Transforming HealTH in Prince george's counTy, maryland

258 Pages·2012·27.8 MB·English

Transforming HealTH in Prince
george’s counTy, maryland:
A Public HeAltH imPAct Study
univerSity of mArylAnd ScHool of Public HeAltH 
JuLY 2012
Table of Contents
Section i: Summary
introduction and PurPoSe i
SnaPShot of findingS ii
anSwerS to framing QueStionS iv
concluSion xix
recommendationS xx
ViSion xxii
Selected referenceS xxiv
gloSSary of Key termS xxv
Study team memberS and contributorS xxvii
adViSory committee memberS and ParticiPantS xxviii
liSt of tableS and figureS xxix
Section ii: technical rePortS
This document is available at sph.umd.edu/princegeorgeshealth.
Acknowledgements
The Study Team benefted from sound advice and input from a variety
of individuals. We extend our appreciation to and acknowledge the
support of individuals from the following organizations:
Prince GeorGe’S county HeAltH dePArtment And otHer Government entitieS
Prince GeorGe’S county office of tHe county executive
Prince GeorGe’S county dePArtment of PArkS And recreAtion
mArylAnd dePArtment of HeAltH And mentAl HyGiene
univerSity of mArylAnd extenSion
mArylAnd HeAltH cAre commiSSion
univerSity of mArylAnd medicAl SyStem corPorAtion
Introduction to the Public Health Impact Study of Prince George’s County
Prince George’s County, Maryland is poised for changes that will lead to improved
health and quality of life for its citizens. Plans for a transformed new regional health
care system that focuses on population health are under way through a unique
partnership among the County, the state and academic and health care institutions.
These plans come at a time of great momentum at the national, state and County
levels to advance health care reform and eliminate health disparities.
On June 28, 2012, the Supreme Court proactively pursuing strategies to pro- “strategy to transform the system into
upheld the constitutionality of the mote health equity, as demonstrated an efficient, effective and financially
Patient Protection and Affordable Care by the passage of legislation creating viable health care delivery system with
Act (ACA). Under the leadership of the “health enterprise zones” to expand and a regional medical center,” a system
O’Malley-Brown administration, the improve access to care in underserved that is “supported by a comprehensive
state of Maryland has created a Health areas. Prince George’s County Execu- ambulatory care network, which will
Benefit Exchange, designed to expand tive Rushern L. Baker, III has placed improve the health of residents of the
health care coverage and fulfill the health as one of his administration’s County and Southern Maryland region
provisions of the ACA. The state also is top priorities, and together with the by providing community-based access
County Council has taken deliberate to high quality, cost-effective medical
steps to enhance the County’s safety care” (from the July 2011 Memoran-
net system and to address social and dum of Understanding).
PRINCE GEORGE’S COUNTY environmental determinants of health. An interdisciplinary team of senior
AT A GLANCE To inform the design of this new School of Public Health researchers
system to improve health and health produced the Public Health Impact
The nation’s most affluent County with an
care in Prince George’s County, the Study of Prince George’s County by
African American majority
University of Maryland School of building upon existing relevant reports
Public Health was commissioned to and studies, such as the 2009 Rand
Maryland’s most diverse County: “minority”
assess the proposed system’s potential report, “Assessing Health and Health
groups account for more than 80 percent of
public health impact and to answer Care in Prince George’s County,” and
the population (blacks, whites and Hispanics
key questions. The study sponsors are collecting and analyzing a wealth of
made up 65 percent, 15 percent and 15 percent
Prince George’s County, the Maryland new data. Representatives of the study
of the population in 2010, respectively)
Department of Health and Mental sponsors served on the advisory com-
The second most populous County in the state Hygiene (DHMH), the University mittee that helped guide the study.
of Maryland (after Montgomery County) of Maryland Medical System and The study team learned from
Dimensions Healthcare System. These resident experiences; listened to policy-
Home to the University of Maryland, College
parties, plus the University System of makers, County and state leaders and
Park; NASA’s Goddard Space Flight Center;
Maryland, signed a Memorandum of health care providers; and explored and
Joint Base Andrews (previously Andrews Air
Understanding in July 2011 to address documented best practices from com-
Force Base) and USDA’s Beltsville Agricultural
long-standing challenges and gaps in parable health care systems. The study
Research Center
the health care delivery system and highlights policy-relevant opportunities,
achieve improved health for the County. focuses on improving health outcomes,
Bordered by Washington, D.C., and Montgomery,
The Public Health Impact Study of provides regional and sub-county
Howard, Anne Arundel, Calvert and Charles
Prince George’s County comes at an mapping of all categories of primary
counties in Maryland
early stage in the development of a care providers and assesses County
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University of maryland school of public health
resident-specific recent hospital dis- quality of life in the County, referrals, availability of specialty care
charge and readmission data. ™ address population health broadly, and perceptions of the quality of care
This study adds new information not focus just on those seeking at local hospitals. Almost 31 percent of
related to: health care, and residents who reported using a hospital
™ improve the capacity to deliver outside of the County did so because
™ how residents use and perceive high-quality primary prevention their physician referred them to do
health care and health issues in and health and hospital care. so, and 13 percent reported that their
the County, insurance coverage dictated their hos-
™ what works in other model health In the snapshot of our results from pital selection. Addressing these issues
care systems that can be applied each study component we highlight will require a multi-pronged effort
in Prince George’s County, findings that provide new informa- aimed at County residents, health care
™ how state and County leaders tion about health care in the County. providers and insurers.
and stakeholders perceive what is
needed for a new health care system Survey of County Residents Interviews with State, County
to succeed, We learned from the Random House- and Local Stakeholders
™ where there is an inadequate supply hold Survey of 1,001 County residents The study team conducted 40 personal
of primary care providers and (referred to throughout as “the survey”) interviews with key stakeholders. They
resources, about current use of and attitudes provided input regarding the current
™ what exists in the public health and toward health care services and gained status of the County’s health care and
public sectors to complement the an understanding of the factors that recommendations for the design of a
new system, and drive residents’ health care decisions. new health care system.
™ how residents with key chronic Key findings include: The lack of primary care resources
health conditions use hospitals in the and concerns about both the percep-
County and region. ™ While 75 percent of residents have tions of quality and the actual quality
a “personal doctor,” 10 percent of the current health care and hos-
of these residents go outside the pital system emerged as themes. As
A SNAPSHOT OF FINDINGS County to see this provider. one stakeholder put it, “Perception
FROM THE PUBLIC HEALTH ™ Of those who use a doctor outside becomes reality unless otherwise
IMPACT STUDY COMPONENTS the County, more than 7 percent challenged and the perception is that
indicated that their insurance we don’t have a good hospital system,
The study team used multiple novel required them to see a physician and for some parts, they’re right, but
and integrated approaches to answer outside the County, and more there are other parts of the hospital
the study’s key framing questions and than 7 percent reported being system that ought to be duplicated.”
to inform the design of the new system. unable to get an appointment with Recommendations for the new system
The Public Health Impact Study was a specialist inside the County. included the need for an academic
guided by the need to: university framework, culturally appro-
The frequency with which residents priate health education and prevention,
™ promote health, prevent disease use hospitals outside the County effective branding and centers of excel-
and support wellness, health remains an even greater issue, and is lence among others.
equity, health literacy and driven by insurance carriers, provider
STUDY COMPONENTS
Random survey of 1,001 Interviews with 40 Analysis and mapping Analysis of hospital Brief overview of public Interviews with leaders
County residents stakeholders of health care workforce discharge and readmis- and private sector from 13 health care
in the County sion data resources systems around the U.S.
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public health impact study
CATEGORIES OF KEY STAKEHOLDERS
Policymakers, elected officials Health practitioners Academic administrators Health system, insurance Community leaders
and administrators company and hospital
administrators
Health Care Workforce ideally be managed more effectively sensitive, innovative, team-based
Assessment outside of a hospital setting. Using and interprofessional care delivery,
The study team cast a wide net to County data, we developed an econo- including embedding primary care
capture existing information and docu- metric model and found an association providers in aftercare settings to
ment the capacity of the full range of between fewer hospitalizations and prevent readmissions,
primary health care workers, including specific health care providers (those ™ investing in building care capacity
primary care physicians, nurse practi- typically focused on care management). of primary care physicians, such
tioners, physician assistants, dentists, as strengthening their ability to
dental hygienists, social workers, psy- Lessons from Other address co-existing mental health
chologists, therapists/counselors and Health Care Systems conditions by adding behavioral
psychiatrists. We found that there are We conducted interviews with leaders health providers to the primary care
far fewer primary care providers for the from 13 health care systems around the physician teams,
population in Prince George’s County U.S. From these interviews, we identi- ™ incorporating a mixture of entities to
compared to that in surrounding juris- fied the following best practices aimed cover primary and tertiary care, such
dictions. Within the County, there is a at achieving integrated, coordinated as community health centers, as well
need for additional providers within the high-quality care that improves popula- as hospitals, private and non-profit
Beltway and in the southern portion. tion health and reduces costs. These entities and mobile clinics (mix of
practices include: public and private health systems),
Overview of Public Health and ™ planning for care strategies to meet
Public Sector Health Resources ™ creating patient-centered, user- the needs of the uninsured and other
We compiled an overview of pub- friendly and population-focused vulnerable populations, such as the
lic health and related facilities and system goals and values, homeless and recent immigrants,
programs that provide health and ™ establishing clear and tested ™ providing incentives for health care
wellness services for County residents. metrics for measuring progress teams to reduce disease rates, and
This overview highlights existing and quality of care, ™ developing their own and/or
capacity and identifies opportuni- ™ using information technology negotiating insurance plan coverage
ties to fill gaps and strengthen the systems that reinforce quality for populations they serve.
health system for County residents, assurance and improvement,
particularly for the underserved. patient care coordination and use of These snapshots summarize select
evidence-based protocols of care, findings from our research. It is impera-
Examination of Hospital ™ focusing on (and creating a culture tive to go beyond the statistics about
Discharges and Readmissions of) health promotion, disease gaps in the health care workforce and
of County Residents prevention and care management to understand the complex factors that
The study team analyzed hospital interventions that are culturally affect health and health care in the
discharges of County residents for appropriate, enhance health literacy County. For further detail on each study
conditions like diabetes, asthma and and build upon community-based component, please see the extensive
other chronic diseases to understand partnerships with established technical reports (in Section II), avail-
the County’s overall system of care community programs that educate able at sph.umd.edu/princegeorgeshealth.
and resident experiences. We reviewed about and reinforce healthy lifestyles,
hospitalizations for conditions that can ™ creating and supporting culturally
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University of maryland school of public health
FRAMING QUESTIONS TO INFORM THE PRINCE GEORGE’S COUNTY HEALTH CARE SYSTEM TRANSFORMATION
What are the key health What is the geographic What resources can be What are the key issues What elements of a health
outcomes in the County distribution of health care mobilized in the public to maximize uptake and care system can affect the
most amenable to improve- resources and where are the health sector to comple- achieve the potential of key health outcomes and by
ment by a new health care areas of greatest need for ment the impact of the a health care system for how much?
system? primary care? health care system? public health?
1. What are the key health outcomes in the County most amenable to improvement
by a new health care system?
ANSWER Chronic diseases—specifically diabetes, heart disease, hypertension,
asthma and cancer—are the health conditions most amenable to improvement by
a new health care system in Prince George’s County. County residents experience a
higher rate of these chronic diseases than those in most of the neighboring counties
and in several cases, at a rate higher than the state average. Racial and ethnic
differences reveal even greater disparities.
These five chronic conditions are
prevalent in the County. Evidence-
based interventions are available
to prevent these conditions, and to TABLE 1 RATE OF EMERGENCY DEPARTMENT (ED) VISITS AND DEATH RATES PER
manage them once they are diagnosed. 100,000 PEOPLE FOR SELECTED CHRONIC CONDITIONS IN MARYLAND COUNTIES
Initiatives using these interventions AND FOR THE STATE (REFERENCE: BASELINE DATA FROM MARYLAND SHIP)
are under way in the County and state,
with a focus on promoting healthy Prince
lifestyles. In addition, primary care net- George’s Montgomery Anne Arundel
Rate per 100,000 County County Howard County County Maryland
works, a component of the new system
plans, are designed to coordinate care Asthma ED visits* 717.0 406.0 505.4 786.0 850.0
and manage such conditions.
Diabetes ED visits* 308.4 168.8 142.1 315.3 347.4
RATIONALE Hypertension ED visits* 257.7 123.3 117.4 183.8 237.9
Both the State Health Improvement
Heart disease deaths 224.2 130.2 169.6 198.8 194.0
Process (SHIP) and the County’s
Health Improvement Plan (CHIP) Cancer deaths 173.8 130.1 161.2 195.2 177.7
highlight these conditions as ones to
*The data for ED visits are limited to Maryland hospitals. Full baseline data should include ED visits of Prince George’s County
be monitored closely. Table 1 provides
residents to EDs in Washington D.C.
health outcome rates for the selected
chronic conditions. The rate of emer-
gency department visits is used for
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public health impact study
TABLE 2 IMPACT OF LEADING CHRONIC DISEASES ON EMERGENCY DEPARTMENT (ED) VISITS
AND DEATH RATES BY RACIAL AND ETHNIC POPULATIONS IN PRINCE GEORGE’S COUNTY
Rate per 100,000 by
Racial/Ethnic Group in County
Entire County
Measure Baseline Rate White Black Hispanic Asian
Health Outcome (per 100,000 population) per 100,000 Rate Rate Rate Rate
Asthma Rate of ED visits for asthma* 717.0 258.0 909.0 305.0 177.0
Diabetes Rate of ED visits for diabetes* 308.4 179.5 388.2 101.6 N/A
Hypertension Rate of ED visits for hypertension* 257.7 101.8 341.7 54.3 67.6
Heart disease Rate of heart disease deaths 224.2 187.5 271.5 66.4 96.0
Cancer Rate of cancer deaths 173.8 157.0 194.5 70.9 87.0
*The data for ED visits are limited to Maryland hospitals. Full baseline data should include ED visits of Prince George’s County residents to EDs in
Washington D.C.
these conditions because the evidence of residents did not know which health
suggests that these visits could have conditions were urgent, indicating a TABLE 3 DIAGNOSED MEDICAL
been prevented with well-coordinated need to inform residents of prevalent CONDITIONS FOR RESIDENTS
primary care in the County. Addition- conditions and of how to prevent and WHO HAVE BEEN TOLD BY THEIR
ally, we examine death rates for two manage them. DOCTOR THEY HAVE A MEDICAL
conditions, heart disease and cancer, The survey gathered more specific CONDITION OR CHRONIC DISEASE
which are leading causes of death in information about residents’ experi-
the County and state. ences with chronic diseases. More than Condition Percent
While the overall health measures a third (37 percent) of the residents
High blood pressure/hypertension 5.5
for several of these conditions appear responded that their doctor or a health
to be better than that for the state care professional had told them that Diabetes 3.7
as a whole, the rates for racial and they have a medical condition or
Asthma 3.3
ethnic County populations (see Table chronic disease. When asked which
Heart disease 2.6
2) provide the imperative for the new conditions they were diagnosed with,
system. Rates for blacks exceed rates residents noted the five key health
High cholesterol 2.6
for whites for all conditions. Emergency conditions among their top listed diag-
Cancer 2.3
department visits by blacks are more noses (see Table 3).
than three times higher for asthma and We were further interested in diag- Chronic arthritis 2.0
hypertension and nearly twice as high noses of two key conditions that can
Thyroid problem/Hypothyroidism 1.7
for diabetes than for whites. Address- contribute to significant morbidity and
ing the underlying causes for these and mortality of these key health conditions Mental illness 1.4
other differences is needed to improve if they are not addressed. When asked
Chronic bronchitis 1.0
the County’s health outcomes. if they ever had been told by a doctor
County residents identified the five or other health care professional that
Note: To estimate the most appropriate prevalence
key chronic conditions among those they have pre-diabetes or borderline for the County, we adjusted the results from that
sub-sample of 423 to the entire sample.
they viewed as the most critical ones diabetes, 17 percent reported being
to address. However, almost 16 percent diagnosed with pre-diabetes. Similarly,
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University of maryland school of public health
when asked if a doctor or other health
care professional had told them that FIGURE 1 BODY MASS INDEX OF SURVEYED COUNTY RESIDENTS*
they have pre-hypertension or border-
line high blood pressure, 33 percent
reported pre-hypertension.
2.3%
County residents are at greater risk
for these chronic disease conditions 28.7% Obese (BMI * 30)
due to contributing factors such as 35.0% Overweight (BMI = 25–29.9)
tobacco use and obesity. More than 11 Underweight/Normal (BMI ) 25)
percent reported daily use of cigarettes Don’t know/refused
while 6 percent reported smoking
cigarettes between one and 29 days a 34.0% *Calculated from self-reported height and weight.
month. Body Mass Index, a calculation + A+2+A+2+
using a person’s height and weight, is
also an important indicator of chronic
disease risk. We found that 34 percent
of County residents are overweight A new health care system that incor- will further contribute to improvements
and 35 percent are obese by using this porates efforts aimed at addressing and in these chronic conditions.
measure (see Figure 1). preventing these and other risk factors
2. What is the geographic distribution of health care resources and where are the areas of
greatest need for primary care?
ANSWER The County has a substantially lower ratio of primary care providers to the
population compared to surrounding counties and the state. The areas of highest
primary care need are within the Beltway and in the southern region of the County.
An additional 61 primary care physicians (13 percent increase) and 31 dentists (7 percent
increase) are needed to meet the minimum recommended ratios in these areas.
We reviewed the geographic distri- have provider-to-population ratios that look at geographic need for primary
bution of primary health care resources meet the federal criteria for primary care, we included population charac-
at the County and two sub-county care physician shortages. For dentists, teristics and hospital use patterns in
levels. There are fewer providers for the two PUMAs have ratios that meet the addition to physician count. Using this
population for each medical, dental and criteria for dentist shortages. We iden- approach, we found seven ZIP codes
mental health primary care category tified geographic primary care need have high primary care need, repre-
compared to surrounding counties. In by ZIP code using several measures. senting 16 percent of County residents.
addition, there are sub-county areas We looked at the ratio of primary care
where this ratio appears worse than physicians to the population and found RATIONALE
the ratio used by the federal govern- that nearly half of County residents live We used a variety of approaches
ment to designate Health Professional in areas that have a sufficient number to review County and sub-county
Shortage Areas. For primary care of primary care physicians, while a third geographic areas of need for primary
physicians, four of the County’s seven live in areas where there is a high need care. One approach uses the ratio of
Public Use Microdata Areas (PUMAs) for these providers. For a more specific health care providers to the population.
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public health impact study
Another approach adds population and primary care physicians who report PRIMARY CARE WORKFORCE
hospital event characteristics to that of providing patient care for 20 hours NEED BY SUB-COUNTY
provider information. or more per week in a practice in the GEOGRAPHIC AREA
County. The County has 465 primary
care physicians, which results in 54 To gain a better understanding
ANALYSIS BY PRIMARY CARE primary care physicians per 100,000 of which areas of the County are
PROVIDER CATEGORIES people (1:1,851). When pediatri- served adequately, we looked at
cians alone are reviewed, the ratio is provider-to-population ratios for each
We closely examined physician avail- 39 per 100,000 children up to age category of providers, and compared
ability and capacity, and also reviewed 18 (1:2,564). More of the County’s them to the Health Resources and
the full array of primary care providers, primary care physicians (42 percent) Services Administration’s (HRSA)
including nine groups that represent are involved only in patient care, criteria used to designate Health
three major categories of primary care compared with primary care physi- Professionals Shortage Areas
providers: medical (primary care physi- cians (37 percent) in the state as a (HPSAs) for those categories.
cians, nurse practitioners, physician whole. Fewer County primary care
assistants); dental (dentists, dental physicians reported being involved in Primary Care Physician-to-
hygienists); and mental (clinical social teaching (21 percent vs. 30 percent) Population Ratios by ZIP Code
workers, psychologists, therapists/ and research (6 percent vs. 10 percent) One condition used by HRSA to des-
counselors, psychiatrists). compared with those in the state. ignate an area as a medical HPSA is a
Databases for active licensed A review of provider-to-population primary care physician-to-population
providers were obtained from the ratios for each category of primary care ratio of 1:3,500 or worse, while a
respective DHMH licensing boards. provider is shown on Table 4. The sup- ratio of 1:2,000 is deemed sufficient.
For all provider groups, except for ply of health care providers for Prince Map A highlights for each County
physicians, counts were based on their George’s County is far below that of ZIP code in which three categories of
practice location and no adjustments other jurisdictions, and for the state ratios are met: those that meet the
were made for specialty focus. We as a whole, for every provider group. recommended ratios for primary care
only counted licensed, board-certified physicians per 100,000 population
TABLE 4 THE RATIO OF MEDICAL, DENTAL AND MENTAL HEALTH PROVIDERS PER 100,000 POPULATION IN MARYLAND
COUNTIES AND FOR THE STATE
Medical Care Dental Care Mental Health Care
Primary Care Physician Nurse Dental
Jurisdiction Physician* Assistant Practitioner Dentist Hygienist Social Worker Counselor Psychologist Psychiatrist
Prince George’s 53.9 39.0 24.2 54.4 17.1 45.9 42.2 13.2 3.6
Anne Arundel 65.7 70.3 64.5 63.1 57.8 78.5 56.4 27.5 3.9
Baltimore County 112.9 115.3 77.3 78.8 48.3 137.8 94.5 47.3 22.4
Howard 77.0 70.7 96.5 123.7 75.9 173.8 78.7 99.6 17.1
Montgomery 94.6 73.0 47.0 123 38.6 146.4 51.7 85.7 18.0
Maryland 84.5 79.0 51.5 71.4 43.8 99.23 68.76 40.37 11.8
*Primary care physicians include specialists in pediatrics, family medicine, internal medicine and obstetrics and gynecology.
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TABLE 5 CURRENT COUNTS AND ESTIMATED ADDITIONAL NEEDED PRIMARY CARE
MEDICAL, DENTAL AND CORE MENTAL HEALTH PROVIDERS BY PUMA BASED ON
PROPOSED SUFFICIENT PROVIDER-TO-POPULATION RATIOS
(green), those that reflect a shortage
(red) and those that fall in between Physicians Dentists Core Mental Health*
(yellow). Almost half (46 percent) of
Additional Additional Additional
County residents live in areas that have
Region Count Needed Count Needed Count Needed
a sufficient number of primary care
Inside Beltway
physicians, while a third (34 percent)
of the residents live in areas where
PUMA 1 37 15 57 — 85 —
there is a high need for these providers.
PUMA 3 34 13 21 10 56 —
Primary Care Provider-to- PUMA 4 35 22 17 21 75 —
Population Ratios by PUMA
PUMA 7 62 — 43 — 36 —
We used the County’s PUMAs to
designate sub-county geographic areas. Outside Beltway
The County has seven PUMAs, each
PUMA 2 102 — 85 — 184 —
reflecting populations about 100,000.
Based on the provider counts in each PUMA 5 128 — 151 — 274 —
of the three primary care categories,
PUMA 6 67 11 96 — 195 —
and the ratio of these providers to the
Total 456 +61 470 +31 905 —
population, we identified PUMAs with
sufficient providers and those that do
*Includes Clinical Social Workers, Psychologists, Counselors and Psychiatrists
not meet HRSA ratios for sufficient
providers. These ratios include 1:2000
for physicians, 1:3,000 for dentists
and 1:10,000 for core mental health
providers. Table 5 provides current sufficient, the count of providers to identify ZIP codes where residents
counts and additional estimated counts per PUMA is substantially lower in may be at higher need for primary care
needed for each category by PUMA. the PUMAs inside the Beltway than services, using provider, population
Using this approach, we found outside. If psychiatrists alone are used and hospitalization data. We reviewed
that several PUMAs need additional to estimate capacity for mental health population income and education data
primary care physicians and dentists care, we estimate the County would since poor health status is associated
to reach a sufficient provider-to- need to double the number of psychia- with low income and low education
population ratio. We estimate that the trists. A more detailed review of the status. We examined the pattern of
County needs to increase the number County’s mental health providers would hospital events by ZIP code, using
of primary care physicians by 61 (about allow for a better assessment of the the ratio of hospital discharges for
13 percent) to meet the sufficient capacity of this workforce category. preventable conditions and 30-day
provider-to-population ratio. Most of readmissions. Hospital readmissions
the PUMAs within the Beltway and within a 30-day period after discharge
one PUMA outside the Beltway would ZIP CODE-LEVEL are viewed as a reflection of insuf-
benefit from additional physicians. Two ANALYSIS OF HIGH ficient treatment to resolve the health
PUMAs within the Beltway would also PRIMARY CARE NEED condition in the prior hospitalization
benefit from additional dentists, which or the lack of appropriate primary care
translates to 31 dentists (about a 7 This assessment complements the ZIP and home care. For hospital discharges,
percent needed increase). While the code area assessment of the primary we looked specifically at conditions
ratio of core mental health providers care physician to population ratios associated with the chronic diseases
to population for each PUMA appears (Map A). We developed an algorithm and conditions identified as being most
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