink at 12 or younger and more than one in thre (37.3%) high schol students reported having their first drink of alcohol at age 13 or older. STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 xiv ‹ While 40.3% and 4.6% of midle and high schol students, respectively reported eating breakfast every day in the seven days prior to completing the YRBS, 2.8% of high schol students reported not eating a fruit and 5.6% reporting no t eating a gren salad in the seven days prior to completing the YRBS. ‹ Though just over thre in 10 high schol students (31.7%) and 24.2% of midle schol students said that they do not watch TV on an average schol night, 36.8% of high schol students an d 46.8% of midle schol students reported spending five or more hours a day playing video or computer games not related to completing schol work. ‹ Almost one in four high schol students (24.3%) and one in five midle schol students (21.2%) reported that they had not ben physicaly active for at least 60 minutes any day during the seven days prior to completing the survey. Physi cal Environment ‹ About one in four high schol students (24.6%) and thre in 10 midle schol students (29.7%) reported not feli ng safe at schol . ‹ More than four in 10 high schol students (42.2%) and midle schol students (43.8%) indicated that there was gang activity at their schols. ‹ While 17.5% of high schol students reported being bulied at schol, twice that proportion, 35.1% of midle schol students reported being bulied at schol. Sexual Behaviors ‹ While aproximately thre in 10 high schol students ( 29.1%) reported ever having had sexual intercourse , fewer than two in 10 midle schol students (15.8%) rep orted ever having had sexual intercourse. ‹ While 9.5% of midle schol students reported having had sexual intercourse for the first time when they were 12 or younger, the largest proportion (15.7%) of high schol students who reported having had sexual int ercourse indicated being 15 or older when they first had sexual intercourse. Depresion and Suicide Ideation and Behaviors (SIB) ‹ More than one - third of high schol students (36.8%) and midle schol students (3.9%) reported that during the past 12 months they felt so sad or hopeles every day for two weks or more in a row that they stoped doing some usual activities. ‹ Just over one in five midle schol students ( 21.3%) re sponded in the afirmative regarding seriously considering atempting suicide in the past 12 months compared to 17.3% of high schol students. ‹ With respect to making a plan about atempting suicide in the past 12 months, 13.6% of high schol students and 1 4.5% of midle schol students responded afirmatively. ‹ While midle and senior high schol students acknowledged seriously considering suicide and even making a plan, 92.6% and 8.7% of midle schol and high schol students, respectively indicated that t hey had never atempted suicide. STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 xv Behavioral Health Asesment 2018 Children and Youth Elementary Schol Students Over 1 5 0 elementary schol students enroled in grades 4 th through 6 th in eight public schols and nine private and parochial schols in the St. Thomas - St. John District completed the 10 - item CTSQ ǰȱæ∞ªØȱ∏º¨∫ª∞∂µ∫ȱ®µ™Ø∂π¨´ȱ∞µȱ∫ªº´¨µª∫Ȃȱ Maria . Some key findings are noted below . ‹ Over Ø®≥≠ȱ∂≠ȱªØ¨ȱ∫ªº´¨µª∫ȱǻśŘƖǼȱ®µ∫æ¨π¨´ȱȃ8¨∫ Ȅȱª∂ȱªØ¨ȱ∏º¨∫ª∞∂µǰȱ ȃ#∂ȱ¿∂ºȱ≠¨¨≥ȱ∂πȱ ªØ¨ȱغππ∞™®µ¨∫ȱ®π¨ȱ®©∂ºªȱª∂ȱØ®∑∑¨µȱ®Æ®∞µǵȄ and śŚƖȱπ¨∫∑∂µ´¨´ȱȃ8¨∫Ȅȱª∂ȱª ȃ#∂ȱ ¿∂ºȱØ®Ω¨ȱ≥∂ª∫ȱ∂≠ȱªØ∂ºÆت∫ȱ∂πȱ¥¨¥∂π∞¨∫ȱ®©∂ºªȱ ‹ For four of the 10 items, there was a statisticaly significant diference in the number of Æ∞π≥∫ȱæØ∂ȱ®µ∫æ¨π¨´ȱȃ8¨∫Ȅ to the questions compared to boys. Two of the questions were: ȃDo you fel or act as if the huricanes are about to hapen again Ȅ? and ȃDo you fel upset by reminders of t he huricanes? Ȅ ‹ For nine of the 1 0 items, there was a statisticaly si gnificant diference in the afirmative responses of children by grade level, with more 4 th graders responded afirmatively to items than 5 th or 6 th graders. Secondary Schol Students A total of 375 7 th to 12 th graders atending private and parochial schols in the St. Thomas - St. John Dist rict completed the 24 - item Child PTSD Screning Scale (CPS) . Aproximately 52% identified as female and 52% of the students were 7 th or 8 th graders. The mean age was 13.7 (SD=1.84). Some key findings are noted below. ‹ !®∫¨´ȱ∂µȱ∫ªº´¨µª∫Ȃȱπ¨∫∑∂µ∫¨∫ǰȱ one in thre students Ȯ 3.4% Ȯ may be at risk for PTSD. ‹ The findings reveal a si gnificant negative relationship betwen PTSD scores and age, with y ounger students having higher PTSD scores than older students. ‹ The findings also revealed a significant positive relationship betwen PTSD scores and Functional Impairment scores, with students having higher PTSD scores having higher Functional Impairment scores, signaling that youth more likely to be at risk for PTSD are more likely to have chalenges in c ertain areas of their lives. Adults '∞ÆØ≥∞Æت∫ȱ∂≠ȱ≠∞µ´∞µÆ∫ȱ©®∫¨´ȱ∂µȱ®´º≥ª∫Ȃ responses to a batery of instruments used to colect data on the ir behavioral health in the aftermath of Huricanes Irma and Maria. Key findings are noted below. ‹ Using the CESD - 10 to ases depresion, 54.7% of adults could be clasified as having depresive symptoms. ‹ Based on a measure of PTSD , the PCL, 58% of adults had scores higher than 30, sugesting posible PTSD symptoms . STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 xvi ‹ With respect to stres, based on responses to the Perceived Stres Scale, 81.7% of respondents could be clasified as having moderate stres and 10.2% as having high stres. ‹ Based on responses to the General Self - Eficacy scale, 59% of respondents could be clasified as having moderate to high self - efica cy. ‹ With respect to resilience, as measured by the Brief Resilience Scale, 17.4% could be clasified as having low resilience , 68.6% as having normal resilience, and 14% as having high resilience. STEMC HRSA - UDS 2016 - 2019 The District - level and center - level data provide an even clearer picture of the overal health status, to include health - related quality of life, health status and chronic conditions, social determinants of health and other key health outcomes of Virgin Is landers. The data show that : ‹ STEMC served 738 total patients in 2019 , with the patients in the 18 Ȯ 64 age group consistently mak ing up the largest category of those treated anualy betwen 2016 and 2019 . ‹ There is an increasing number of patients being treated at the health center who are not native English language speakers. The percentage of patients best served in a language other than English has increased from nine percent in 2016 to 16% in 2019. Health Status of STEMC Clients with Respect to Chronic Health Conditions ‹ Betwen 2016 and 2019, there was a dramatic increase (64%) in the number of patients presenting with hypertension and a 47% increase in those presenting with diabetes during the same period. ‹ The number of patients presenting with persistent asthma treated with pharmacological intervention fluctuate d , during the period under review. Notably, t here was a 36% decrease in the total number of patients treated at the health center betwen 2016 and 2019 . ‹ The number of diabetic patients wi th porly controled hemoglobin A1C or no test during the year ranged from 136 in 2016 to 195 in 2018, before declining to 178 in 2019. ‹ For symptomatic/asymptomatic HIV patients, 2019 saw the highest number of total patients (76) being treated at STEMC. The 2019 totals reflect a 36% increase over the 2016 patient load. Healthcare Aces and Quality and Other Health Outcomes ‹ An increasing number of patients are receiving dental and mental health services at the health care center. The percentage change betwen 2016 and 2019 for dental and mental services is 64% and 1 4 7% respectively. ‹ An average of 98% of STEMC patients are at or below 20% of Federal Poverty Guideline resulting in m ore than one half of the clients served at STEMC rely ing on STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 xvi Medicaid or CHIP for insurance coverage for health care. Uninsured patients comprise the second largest group of patients served at the health center . ‹ Among pregnant women, 5% to 65% of th ose receiving perinatal service at the Center acesed care in their first trimester. C lient Satisfaction STEMC administers patient satisfaction surveys to ascertain client satisfactio n with services and to u se responses to improve service delivery. Key findings from the 2019 Patient Satisfaction Survey are noted below. ‹ Ninety - s ix percent (9 6 %) of respondents reported being satisfied or very satisfied with the overal care received at STEMC (4.67 on a 5 - point Likert scale). Likewise, 96% of respondents reported that the operating hours are convenient for them . ‹ Ninety - seven percent ( 97% ) of clients indicate d that they would refer their family and friends t o the Center for health care services . ‹ Providers ( nurses , physicians, dentists , psychologist , and physician asistant ) received the highest rating with respect to client satisfaction Ȯ 4.72 on a 5 - point Likert scale. ‹ Clients were least satisfied with the w ait time (including waiting in the waiting or exam rom , waiting for procedures and results) they had before receiving services . P RIORITY H EALTH AND P ROGRAMATIC I SUES Priority health isues emerged from the secondary and administrative data reviewed are noted below, while the priority programatic isues emanate primarily from the Patient Satisfaction Survey findings , Case Managers and Outreach Workers focus group discusion findings , and pr iority programatic focus areas documented by the STEMC leadership . Key priority health and programatic isues are noted below. Priority Health Isues ‹ Neded h ealth education for adults in the areas of health screnings , dental health, and weight manage ment. ‹ Neded health education for adolescents around nutrition, sedentary behavior , and unprotected sex. ‹ Neded health education for pregnant women around the importance of acesing prenatal care in the first trimester. ‹ Ned to adres b ehavioral health i sues particularly around depresion and PTSD for adults, adolescents, and children. ‹ Ned to adres reduction of non - academic - related scren time for adolescents. ‹ Ned to adres physical environment for adolescents in schol setings with respect to reported gang presence in USVI public midle and high schols. ‹ Increasing aces to secondary and tertiary cancer treatment particularly for clients who are uninsured, underinsured, and those insured through Medicaid. STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 xvi Priority Programatic Isues ‹ Continued expansion of behavioral health providers and services to STEMC clients, to include children and adolescents . ‹ Expansion of curent colaborations by establishing tar geted colaborations with VIDE to adres risky health behaviors, behavioral health isues, and safety considerations asociated with the physical environment of public secondary schols in the St. Thomas - St. John District . ‹ Formalization of colaboration a grements/understandings with VIDHS and other key government agencies for Case Managers and Outreach Workers to be able to timely and efectively asist clients neding suport. ‹ Explore options for identification of financial suport for uninsured and underinsured clients neding secondary and tertiary care, based on laboratory and other test results . ‹ Provide targeted training for Case Managers and Outreach Workers to be able to optimaly suport clients within the context of COVID - 19, to include consid eration of the ned for social distancing and facilitate increased use of Telehealth services . ‹ Mitigate wait - ª∞¥¨ȱ≠∂πȱ™≥∞¨µª∫ȱæ∞ªØȱπ¨∫∑¨™ªȱª∂ȱ®∑∑∂∞ experience during visits to the Center . S TRENGTHS , G APS , AND O PORTUNITI ES Strengths ‹ Responsivenes to recomendations of 2016 C 2 HNA as evidenced by the adition of a separate, dental health unit which provides dental services to pediatric and adult clients. ‹ Ongoing, incremental expansion of behavioral health providers and se rvices available to clients. ‹ Expansion of non - clinical staf Ȯ Case Managers and Outreach Workers Ȯ to suport clients as they navigate chalenges and aces neded secondary and tertiary care and related services. ‹ Expansion of pharmacy and laboratory serv ices for clients. ‹ Providing care for an increased number of clients after disruptions asociated with huricanes in 2017 and despite dificult conditions of the recovery . ‹ Availability of services and informational campaigns suporting an increase in scre nings for colorectal cancer and cervical cancer. ‹ Maintenance and expansion of agrements with key agencies within the V.I. Government and other medical facilities within and outside the Teritory in suport of mision fulfilment. ‹ Sought and sucesfuly obtained grant funding and comunity suport for improving staf and services, including outreach and transportation services for clients neding targeted suport. STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 xix Gaps ‹ Insuficient staf with language skils to met growing comunication neds of diverse client pol. ‹ Ned for targeted programs to adres patient suport for management of key chronic ilneses, to include obesity, hypertension, HIV, cancer, and overal welnes. ‹ Minimaly targeted services for adolesc ents. ‹ "≥∞¨µª∫Ȃȱ™∂¥∑≥®∞µª∫ȱπ¨Æ®π´∞µÆȱæ®∞ª - time may signal the ned for aded providers. ‹ Because of COVID - 19 and social distancing requirements, curent space does not alow for the provision of targeted clients services by Case Managers and Outreach Worker s at the Health Center. ‹ Insuficient programs to provide special information and suport neded for disease - management and welnes of children and adolescents and geriatric clients (ages 65 and older) . Oportunities ‹ Targeted colaboration with the publi c education system in the St. Thomas - St. John District to adres identified health priorities for children and adolescents, particularly around behavioral health isues, the physical schol environment for midle schol and high schol students, and nutri tion education. ‹ New or expanded MOAs and colaborations asociated with funding in suport of huricane recovery and resilience and climate change impact mitigation , especialy focused on public health isues . ‹ Expansion of telehealth, outreach, and case ma nagement to mitigat e negative impacts of COVID - ŗşȱ∞¥∑®™ª∫ȱ∂µȱ™≥∞¨µª∫Ȃȱب®≥ªØǯ ‹ Expansion of physical space at Health Center to acomodate new realities asociated with COVID - 19. ‹ Consideration of revisiting apointment scheduling or increase of providers to reduce client wait - time while at Health Center to se providers. ‹ The modification of training for outreach personel and providers to include bilingual comunication and consideration of conversational English clases for clients based on the demographic shifts in populations served by STEMC . C ONCLUSIONS AND R ECOMENDATIONS The contextual information and findings presented i n this neds asesment provide a solid foundation upon which the STEMC leadership can continue to build and expand the services provided to clients as wel as the continued growth and development of both clinical providers and other suport personel that are part of the Center. The findings afirm the diversity and complexity of the context within which STEMC operates, but also ´¨¥∂µ∫ªπ®ª¨∫ȱªØ¨ȱ∫¿∫ª¨¥®ª∞™ȱ∞µ™π¨®∫¨ȱ∂≠ȱªØ¨ȱ"¨µ - driven ®∑∑π∂®™Øȱª∂ȱ¥¨¨ª∞µÆȱ™≥∞¨µª∫Ȃȱ¥¨´∞™®≥ǰȱ´¨µª®≥ǰȱ® - social ne eds through integrated STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 x services and partnerships with a ranges of entities and providers within and outside 23$$,""Ȃ∫ȱ™®ª™Ø¥¨µªȱ®π¨®ǰȱªØ¨ȱ2ªǯȱ3Ø∂¥®∫ - St. John District, and the Teritory. 3بȱ≠∞µ´∞µÆ∫ȱ®≠≠∞π¥ȱ™≥∞¨µª∫Ȃȱ™∂µª∞µº¨´ȱ∫®ª∞∫ s received through the Center and reveal that, despite the significant disruption in infrastructure, educational, healthcare, and other areas of the Teritory generaly, and the St. Thomas - St. John District, in the aftermath of Huricanes Irma and Maria, S TEMC, some thre years later, has not only ben able to expand services in the areas of behavioral health, case management and outreach, laboratory, and pharmaceutical services to clients, but has ben able to build back the number of clients served to n umbers close to pre - huricane levels. Five recomendations are ofered: ‹ First, STEMC neds to recognize what it does wel and build on this, particularly in the area of the provision of high quality care and services to clients, as evidenced from client satisfaction survey results. ‹ Second, STEMC should incorporate, within its strategic priorities, adresing the health and programatic priorities noted, and, in particular, adresing areas where indicators related to client health outcomes fal short of Healthy People 2020 targets . ‹ Third, STEMC should embrace and act on t he oportunities enumerated, particularly around increased colaboration to expand its reach to suport clients . ‹ Fourth, within the curent realities of COVID - 19, STEMC should make the neded investment to ensure that optimal telehealth services are prov ided to clients and that oportunities are provided to suplement telehealth services with face - to - face services ª∂ȱ¨µ∫ºπ¨ȱªØ®ªȱªØ¨ȱ"¨µª¨πȂ∫ȱ¥∂∫ªȱΩº≥µ¨π®©≥¨ȱ ‹ Fifth, STEMC should continue to anchor decisions around s ervice expansion, colaboration, and overal priorities in the best data available so that clients most critical medical, dental, and behavioral health care neds can be met, thereby improving the health and wel - being of as many STEMC clients as posibl e, on an ongoing basis. STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 1 INTRODUCTION O VERVIEW The St. Thomas East End Medical Center Corporation (hereinafter STEMC) is one of two federaly qualified health centers (FQHCs) in the U.S. Virgin Islands (USVI) and the only FQHC in the St. Thomas - St. John District . Established in 20 as a private, non - profit corporation, STEMC as a National Health Services Corps site ensures the availability of primary healthcare to the residents of the St. Thomas - St. John District, regardles of age, educational level, primary language, citizenship status, or economic status, through the use of a discounted/sliding scale fe schedule. Though STEMC has clients from al geographic locations acros the St. Thomas - 2ªǯȱ)∂صȱ#∞∫ªπ∞™ªǰȱªØ¨ȱ%0'"Ȃ∫ȱ™®ª hment area comprises thre census sub districts on St. Thomas, namely, East End, Tutu, and Southside , and al census sub districts on St. John. Together, the census sub districts encompas 1 estates Ȯ 64 on St. Thomas and 47 on St. John. Based on the n umber of clients served through its delivery of comprehensive primary healthcare services, STEMC is recognized as one of the largest service providers in this sector in the St. Thomas - St. John District. STEMC has colaborative agrements with the Virgi n Islands Department of Health (VIDOH), the Virgin Islands Department of Human Services (VIDHS), and the Schneider Regional Medical Center (SRMC) which operates the only public hospital in the St. Thomas - St. John District. With respect to funding, STEMC is a Health Center Program grante under 42 U.S.C. 254b and is demed a Public Health Service employe under 42 U.S.C. 23(g) - (n). STEMC also receives funding from the Government of the Virgin Islands (GVI). STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 2 B ACKGROUND The Caribean Exploratory Research Center (herein after CERC or CERC - UVI) is a part of the Schol of Nursing (SON) at the University of the Virgin Islands (UVI). CERC and STEMC have colaborated in a number of projects over the years, with STEMC active ly engaged as a partner over a five - year period while CERC lead the Human Services Research Partnerships: U.S. Virgin Islands (HSRP - VI), a project funded by the Administration for Children and Families (ACF) within the Department of Health and Human Servic es (DHS). The project brought key comunity partners together to lok at Head Start (HS), Early Head Start (EHS), and the Temporary Asistance for Nedy Families (TANF) and how families were being served through these programs to improve their overal out comes . Aditionaly, CERC completed a comprehensive comunity health neds asesment (C 2 HNA) for STEMC betwen April 2015 and February 2016, which provided critical information on gaps and oportunities that informed eforts by STEMC to improve and expand services, particularly in the areas of dental health services and behavioral health services. More recently, CERC completed an evaluation of a public education and awarenes program that STEMC conducted to increase comunity awarenes and health l iteracy regarding the efects of climate change on the health of U . S . V irgin Islands (USVI) residents. Within this framework, STEMC engaged CERC UVI to conduct a comunity health neds asesment (CHNA) , to update information reported in the 2016 C 2 HNA. P URPOSE AND S COPE 23$$,""Ȃ∫ȱ¥∞∫∫∞∂µȱ∞∫ȱª∂ȱȃ∑π∂¥∂ª¨ȱ™∂¥∑π¨Ø¨µ∫∞ - efective primary health care services , through integrated clinical practices, education, ™∂¥¥ºµ∞ª¿ȱ∂ºªπ¨®™Øȱ®µ´ȱπ¨∫¨®π™ØǯȄ With its recognition that to f ulfil its mision, there is a ned to ground decisions regarding care and resource alocation in the most curent data, STEMC engaged CERC to conduct its 2019 - 2020 Comunity Health Neds Asesment. STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 3 The CHNA, completed within the framework of the socia l determinants of health adreses and reports on the folowing: 1. Key population information on curent residents of the USVI (based on the most curent Virgin Islands Comunity Survey [VICS] ). 2. A description of the social and economic context of the USVI (adreses Economic Stability and Social and Comunity Context ). 3. Information on households and families. 4. Documentation of the education, health, nutrition, and social services neds of children and families in the STEMC catchment area. 5. Documentation of the economic, social, educational, health, and environmental factors that impact eligible children and families in the STEMC catchment area. 6. Documentation of resources available to serve children and families in the district and catchment areas; and, 7. Delineation of the gaps, strength, and oportunities of the comunity and of STEMC. STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 4 COMUNITY DEFINED : POPULATION AND DEMOGRAPHIC PROFILE This section of the CHNA provides key population information on curent residents of the USVI, primarily based on the most curent Virgin Islands Comunity Survey [VICS], published in 2018, but based on data colected in 2015. As such, when used as a source, reference wil be made to the 2015 VICS. Aditionaly, this section of the CHNA provides a d escription of the social and economic context of the USVI , paying atention to factors that ∞¥∑∞µÆ¨ȱ∂µȱªØ¨ȱ3¨ππ∞ª∂π¿Ȃ∫ȱ¨ conomic s tability . The information also provides an understanding ∂≠ȱªØ¨ȱ™∂¥¥ºµ∞ª¿ȱ™∂µª¨øªȱ∂≠ȱ3¨ππ∞ª∂π¿Ȃ∫ȱ®µ´ȱ the St. Thomas - St. John Di strict. Finaly, this section provides information on the composition of households/families in the Teritory. This information provides an understanding of the context within which STEMC operates to met the neds of vulnerable families in the St. Thoma s - St. John District, broadly, but more particularly, its largest client pol, which comes from its catchment area. Population The population of the USVI continues to be a multiracial, multiethnic diverse group, living on the thre major islands of the Te ritory. The population has continued to decline , T eritory - wide. However, a review of Figure 1 reveals a slight increase in the population on St. Croix from 2014 - 2015, while there were declines on both St. John and St. Thomas (which included Water Island ). Figure 1 . Population: Teritory and Islands œ 2014 and 2015 102,07 10,768 47,735 48,502 49,835 48,425 4,438 3,841 0 20,0 40,0 60,0 80,0 10,0 120,0 2014 2015 USVI St. Croix St. Thomas St. John STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 5 The population of the USVI has ben reported as declining from the 106,405 r eported in 2010 (US Census) to 102,07 in 2014 ( VI Comunity Survey) to 10,768 in 2015 (VI Comunity Survey). (Figure 1 ). In 2016 the USVI Bureau of Economic Research provided a non - census report estimating the population to be 97,373, continuing the decline sen since 208. There is no oficial single estimate of the extent of the population decline in 2017 due to the two Category 5 Huricanes Ȯ Irma and Maria, but al thre main islands apeared to lose people based on informal and recovery counts, especialy with respect to e stimates b ased on economic activity or schol populations . Post huricane neds asesments reported reductions in schol enrolment from 13,194 in SY2016 - 2017 to 10,86 in SY2017 - 2018 (Michael, et al., 2019) that could be used as indications of population changes. Data from the 2020 Census proces are expected to answer questions regarding volatility and trends in the population folowing the 2017 huricanes and to some extent the impact of the COVID - 19 pandemic. In 2015 the US Virgin Islands was characterize d as ap roximately 50% female , 80% Black (African American or African Caribean), 1.5% White and 8.5% Other Races with 16% of the population reporting Hispanic rots in the VICS 2015. (Figure 2 ). On the island of St. Croix, as has ben reported in the past, aproximately 1 in 4 individuals identify as having Hispanic rots, the highest percentage in the Teritory. On St. Thomas and St. John, the population is aproximately ten percent and twenty - one percent Hispanic , respectively. The economic and health c halenges of the Teritory are exacerbated by the requirements and streses of living with huricane recovery and COVID - 19 conditions . The 2015 VICS reported that the numericaly declining USVI population was also an aging population with the median age o f 4.5, a five - year increase from the median age of 39.2 reported in 2010 (U.S. Census Bureau 2010). The data indicate that before the aditional impacts of the huricanes and the pandemic, 62% of the population was older than 35 years of age while only 2 0% was 19 years old or younger. As the USVI population continues to change, the recognition that at least 41% of the population is over 50 years of age wil require focused atention on emerging neds and changes in healthcare, education, the workforce, p ublic STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 6 housing, especialy while adresing the requirements for adaptation to climate impacts, disaster preparation and disease outbreaks. Figure 2 . USVI Population by Ethnicity: Teritory and Island s , 2014 and 2015 Figure 3 . USVI 2015 Population by Age Group : Teritory and Islands Source: VICS 2015 The decline in the USVI population over the last 2 decade s has not decreased the diversity of the comunities on the thre major islands. The population of the USVI comprises various size groups of people from many places, with the largest groups asociated with the island - states and teritories of the Caribean and states of the US. In both the 2014 and 2015 17,093 84,914 16,081 84,68 1,052 36,684 10,302 38,201 5,416 4,419 5,106 48,425 626 3,81 673 3,168 0 10,0 20,0 30,0 40,0 50,0 60,0 70,0 80,0 90,0 Hispanic Non-Hispanic Hispanic Non-Hispanic 2014 (Total Population 102,07) 2015 (Total Population 10,728) USVI St.Croix St.Thomas St.John 4,10 5,109 5,37 5,415 18,80 2,927 2,380 17,890 2,297 2,397 2,901 3,05 9,63 9,935 9,409 8,156 1,717 2,496 2,368 2,326 8,159 1,871 1,712 9,186 96 216 108 84 1,06 1,120 1,259 546 0 5,0 10,0 15,0 20,0 25,0 Under 5 years 5 to 9 years 10 to 14 years 15 to 19 years 20 to 34 years 35 to 49 years 50 to 64 years 65+ years USVI St. Croix St. Thomas St. John STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 7 VICS , i ndividuals from Canada, Europe, Central and South America, India, the Midle East, China , and African countries are clasified in the Elsewhere category . The 2015 VICS reports the largest group of residents born outside of the USVI come from the island - states of the Carib bean, with English and French Creole speakers from Dominica contributing 15% and Spanish speakers from the Dominican Republic ading 14% to this group. Primary Language Spoken at Home Acros the Teritory , 24.7% of individuals over 5 years of age reported speaking a seco nd language in the home, while in the St. Thomas - St . John District, 21% indicated a second language was spoken at home. Although English is the primary language spoken in the US Virgin Islands , on each of the thre main islands everyday life requires the integration and recognition of various aspects of the diverse cult ures and ethnicities i n the population as a part of comunity Ȯbuilding. The 2015 VICS reports Spanish and French Patois or Creole as the two most prevalent non - English languages spoken by individuals over 5 years old in the USVI (Figure 4 ). Acros the Teritory, sixty percent of the second language speakers are conversing in Spanish that may reflect the dialects and vocabulary of the Latin cultures represented in the comunity, includi ng Puerto Rico, the Dominican Republic, Cuba and South American countries. Figure 4 . First Language Spoken at Home for Persons over 5 Years Old : Teritory and Islands, 2015 14,36 8,060 8,892 3,58 4,671 4,179 803 294 0 2,0 4,0 6,0 8,0 10,0 12,0 14,0 16,0 1st Language Spanish 1st Language French, Patois, Creole USVI St. Croix St. Thomas St. John STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 8 Source: VICS 2015 Family Structure Families in the USVI are also diverse in structure, yet it is comon to find them characterized by the shar ing of a special type of kinship that comes in difer ent forms but focuses on suport and decision - making critical to producing engaged, productive comunity members. The dominant family structure in the USVI is the single female as head of the household with at least one child. In 2015 the US Census Bureau reports 23% of United States ( US ) families as having a single female as the head of the household, in comparison to 58% of families in the USVI having a single female as the head of the household. Figure 5 presents the USVI po pulation by family composition based on 2015 VICS data. Single - female households made up 50% of households living below the poverty level in the Teritory in 2015 . Figure 5 . USVI 2015 Population by Family Composition Selected Economic Characteristics The USVI, like other smal island groups, must adres the chalenges asociated with the economic costs of being physicaly isolated from the US mainland and large markets by over a thousand miles of ocean, limited natura l and institutional resources, and vulnerability to natural hazards like huricanes and earthquakes , within the constraints of limited human resources because of size. Employment and economic activities in the USVI have ben in a weakened state since 20 8 begining with the econom ic contract ion due to the Great Recesion , 4607 , 23% 1479 , 58% 2018 , 10% 860 , 5% 76 , 4% Maried Couple Female Parent Only Male Parent Only Grandparents Other Relatives or Non-Relatives STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 9 the aded stres in 2012 when the oil refinery on St. Croix closed , and the economic impacts of recovery from huricane devastation in 2017 . (USVI Bureau of Economic Research). These conditions have negatively impact ed the standard of living and quality of li fe of Virgin Islands residents and their families through downturns in employmen t and an increased ned for migration . Figure 6 . USVI Household Income Levels: Teritory and Islands, 2015 The most recent negative impacts on the USVI economy and the standard of living in the Teritory came from Huricane s Irma and Maria in 2017 and the COVID - 19 pandemic t hat began t o be evide nt in this region in March 2020. The USVI Bureau of Economic Research reported unemployment levels in 2016 at 1.5 % , shrinking of the Teritorial GDP by 1.7% in 2017 as a consequence of the category 5 huricanes, unemployment at aproximately 10.5% for 2 years as recovery efort s unfolded under conditions of a smaler workforce and dec r eased economic activity , and a spike to over 13% in unemployment asociated with forced lockdowns and closures in response to the COVID - 19 pandemic. The short to medium - term future of t he USVI wil be characterized by recovery from economic downturns and Category 5 huricanes and require atention be given to the 20% (5,197) of t he families in the Teritory that are living below the Federal Poverty Line (2015 18,461 6,807 9,07 7,260 3,732 3,853 10,27 2,710 4,151 3,090 1,19 1,540 7,676 3,873 4,453 3,571 2,192 2,101 560 24 402 59 340 212 Les than $24,9 $25,0 to $34,9 $35,0 to $49,9 $50,0 to $74,9 $75,0 to $9,9 $10,0 and Over USVI St. Croix St. Thomas St. John STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 10 VICS) , especialy the 49.5% (2,594) of these families that have single - female householders. Part of the chalenge can be sen in Figure 6 which shows that 2,356 households (49.8%) are earning at or below the median income level of $3,964, disqualify ing some households from receiving asistance even though they are not earning enough to fuly adres the costs of living with their income . These dificult economic conditions and disruptions in paterns of life are increasing stres levels and resulting in escalated signals that the Teritory may have to adres PTSD as a part of its comunity development and public health plans going forward (Michael, N. et.al. 2019) . The St. Thomas - St. John District The St. Thomas - St. John district, the location of and most imediate area served b y STEMC, was reported in the 2015 VICS as h aving 52% of the Teritorial population. The St. Thomas - St. St. John population , much like the entire Teritory was 5 % female, predominantly Black ( Afr ican Caribean or African American ) and agin g. The median age of the St. Thomas - St. John population was 45.2 years of age, more than a year and a half ol d er than the St. Croix population median age of 43.6. The decline in total population number reported at the teritorial level is mirored in the St. Thomas Ȯ St. John district . The diversity of the St. Thomas - St. John district was reflected in the VICS 2015 report indicating 2 0 % of the popul ation speaking a language other than English at home , mostly French Creole or Patois and Spanish, but it was lower than t he 28% of the population on St. Croix that did not speak English as the first language at home. The impacts of Huricanes Irma and Maria in 2017 and the COVID - 19 pandemic in 2020 include fluctuation s in the population size and composition that should be documented in the 2020 Census reports , along with changes in median age and levels of diversity in the population. The 2015 VICS reported 20% of the USVI population l i ving below the poverty level as compared to 13.5% of the entire US living below the line. T h is socio - demographic parameter highlights one of the diferences betwen the isla nds in the St. Thomas - St. John district. On St. John, 12% of families w ere reported as living below the poverty line , with 36% of this group STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 1 having children younger than 18 years old. In contrast, on St. Thomas, 2 % of families were categorized as livi ng below the poverty line , with 49% of this group inc luding children in the family younger than 18 years old. The high poverty level in the Teritory has ben exacerbated and partialy fueled by high levels of unemployment over the last 10 yea rs. The VI Bureau of Economic Research reported improvements in e conomic activity in the Teritory had decreased unemployment to 8.6% in the St. Thomas - St. John district at the end of 201 8 as the recovery from Huricanes Irma and Mari a increased economic activity , but in the spring of 2020 the eforts to contain the spread of COVID - 19 in the Teritory resulted in a spike of unemployment to 13.5% . The cost of health care services and managing the high levels of non - comunicable diseases (NCDs) in the USVI are significant comunity chalenges, especialy with one in five individuals lack ing health insurance. In the St. Thomas - St. John district the last Comunity Survey in 2015 reported 25% of the district population as uninsured. By 2016 eligible families and children were benefiting from the increase in the Medicaid C ap in the USVI , alowing many that were previously uninsured to sek medical services on a more regular basis. Sixty percent of the individuals with medical insurance in the St. Thom a s - St. John district received coverage un der an employer like the VI Government or busines ( 2015 VICS ) . The STEMC Catchment Area As described on its website , STEMC serves persons from al zip codes acros the Teritory who ned preventative primary healthcare, dental services, and related healthcare ∫¨πΩ∞™¨∫ǯȱ'∂æ¨Ω¨πǰȱªØ¨ȱ23$$,""Ȃ∫ȱª®πƨªȱ∑ opulation can best be described as the low income, medicaly underserved and unserved who live below the poverty line. The STEMC catchment area was reported as predominantly Black, low to moderate income, and ethnicaly diverse, characteristics that reflect the St. Thomas - St. John district , but at higher levels than the entire district (US Census 2010) . STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 12 The comunities on St. Thomas and St. John and the specific catchment area that STEMC serves portray some unique characteristic s when compared to the Teritory in general. The eastern third of St. Thomas and the populated centers of St. John coincide with the catchment areas of STEMC and fal in densely populated low to moderate income areas. Figures 7 and 8 ilustrate the lev el of poverty, health insurance status and languages spoken at home for the multiracial and multi - ethnic residents in the STEMC catchment area (US Census 2010). Figure 7 . Race/Ethnicity and Language Spoken at Home: STEMC Catchment Area, 2010 Source: Eastern Caribean Center (EC) STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 13 Figure 8 . Poverty and Insurance Status: STEMC Catchment Area, 2010 Source: Eastern Caribean Center (EC) The huricanes of 2017 devastated the Teritory, especialy comunities on the islands of St. Thomas and St. John. The maps of damages and loses to structures show great impacts and chalenges in t h e catchment area of STEMC clients , including the destruction of a n entire public housin g (PH) comunity in Tutu (Figure 9) . T he same comunity was also required to help the students of one schol that was destroyed b y the storm adjust to the merging of two schols during the recovery. Economic downturn and recovery chalenges produce aditional stresors that may negatively impact health of the population. Figure 9 . Housing Units Damaged and Severity of Damage - STEMC Catchment Are a s STEMC 2020 COMUNITY HEALTH NEDS ASESMENT NOVEMBER 2020 14 O THER H EALTH S ERVICES A VAILABLE IN THE S T . T HOMAS - S T . J OHN D ISTRICT Table 1 . Healthcare Services Available in the St. Thomas - St. John District, 2020 3Ø∂ºÆØȱ23$$,""Ȃ∫ȱ™®ª™Ø¥¨µªȱ®π¨®ȱ™∂¥∑π∞∫¨∫ȱ∑π ®µ´ȱªØ¨ȱ∞∫≥®µ´ȱ∂≠ȱ2ªǯȱ)∂صǰȱ23$$,""Ȃ∫ȱ™≥∞¨µª∫ȱπ Aditionaly, over the past few years, STEMC has documented clients who list their island