Making a Difference IN THE HEALTH OF OUR COMMUNITY - COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) - Saint Joseph Mercy Health System
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Making a Difference
IN THE HEALTH OF OUR COMMUNITY
COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA)
Adopted FY2021 for FY2022-24
LIVINGSTON
A Member of Trinity Health
St. Joseph Mercy Livingston
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2021 Community Health Needs Assessment
TABLE OF CONTENTS
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Community Health Needs Assessment Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Summary and Impact of 2018 CHNA and Implementation Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Community Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Community Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Community Health Needs Assessment Methodology and Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Qualitative Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
CHNA Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Community Forum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Other Input Received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Quantitative Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Information Gaps and Process Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Significant Community Health Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Process for Prioritizing Identified Health Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Prioritized Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Community Resources to Address Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
SJML Internal Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
External Community-Based Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Conclusion and Strategic Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Appendix A Community Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Appendix B U.S. Census Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Appendix C Asset Map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Appendix D CHNA Survey Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Appendix E CHNA Survey Highlighted Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Appendix F Trinity Health CARES Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
St. Joseph Mercy Livingston
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2021 Community Health Needs Assessment
St. Joseph Mercy Livingston (SJML)
CHNA FY 2021 for FY 2022-2024
Executive Summary
As a faith-based health care organization in the Catholic Christian tradition, St. Joseph Mercy Livingston’s (SJML)
work of providing services that benefit the community is core to our identity. Our Mission guides everything we
do. At St. Joseph Mercy Livingston, a member of Trinity Health, we continue our healing ministry and are called to
both serve others and transform care delivery, reinvesting our resources back into the community through new
technologies, vital health services and access for everyone regardless of their circumstances. Our Mission: We, Trinity
Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our
communities.
SJML completed a comprehensive Community Health Needs Assessment (CHNA) that was presented to the SJML
local Board of Directors for review and approval on June 23, 2021. SJML performed the CHNA in adherence with
certain federal requirements for not-for-profit hospitals set forth in the Affordable Care Act and by the Internal
Revenue Service. The assessment considered input from community leaders, community members and various
community organizations. No written comments were received on the last CHNA and Implementation Strategy.
The complete CHNA report is available electronically at stjoeshealth.org. Contact St. Joseph Mercy Livingston,
Office of Community Health, 620 Byron Road, Howell, Michigan 48843 to submit written comments on the CHNA
or to request a printed copy of the report.
The service area for this assessment was defined as Livingston County, SJML’s primary service area. The population
for these communities is 188,482 residents.
The CHNA process included:
• Many collaborative partners, including the Livingston County Health Department (LCHD), were engaged to
advise the Community Health Needs Assessment process. The Livingston County Community Needs Assessment
(CNA) Work Group was designated as the SJML CHNA Advisory Group. These members were involved in
survey distribution as well as needs identification and prioritization. A number of community stakeholders
and organizations were interviewed for the purpose of providing input and informing the CHNA process.
• The SJML Community Health Needs Survey was branded with the banner “Making a Difference in the Health of
our Community.” A paper and online survey, composed of 27 questions about access to care, personal health
behaviors, perceived community health needs and participant demographics was promoted through various
community partners. Distribution was different this year because of COVID-19 restrictions. The survey included
additional questions related to the COVID-19 pandemic. For Livingston County, there were a total of 426 survey
responses received from both online and paper submissions.
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2021 Community Health Needs Assessment
• On November 10 and 12, 2020, virtual Community Forums were held in conjunction with the Michigan Institute
for Clinical and Health Research (MICHR) and the Livingston County Health Department. The Forums were
conducted to gain community input on the most pressing health needs, barriers to health care/access, and
which health needs to address.
• Ensuring the most accurate demographic information and community health concerns, data was gathered
from numerous sources. Primary data was obtained through the survey, Community Forums and information
gathered from the community partners. Secondary data analysis was conducted utilizing national, state and local
demographic and community health databases including, but not limited to the Trinity Health CARES data, SJML
patient data, Community Commons and County Health Rankings & Roadmaps.
• Needs were identified through the analysis of data from multiple data sources, Community Forums, and key
stakeholder interviews. The CHNA process identified four top health needs for prioritization. During the early
months of 2021, the CNA Advisory Group, and the SJML Patient Advisory Committee prioritized the significant
needs using the following framework:
• Key factor in achieving health equity
• Urgency for addressing the need/severity of need
• Potential impact on the greatest number of people
• Feasibility of effective interventions/measurable outcomes in three years
• Consequences of inaction
Potential priorities were identified using a ranking system based on how well the potential priorities met the criteria
listed above. Top needs were presented to the SJML Leadership Forum, prior to being presented for approval and
adoption to the hospital board.
The following top needs were identified and prioritized for this CHNA cycle:
1. Access to Care including transportation, health information/digital divide, cost and local providers
2. Behavioral health including mental health and substance use disorder including suicide, anxiety/depression
and social isolation.
3. Food Security/Access
4. Transportation
Over the next three years, health improvement programs as identified in the CHNA Implementation Plan will
be carried out with identified collaborative partners according to the plan and metrics collected. Specifics will
be contained in the Implementation Strategic Plan, which is a separate document and located on the hospital
webpage under community health and well being at stjoeshealth.org.
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2021 Community Health Needs Assessment
Introduction
About St. Joseph Mercy Livingston
St. Joseph Mercy Livingston (SJML) is one of hospitals comprising Trinity Health Michigan. Trinity Health Michigan
hospitals span across western and southeast Michigan. St. Joseph Mercy Livingston is a 66-bed hospital located
in Howell and serving Livingston County. Additional services in the community are provided in part through St.
Joseph Mercy Brighton, an outpatient health center housing primary care and specialty physicians, comprehensive
diagnostic and testing services, emergency services, outpatient surgery and cancer care.
About Saint Joseph Mercy Health System
SJML is a member of the Saint Joseph Mercy Health System (SJMHS). SJMHS is a health care organization serving
seven counties in southeast Michigan including Livingston, Washtenaw, Wayne, Oakland, Macomb, Jackson, and
Lenawee. It includes 548-bed St. Joseph Mercy Ann Arbor, 497-bed St. Joseph Mercy Oakland in Pontiac, 304-bed
St. Mary Mercy Livonia, 66-bed St. Joseph Mercy Livingston in Howell, and 133-bed St. Joseph Mercy Chelsea.
Combined, the five hospitals are licensed for 1,548 beds, have five outpatient health centers, six urgent care
facilities, more than 25 specialty centers; employ more than 15,300 individuals and have a medical staff of nearly
2,700 physicians. SJMHS has annual operating revenues of about $2 billion and returns about $115 million to its
communities annually through charity care and community benefit programs. For more information on health
services offered at Saint Joseph Mercy Health System, visit stjoeshealth.org.
About Trinity Health Michigan
SJMHS is a member of Trinity Health Michigan. Trinity Health Michigan is a leading health care provider and one of
the state’s largest employers. With more than 24,000 full-time employees serving numerous counties, Trinity Health
Michigan is composed of eight hospitals, including the five hospitals of Saint Joseph Mercy Health System located
in Ann Arbor, Chelsea, Howell, Livonia and Pontiac, and the three-hospital Mercy Health, operating in Grand Rapids
and Muskegon. The health system has 2,348 beds and 3,400 physicians. With operating revenues of $3.4 billion,
Trinity Health Michigan returns $195 million back to their local communities each year. Together with numerous
ambulatory care locations, three home health agencies, one hospice agency and 17 senior living communities
owned and/or operated by Trinity Health, Trinity Health Michigan provides the full continuum of care for Michigan
residents.
Nationally, Trinity Health is among the country’s largest Catholic health care systems. Based in Livonia, Michigan,
with operations in 22 states, Trinity Health employs about 129,000 colleagues, including 7,500 physicians and
clinicians. The system has annual operating revenues of $18.3 billion, assets of nearly $27 billion, and returns
about $1.2 billion to its communities annually in the form of charity care and other community benefit programs.
For more information, visit trinity-health.org.
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2021 Community Health Needs Assessment
Mission, Vision and Values
As a faith-based health care organization in the Catholic Christian tradition, St. Joseph Mercy Livingston’s work
of providing services that benefit the community is core to our identity. Our Mission guides everything we do.
As St. Joseph Mercy Livingston, a member of Trinity Health, we continue our healing ministry and are called to
both serve others and transform care delivery, reinvesting our resources back into the community through new
technologies, vital health services and access for everyone regardless of their circumstances.
Mission: We, Trinity Health, serve together in the spirit of the Gospel to be a compassionate and transforming
healing presence within our communities.
Core Values: Reverence, Commitment to Those who are Poor, Justice, Stewardship, Integrity, Safety
Vision: As a mission-driven innovative health organization, we will become the national leader in improving the
health of our communities and each person we serve. We will be the most trusted health partner for life.
Community Health Needs Assessment Partners
As St. Joseph Mercy Livingston embarked on the Community Health Needs Assessment; many collaborative
partners were engaged in the process.
A. SJML Community Health Needs Assessment (CHNA) Advisory Group
As part of the Human Services Collaborative Body (HSCB) in Livingston County, there is a Community Needs
Assessment (CNA) Work Group which includes members from a variety of community organizations. The CNA
Work Group was engaged in October 2020 in the hospital’s CHNA process. The CNA Work Group’s purpose is
to assess and increase community awareness of the health and human service needs in Livingston County
and assist in evaluation of collaborative projects. Members of the work group include, but are not limited to,
representatives from the Livingston County Health Department, LACASA, Livingston County Catholic Charities
(LCCC), Livingston United Way, Community Mental Health Partnership of Southeast Michigan, Great Start
Livingston and Key Development Center. This group has been a valuable asset in the CHNA process. Additionally,
the SJML Director of Community Health and Well Being led the CHNA work and other Trinity Health colleagues
participated and attended the meetings as appropriate. See Appendix A for a list of CHNA Advisory Group
(CNA Work Group) members.
B. Southeast Michigan (SEMI) CHNA Steering Committee and the SJML Patient Advisory Committee
The Southeast Michigan (SEMI) CHNA Steering Committee was convened in late 2020. The group draws on the
strengths of our regional health system to advise the CHNA process and brings together expertise across the
health system domains to develop shared strategies to address priority needs where possible to advance policy,
system and environmental changes across our ministries. The SJML Patient Advisory Committee comprised of
SJML leaders and community members, provided input into the prioritization process and will also inform and
support the progress of the implementation plan.
C. Livingston County Health Department (LCHD) was involved throughout the CHNA process from August 2020 to
present, including the CNA Work Group, co-leading individual community stakeholder interviews, co-hosting the
CHNA Community Forums, as well as participating in identifying the significant health needs, prioritization and
the next steps implementation planning.
D. Outreach to Vulnerable Populations
To gain input from the vulnerable populations in our area, we engaged the leadership of the of the CNA Work
Group to assist with survey communication and distribution. Any paper surveys completed were manually
added to the online survey database. There was also leadership representation from Livingston United Way,
LCCC and Community Mental Health on the CNA Advisory Group and/or who participated in informing the
process and/or prioritization of needs.
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2021 Community Health Needs Assessment
Summary and Impact of 2018 Community Health Needs Assessment and Implementation Plan
St. Joseph Mercy Livingston (SJML) conducted a Community Health Needs Assessment (CHNA) in 2018. The
three prioritized needs for Fiscal Year (FY) 2019 – 2021 were 1. behavioral health, 2. obesity and cardiovascular
disease, and 3. access to care. The hospital periodically reviewed these needs, tactical plans and budget related to
addressing these needs. Listed below is a summary of the strategies and impact for these health needs.
1. Behavioral Health: Improve mental health through prevention and by ensuring access to
appropriate, quality mental health services and support and reduce substance use disorders
to protect the health, safety, and quality of life for all Livingston County residents.
Outcomes
• In FY20, as part of a Social Influencer of Health (SIoH) Project, SJML addressed social isolation through its support
of the Livingston County senior millage and integration of a new social needs screening tool which in part
assesses social isolation for all patients in the Emergency Department and in our primary care offices. While the
millage couldn’t gain enough traction during the previous cycle to be put on a ballot for community voting,
there is still momentum in the community to continue exploring this as an option in the future. The screening
tool went live in January 2020, and while we have seen slow implementation due to the COVID-19 pandemic
and other workflow concerns, our health system has stood up work groups to solidify consistent screening and
subsequent referral to social needs and this is underway.
• SJML continued to collaborate with Community Mental Health (CMH) around Peer Support models for substance
use disorders. A plan was in place in early 2020 to move forward with the program through grant funding, but it
was paused because of the COVID-19 pandemic. Work is being done to initiate the program in mid-2021.
• Working with behavioral health services and community organizations, SJML participated in efforts to address
housing issues of vulnerable populations and improve access to SSI/SSDI benefits for eligible community
members through SOAR coordination. With COVID-19 and the open SOAR Coordinator position during 2020, the
service was paused. There are plans to reestablish that program in 2021.
• Funding support was provided by SJML to the Livingston County Community Alliance’s (LCCA) Drug Free
Community (DFC) through $20,000 in annual match funds. The funds target interventions for decreasing the
use of opioids and the use of alcohol and marijuana in youth. This is a five-year commitment, beginning in FY18,
made by the hospital. Additionally, SJMHS supports tobacco free advocacy efforts by being represented in State-
level tobacco workgroups.
• SJML has a barrel for medication collection in the Emergency Room entrance. This offers an additional
opportunity for community members to properly dispose of unused medications into this secured and monitor
barrel available 24 hours a day, seven days a week. This option is part of the continuing effort to address
substance use disorders and the problems resulting from access to prescription drugs,
• The tobacco cessation referral programming has been enhanced for lung cancer screening patients and
oncology patients, showing a much higher rate of cessation than direct assistance through referrals to the
Quitline. The Tobacco Cessation Program’s strategic plan includes expanding access to this service outside of
lung screening and oncology programs.
2. Obesity and Cardiovascular Disease: Promote healthy weight and reduce chronic disease risk,
incidence and prevalence among youth and adults and improve food systems infrastructure in
the community through collaboration to increase equitable access to healthy food.
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2021 Community Health Needs Assessment
Outcomes
• Staring in FY19 and continuing through FY21, SJML offered, through the SJMHS 1705 ADAPT Diabetes
Prevention Program (DPP) Grant, onsite and community classes in Livingston County. The goal of the grant is
to provide the year-long evidence-based CDC program that would expand DPP capacity, especially for men
and Medicare eligible residents in Livingston County. The program was eventually also expanded to cover
Washtenaw County because of an identified need for this program. From July 2018 through December 2020
there were a total of 248 individuals enrolled in over 10 Grant DPP cohorts.
• SJML partnered with the Livingston County Health Department, physician groups, community organizations
and farmers markets to provide the Prescription for Health program. The program aims to increase fruit and
vegetable consumption and support healthy behavior change among persons with lower incomes and a chronic
disease risk. SJML committed to providing annual funding for the 2019, 2020 and 2021 market seasons. For 2019
there were 175 participants enrolled in the program and 1157 market visits. For the 2020 season, 174 participants
were enrolled with 499 market visits. While visits were down in 2020 because of the pandemic, we anticipate an
increase in participation in the 2021 season as well as the addition of new referral partners.
• St. Joe’s ShapeDown Healthy Families, Healthy Kids provides a multidisciplinary (dietitian, exercise and behavior
specialist) approach to weight management for children, teens and their parents. There were 197 parents and
children participants in the St. Joe’s Livingston program since July 1, 2018 to present. Beginning and end habit
surveys show children/teens have significant improvements including 1. activity level increased by 82% (more
movement individually and with the family. Less screen time), 2. food habits improved by 71% (decreasing fat
and sugar consumption, increasing fruit and vegetable consumption, decreasing sugary drinks and increasing
water intake), and 3. quality of life increased by 86% (spending more quality time together as a family, more
frequent daily communication between partents and child/teen and improved self-esteem).
3. Access to Care: Improve healthcare access for community members.
Outcomes
• Funding was provided to support the Livingston Essential Transportation Service (LETS) in collaboration with
Ascension and Michigan Medicine. The combined $100,000 in annual match funding ($40K from SJML), from
July 2019 through July 2022, supports access to State and Federal funds. This funding provides rides to medical
appointments for those with a need, thereby expanding access to care and reducing the general waitlist. For
FY20 and FY21 there were an estimated average of 13,500 additional service hours annually which is up from
the 3,700 hours of additional service hours that was proposed. From July 2018 to March 2021, almost 5000
rides were provided to St. Joe’s Livingston locations. During FY21, in response to the COVID-19 pandemic, free
transportation to vaccine appointments were available for anyone in need of a ride.
• Complex Care Coordination continued through the emergency department to assist with health care navigation
to support those individuals experiencing a combination of multiple chronic conditions, mental health issues,
medication-related problems, and social vulnerability.
• Social care support has become a top priority for SJML, especially as a result of the COVID-19 pandemic. SJML
collaborated with the health ministries in Saint Joseph Mercy Health System to initiate a Social Care Call Service
to assist those who need support with Social Influencers of Health (SIoH). Additionally, while more work
continues, as part of Trinity Health TogetherCare, all Michigan Health Ministries have integrated SIoH screening
into our electronic medical record and have a Community Resource Directory available to us and the community.
• A Graduate Medical Education (GME) Health Disparities annual didactic session with Brighton Family Medicine
residents was conducted during FY19 and FY20 in support of increasing focus on equity in health care access.
SJML made forward progress and collective impact on several of the objectives set forth in the 2018 CHNA
Implementation Plan, yet many of these needs will continue and multiple years are needed to significantly make
large changes. Additionally, addressing policy, systems and environmental changes requires a long-term approach
to create a shift.
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2021 Community Health Needs Assessment
Community Description
The service area for St. Joseph Mercy Livingston’s CHNA is defined as Livingston County in general, as most patients
served by the hospital are from this county, but also includes some of the communities at the boundaries of
the county. Livingston County is located on the southeast side of Michigan, bordered by Washtenaw, Genesee,
Shiawassee, Oakland, Ingham and Jackson counties. The Census Bureau 2019 population estimates are at 188,482,
which is consistent with the last CHNA cycle. For Livingston County demographic data refer to Appendix B.
SJML CHNA GEOGRAPHIC SERVICE AREA
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2021 Community Health Needs Assessment
Community Assets
An Asset Map was created for Livingston County identifying existing community strengths, which support the health
of community. The assets that were consider included human, physical, information, governmental, existing programs
and services (prevention, wellness), support services and community resources.
These assets were utilized to evaluate gaps and to also consider opportunities for collaborative partnerships.
Additionally, this review will contribute to the CHNA process by identifying potential opportunities to expand,
connect, or leverage current resources in order to provide greater impact. To that end, the assets identified will be
considered as the Implementation Plan is developed. See Appendix C for the Asset Map.
St. Joseph Mercy Livingston
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2021 Community Health Needs AssessmentCommunity Health Needs Assessment (CHNA) Methodology and Process
The purpose of the CHNA was to 1) evaluate current health needs of the St. Joseph Mercy Livingston community
and prioritize them; 2) identify resources available to meet both the priorities as well as opportunities identified
through the CHNA; 3) inform an Implementation Plan to address the health priorities; and 4) build capacity to
address the opportunities within the context of the health systems existing programs, resources, priorities,
and partnerships.
This CHNA cycle, all Trinity Health Michigan hospitals have aligned their CHNA timelines to create opportunities to
identify areas for shared commitment and action across our health ministries while keeping a focus on local health
needs. This will enable us to share processes and generate opportunities for greater collective impact across the
state.
From September 2020 through January 2021, qualitative input was obtained, and quantitative data was gathered
and reviewed.
The assessment considered input from community leaders, community members and various community
organizations. No written comments were received on the last CHNA and Implementation Strategy. The
complete CHNA report is available electronically at stjoeshealth.org. Contact St. Joseph Mercy Livingston Office
of Community Health, 620 Byron Road, Howell, Michigan 48843 to submit written comments on the CHNA or to
request a printed copy of the report.
Qualitative Data
Community input into the assessment is a critical component of success. Community input was obtained through
the Community Health Needs Assessment Survey, Community Forums as well as other avenues.
A. SJML Community Health Needs Assessment Survey
A survey was created in the fall of 2020 to evaluate the changing health needs
in the SJML service area. The survey tool was branded with the banner “Making SJML
a Difference in the Health of our Community” and was utilized by three of the
SJMHS hospitals conducting their CHNAs this year. The survey was composed 426 CHNA Survey
of 27 questions about access to care, personal health behaviors, perceived Responses
community health needs, and patient demographics. With an equity lens
and focus on the COVID-19 pandemic, several of the questions asked about Health Conditions
conditions since the beginning of the pandemic and one question related to Identified
diversity and inclusion. The paper and online survey was available to the public • Obesity
from October 1 through November 15, 2020. The survey was promoted by and
• High Blood Pressure
distributed through our collaborative partners, the hospital website and social
media accounts, email blasts to community leaders in businesses, schools and • High Cholesterol
churches, and SJML employees and physicians. There was a total of 426 surveys • Arthritis
returned. Refer to Appendix D to review a copy of the survey tool.
Respondents
Survey respondents were mostly female (77%) and Caucasian (91%). The Survey • 77% Female
identified four health conditions that respondents indicated were diagnosed:
obesity, high blood pressure, high cholesterol and arthritis. Additionally, • 91% Caucasian
emotional health since COVID-19 was also self-reported as a key factor. In • 41% College Graduate
reviewing responses by race and older adults, no significant changes in top • 25% Age 45-54
needs were identified for those populations. • 63% reported
emotional health issues
since COVID-19
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2021 Community Health Needs AssessmentSJML CHNA FY21 Survey Respondents by Age
74+ 8.64%
65-74 18.69%
55-64 21.96%
Age
45-54 25.47%
35-44 14.25%
25-34 9.11%
18-24 1.87%
0 .00 % 5.00% 10.0 0 % 15.0 0 % 20.0 0 % 25.0 0 % 30.0 0 %
18-24 25-34 35-44 45-54 55-64 65-74 74+
Percent 1.87% 9.11% 14.25% 25.47% 21.96% 18.69% 8.64%
Percent
SJML CHNA FY21 Survey Respondent by Race
Other 0.70%
Prefer not to answer 4.92%
White/Caucasian 90.87%
Native Hawai ian/pacific Isl ander 0.23%
Mult i-racial 0.47%
Race
Hispanic/Latino 0.70%
Blac 0.94%
Asian 0.94%
Arab/Midle Eastern 0.23%
American Indian/Al aski an Indian 0.00%
Percent
SJML CHNA FY21 Survey Responses by Zip Code
1.38%
6.22%
18.43% 6.00% 48169
48353
48836
10.83% 48843
48855
41.01% 48114
16.13%
48116
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2021 Community Health Needs AssessmentB. Community Forum
On November 10 and 12, 2020, virtual Community Forums were held in conjunction with the Michigan Institute
for Clinical and Health Research (MICHR) and the Livingston County Health Department. The Forums were
conducted to gain community input and focused discussion on answering the following three questions:
• What are the most pressing health needs in the community?
• What are the barriers to health care or access?
• What health needs should be addressed?
Invitations to the Forum were sent to community leaders and organizations with a focus on groups where those
who are underserved, or low income were represented. Also, personal phone calls were made and/or emails
were sent to those individuals providing their contact information on the CHNA Survey and indicating that they
were interested in providing more input in the CHNA process.
The 90-minute virtual Forums were managed and moderated by a representative of MICHR. All participants were
provided with ample opportunity to share responses. A Community Stakeholder Input Summary was created
from the Forum and combined with individual interview responses. See below.
SJML COMMUNITY STAKEHOLDER INPUT SUMMARY
SJML COMMUNITY STAKEHOLDER INPUT SUMMARY
Health Issues to Address Pressing Health Issues Barriers to Accessing Care/Needs
Nutrition/healthy lifestyle/outreach More providers in county (versus driving to Ann Arbor, Type2 Diabetes education resources (easy to find)
etc.)
Mental Health (social isolation) Mental Health (social isolation, anxiety/depression, grief Transportation for those who need daily treatment
counseling, caregiver support, inpatient services, (cancer)/more than what is provided by LETS
coverage, adolescent care, trauma support)
Substance Use Disorder/Addiction Vaccinations Too far to drive for care/US23 traffic
End of life care COVID Testing sites Health Education availability/technology a barrier
Education: immunizations, COVID Subacute care access (right care/right time) Not enough providers especially mental health
Out of pocket health care cost for families Affordable and accessible food (student meals, list of Health insurance/resources to assist
resources)
Premium costs for employers Information/reliable facts/resources/managing Not sure if available health information is accessible/
misinformation prioritized and reliable
Alternative communication options (not only Older Adult Needs (homebound) Fear of seeking health care/doctor’s office
social media or electronic)
Non-biased/reliable resources Addressing transition/remote student needs Telehealth available but not everyone has access to
(‘evaporating’ from system) technology
Transportation Transportation (especially elderly) Collaboratives working on it but stigma still a barrier
especially around mental health
Food Security Space to be mindful/tools for stress management Education on healthy lifestyle
Housing People need to wear masks “Politics”
Living wage Housing Physical barrier of transportation/limited access
Older Adult needs Affordable health care Demands of health care system. Need to sustain
current services
Substance Use Overcoming stigma of mental health and substance
use
Direct care crisis (staffing) Lack of awareness (programs/where to locate
information)
Youth services for kids in crisis Lack of the right people at the table
Diabetes/obesity Cost of health care benefits, inability to provide ala
carte options, premium costs
Internet/broadband access Funding for programs
Overcoming stigmas to assistance Internet/broadband access
A trusted source for health information and education, as well as the digital divide were identified as key issues
under access to care, as was navigation, cost, local providers and transportation. Additionally, social isolation in
students and older adults, as well as stress, anxiety, suicide risk and substance use were highlighted for behavioral
health. The key factor of food security/access was identified this year.
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2021 Community Health Needs AssessmentC. Other Input Received
In late 2020, input on health needs were received from the LCHD and in early 2021 from the SJML Operations
Council and the SJML Patient Advisory Committee. Information from the Asset Map, County Health Rankings
and CNI Index were reviewed with the groups.
For Livingston County, the LCHD is currently conducting its own community needs assessment. While we are
utilizing two separate processes due to timing, we are collaborating on many of the inputs and will continue
to do so into implementation planning.
To date, no written comments were received as input from the 2018 CHNA Report and Implementation Plan.
Information on how to provide written comments or obtain a written copy of the assessment is posted on the
website and is available on an ongoing basis.
Quantitative Data Gathering
Ensuring the most accurate demographic information and community health concerns, data was gathered from
numerous sources. Secondary data analysis was conducted utilizing national, state and local demographic and
community health databases. Data sources are listed in the reference section.
A. County Health Rankings
The County Health Rankings measure vital health factors, including high school graduation rates, obesity,
smoking, unemployment, access to healthy foods, the quality of air and water, income and teen births in nearly
every county in America. These rankings provide a revealing snapshot of how health is influenced by where we
live, learn, work and play, and provides a starting point for change in communities. In the 2020, County Health
Rankings Report Livingston County ranked 4/83 in health outcomes and 4/83 in health factors.
2020 COUNTY
2020 COUNTYHEALTH RANKINGS
HEALTH RANKINGS
County Health Health Factors
Outcomes
Livingston 4 4
2020 COUNTY HEALTH RANKING INDICATORS
Health Behaviors Livingston Michigan
Adult Obesity 28% 32%
Food environment index
Index of factors that contribute to a healthy food 8.9 7.1
environment, from 0 (worst) to 10 (best)
Physical Inactivity 22% 23%
Access to exercise opportunities 89% 85%
Excessive drinking 20% 20%
Alcohol-impaired driving deaths 29% 29%
Health Outcomes
Poor physical health day (per 30 days) 3.4 4.3
Poor mental health days (per 30 days) 4.1 4.4
Clinical Care
Uninsured 4% 6%
St. Joseph
Primary care physicians Mercy Livingston 2,020:1 1,280:1 14
2021 Community Health Needs Assessment
Mental health providers 540:1 370:1
Preventable hospital stays 3,837 5,203
Social & Economic FactorsCounty Health Health Factors
Outcomes
Livingston 4 4
The table below lists the key health behaviors and health outcome indicators in Livingston County as compared
to the state of Michigan. The ranking includes all zip codes in the county.
2020 COUNTY HEALTH RANKING INDICATORS
2020 COUNTY HEALTH RANKING INDICATORS
Health Behaviors Livingston Michigan
Adult Obesity 28% 32%
Food environment index
Index of factors that contribute to a healthy food 8.9 7.1
environment, from 0 (worst) to 10 (best)
Physical Inactivity 22% 23%
Access to exercise opportunities 89% 85%
Excessive drinking 20% 20%
Alcohol-impaired driving deaths 29% 29%
Health Outcomes
Poor physical health day (per 30 days) 3.4 4.3
Poor mental health days (per 30 days) 4.1 4.4
Clinical Care
Uninsured 4% 6%
Primary care physicians 2,020:1 1,280:1
Mental health providers 540:1 370:1
Preventable hospital stays 3,837 5,203
Social & Economic Factors
Unemployment 3.3% 4.1%
Children in poverty 6% 19%
Income Inequality 3.7 4.7
Physical Environment
Severe housing problems 10% 15%
Source:
Source: www.countyhealthrankings.org/michigan
countyhealthrankings.org/michigan
B. Community Need Index
The Community Need Index (CNI) identifies the severity of health disparity for every zip code in the United States
and demonstrates the link between community need, access to care and preventable hospitalizations.
The CNI accounts for the underlying economic and structural barriers that affect overall health. Using a
combination of research, literature and experiential evidence, Catholic Health West identified five prominent
barriers that enable us to quantify health care access in communities across the nation. These barriers include
those related to income, culture/language, education, insurance and housing.
To determine the severity of barriers to health care access in each community, the CNI gathers data about that
community’s socio-economy. A score is given to each barrier condition with one representing less community
need and five representing more community need. Scores are then aggregated and averaged for a final CNI
score. Zip codes with a score of one indicate those with the lowest socio-economic barriers, while a score of
five represents a zip code with the most socio-economic barriers.
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2021 Community Health Needs AssessmentLIVINGSTON COUNTY COMMUNITY NEED INDEX (CNI)
Zip Code CNI Score City
48169 1.0 Pinckney
48353 1.6 Hartland
48836 1.6 Fowlerville
48843 1.6 Howell
48855 1.6 Howell
48114 1.4 Brighton
48116 1.6 Brighton
48137 1.2 Gregory
48139 1.4 Hamburg
Source: cni.dignityhealth.org
D. Trinity Health CARES Data
The Trinity Health Data Hub is available to all colleagues and partners of Trinity Health. It has tailored data
sets to support the CHNA service area for each Health Ministry and other community level data and mapping.
The lowest available data source is provided for the service area reports. See Appendix F for full data report.
Economic Stability Challenges
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2021 Community Health Needs AssessmentEducation
Health and Healthcare
Healthcare Access Livingston County Michigan Need Differential
Primary Care Physicians, Rate per 100,000 Pop. 49.5 78.2 36.70%
Mental Health Care Provider Rate (Per 100,000
Population) 184.6 268 31.12%
Dentists, Rate per 100,000 Pop. 58.72 70.2 16.35%
Percent Adults Without Any Regular Doctor 16.75% 15.68% 6.39%
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2021 Community Health Needs AssessmentHealth Outcomes and Behaviors
Neighborhood and Built Environment
St. Joseph Mercy Livingston
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2021 Community Health Needs AssessmentNeighborhood and Built Environment
Social Support and Community Context
The Community Dimension looks at
factors affecting community health and
civic life, including volunteerism, voting
registration, the percentage of teenagers
not working and not in school, community
safety, access to primary healthcare,
incarceration, and availability of healthy
foods. A score has been generated based
on these indicators compared against the
national average.
The Opportunity Index includes indicators within four dimensions
of community well-being: Economy; Education; Health; and
Community. The overall score combines sixteen underlying
indicators for states, and fourteen for counties. The Opportunity
Index score has a potential range of 0 (indicating no opportunity) to
100 (indicating maximum opportunity).
Source: https://opportunityindex.org/
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2021 Community Health Needs AssessmentE. Information Gaps and Process Challenges
Some challenges working with the available data arose which led to information gaps. Zip code data is limited.
The bi-annual Michigan Profile for Healthy Youth (MiPHY) is an online student health survey offered by the
Michigan Departments of Education and Health and Human Services to support local and regional needs
assessment. The survey is usually conducted during the spring portion of the school year. With the COVID-19
pandemic, the survey wasn’t completed prior to shut down so, SJML did not utilize the MiPHY data for this
CHNA cycle.
It should also be noted that some data sources or methodologies have changed and a comparison to previous
data wasn’t advised.
With the restrictions in place for the COVID-19 pandemic, the Community Forums were held during the month
of November and because they were held virtually, we offered two Forums at different times of the day to
maximize participation. These Forums were held in conjunction with the Michigan Institute for Clinical and
Health Research (MICHR) and the Livingston County Health Department. Although there was a smaller turnout
than hoped, there was robust engagement during the sessions. Multiple efforts, including emails and social
media, were put into place to improve turnout without much success. Timing of the event just prior to a holiday
may be of issue.
Another process challenge was conducting the CHNA survey during a pandemic. Recognizing that survey
fatigue could also be an issue, we utilized CNA Work Group members to encourage clients, stakeholders and
the community in general to participate in the survey.
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2021 Community Health Needs AssessmentSignificant Community Health Needs
Needs Identified
Community input from the CHNA Survey and Community Forums as well as the quantitative data was reviewed by
the CHNA Advisory Group (CNA Work Group). There were seven (7) identified health needs within the SJML service
area. The identified health needs were refined in conjunction with the LCHD to reveal four (4) significant health care
needs.
The CHNA process identified four health needs: food security/access; behavioral health (mental health and
substance use disorder) including stress/anxiety, isolation in older adults and suicide prevention, especially in
youth; access to care, especially trusted health information, the digital divide, cost, and local mental health and
specialty providers; and transportation for basic needs, employment and for older adults. The needs were similar
to those identified in the 2018 CHNA but food security replaced obesity and cardiovascular disease. In consultation
with the LCHD and during presentations at the CNA Work Group meeting and the SJML Patient Advisory Committee,
attendees validated these as the most significant health needs in our community which could be addressed.
SJML TOP HEALTH NEEDS
Access to Care • 4% of Livingston County residents are uninsured compared to 6% of Michigan
Residents
• 16.3% of the adults in the CHNA Service Area lack consistent Primary Care compared
to 15.7% for Michigan
Behavioral Health • 17.1% of the CHNA Service Area (age-adjusted) experience lack of social/emotional
(Mental Health support compared to 19.6% for Michigan
and Substance Use • Livingston County residents experience 4.1/30 poor mental health days as compared
Disorder to 4.4/30 in Michigan.
• 20% of Livingston County residents partake in excessive drinking as compared to 20%
in Michigan
Food Security/ • 1 out of 7 people in Michigan experience hunger
Access • 9.1% Food Insecurity Rate for Livingston County compared to 13.7% for Michigan
• 8.9 Food Environment Index for Livingston County compared to 7.1 for Michigan
Transportation • 54% of Livingston County residents have long commutes/drive alone compared to
33% for Michigan.
• Community and stakeholder input indicate that transportation is a pressing issue that
needs to be addressed in the County not only for medical care, but for older adults
and for basic needs.
countyhealthrankings.org/michigan
Michigan 2018 Behavioral Risk Factor, Annual Report
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2021 Community Health Needs AssessmentProcess for Prioritizing Identified Health Needs
Needs were identified through the analysis of data from multiple data sources, Community Forums, and key
stakeholder inputs. The CHNA process identified four significant health needs for prioritization. During the early
months of 2021, the CHNA Advisory Group (CNA Work Group), and the SJML Patient Advisory Committee prioritized
the significant needs using the following framework:
• Key factor in achieving health equity
• Urgency for addressing the need/severity of need
• Potential impact on the greatest number of people
• Feasibility of effective interventions/measurable outcomes in three years
• Consequences of inaction
These five criteria were used by the individuals of the above groups to rank each health need. Each person was
requested to prioritize the health need by scoring the need through the lens of each criteria on a scale of 1-4
(1=lowest importance; 4=highest importance). A total average score was determined for each health need and the
score was utilized to rank each need. The results from the process are shown below.
SJML SUMMARY
HEALTH NEED PRIORITIZATION
Total Average
Health Need Score Priority
Access to Care 2.84 1
Behavioral Health 2.56 2
Food Security/Access 2.28 3
Transportation 2.25 4
Prioritized Needs
Needs that St. Joseph Mercy Livingston will directly address are listed in order of priority below. In collaboration
with our community partners, we will focus on developing and/or supporting initiatives and measure their
effectiveness.
While transportation was singled out as a community need, transportation will be considered across all identified
needs during the implementation strategy phase.
1. Access to Care including transportation, health information/digital divide, cost and local providers
2. Behavioral health including mental health and substance use disorder including suicide, anxiety/depression
and social isolation
3. Food Security/Access
4. Transportation
As we looked at the qualitative and quantitative data for this CHNA cycle, we did so with equity in mind. The CHNA
Survey included several targeted questions around needs since the COVID-19 pandemic. Additionally, we stratified
the responses from the survey by race and older adults to determine if there were any noted disparities. The survey
data did not indicate any significant difference from total responses.
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2021 Community Health Needs AssessmentAccess to Care
In 2018, an estimated 14.3% of Michigan adults reported poor physical health and 14.3% reported poor mental
health. Poor physical health increased with age, while poor mental health decreased with age. Both poor physical
health and poor mental health decreased with increasing household income level.
Michigan continues to make strides in increasing access to health care coverage. In the 2018 Michigan Behavioral
Risk Factor Survey (MiBRFS), an estimated 9.0% of Michigan adults aged 18-64 years reported not having any form
of health care coverage. This represents a significant decrease of 7.6 percentage points since 2012 (16.6%). From
2012 to 2018, the prevalence of no health care coverage decreased among males (2012: 18.9% vs. 2018: 11.3%)
and females (2012: 14.2% vs. 2018: 6.8%), as well as White, non-Hispanic (2012: 15.1% vs. 2018: 8.1%) and Black,
non-Hispanic adults (2012: 24.3% vs. 2018: 9.7%). The Healthy Michigan Plan, which was implemented in April 2014,
makes health care benefits available to individuals at a low cost and we are hopeful for its continuation.
Two additional indicators related to health care access are: 1) not having a personal doctor or health care provider
and 2) having had a time during the past 12 months when an individual needed to see a doctor but could not
because of the cost. Increases in access to primary care have been shown to substantially improve health-related
outcomes. For the SJML CHNA Service area, about 18% of adults reported not having a personal health care
provider compared to 15% for Michigan, while over 20.19% of the CHNA Survey respondents indicated that high
co-pays and deductibles have limited them seeing their doctor.
The benefits of having an annual checkup include early diagnosis and treatment of existing conditions and
prevention of future medical problems. In 2018, an estimated 79.5% of Michigan adults reported having a routine
medical checkup within the past year and the prevalence of having a routine checkup within the past year
increased with age. Males (75.4%) reported a significantly lower prevalence of having a routine checkup within
the past year than females (83.5%). White, non-Hispanic adults (78.9%) and Hispanic adults (74.2%) reported a
significantly lower prevalence of having had a routine checkup within the past year than did Black, non-Hispanic
adults (83.8%). Insured adults and adults with disabilities (82.1% and 86.7%, respectively) were more likely to
have had a routine checkup within the past year than uninsured adults and adults without disabilities (46.6% and
77.0%, respectively). Michigan adults 65+ years who had a routine checkup within the past year were more likely to
have had a flu vaccine within the past year (5.0% vs. 29.2%), and to have ever had a pneumonia vaccine (71.9% vs.
50.4%) when compared to those who had not had a routine checkup. A combined 42% of the SJML CHNA Survey
respondents indicated that being too busy or being unable to take time from work was a limiting factor in seeking
health care.
In Livingston County, 8,365 people are enrolled in the Healthy Michigan Plan. This plan covers people who are
eligible or enrolled in Medicaid or Medicare, aged 19-64, not pregnant and have income of up to 133 percent of
the Federal Poverty Level (FPL), which is about $15,000 for a single person.
To address the issue of rising health care costs and decreasing coverage, discount services and businesses like
Meijer, Kroger and Walmart offer prescription drugs at low flat rates. For those who are uninsured, Federally
Qualified Health Centers (FQHCs) and other free or low-cost clinics, such as retail clinics, are integral in providing
access to care.
SJMHS and IHA over the last few years have focused on the availability of primary and specialty care. Growing our
capabilities to address social care needs of the community is a cornerstone of our CHWB work moving forward.
Access to resources through the SJMHS Social Care Call Line has helped many individuals already foremost with access
to testing and other medical resources during COVID-19 and moving toward other community resources. Additionally,
growing our capacity in the region for Community Health Workers (CHW) will also make a transforming impact on
our communities.
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2021 Community Health Needs AssessmentBehavioral Health
Substance Use
Substance use includes binge drinking, prescription drug abuse and tobacco use. The underlying causes for binge
drinking and prescription drug abuse described by those who provided input exist dually, along with mental illness
or poor mental health and availability of alcohol and prescription drugs.
Excessive alcohol use contributes to approximately 88,000 deaths each year within the U. S. In the 2018 Michigan
Behavioral Risk Factor Survey (MiBRFS), an estimated 17.2% of Michigan adults reported binge drinking on at least
one occasion within the past month, and 6.0% reported heavy drinking over the past month. Both binge drinking
and heavy drinking are more prevalent within the younger age groups and decrease significantly within the older
age groups. The prevalence of binge drinking is highest within the 25-34 year-old age group (26.8%), followed by
the 18-24 year-old (26.1%) and 35-44 year-old (21.2%) age groups. Males (22.3%) reported a significantly higher
prevalence of binge drinking than females (12.3%), the prevalence of binge drinking is significantly higher in White,
non-Hispanic adults (17.7%) than in Black, non-Hispanic adults (13.4%), and adults with disabilities (11.7%) reported a
significantly lower prevalence.
Mental Health
The National Alliance for Mental Illness (NAMI), indicates that millions of people in the U.S. are affected by mental
illness each year. Knowing the numbers is important to understand its physical, social and financial impact and for
raising public awareness, stigma-busting and advocating for better health care. In the U.S., 1 in 20 adults experience
mental illness and 17% of youth age 2-17 years. Mental illness and substance use disorders are involved in 1 out of
8 emergency department visits by a U.S. adult (estimated 12 million visits). Almost all people who complete suicide
have a diagnosable mental or substance use disorder or both, and the majority has depressive illness. The most
promising way to prevent suicide and suicidal behavior is through early recognition and treatment of depression
and other psychiatric illnesses.
Suicide in Michigan is a hidden health issue especially among the older adults. Suicide is more common among
elderly males than females, and rates generally increase with age for both sexes. Suicide is the 10th leading cause of
death in the U.S. and it is the 2nd leading cause of death for people ages 10-34. Suicide rates were highest among
males aged 45-64. The overall rate was 3.6 times higher among males than females. According to the America’s
Health Rankings, Michigan 2020 Annual Summary, the suicide rate for Michigan residents ages 15 to 24 is 16.8%
compared to 14.5% in the U.S.
Depressive feelings are defined as feeling so sad or hopeless, almost every day for two weeks or more in a row,
that the person has stopped doing some of their usual activities. Depression is a common and treatable medical
disorder that is more common among individuals with chronic conditions such as obesity, diabetes, and arthritis.
In the 2018 MiBRFS, an estimated 23.2% of Michigan adults reported ever being told by a doctor that they had a
depressive disorder including depression, major depression, dysthymia, or minor depression. The prevalence of
depression decreased with age and increasing household income level. Females (28.5%) reported a significantly
higher prevalence of depression than males (17.5%). The prevalence of depression was similar by race/ethnicity and
insurance status. Adults with disabilities (43.5%) were more likely to have been diagnosed with depression than
adults without disabilities (15.5%). White, non-Hispanic females (29.3%) reported a significantly higher prevalence
of depression than White, non-Hispanic males (17.0%). In 2018, the prevalence of depression among Michigan
adults (23.2%) was higher than the U.S. median prevalence (19.6%).
Depression in older adults is often not recognized or treated. Most older adults are treated by the primary care
physician and depression is only recognized in about 50 percent of the patients. Depression is not a normal part
of aging. While older adults may face widowhood, loss of function or loss of independence, persistent bereavement
or serious depression is not normal and should be treated. Depression complicates chronic conditions such as
heart disease, diabetes, and stroke; increases health care costs; and often accompanies functional impairment
and disability. Depression is also linked to higher health care costs and tied to higher mortality from suicide and
cardiac disease.
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