A Survey of Primary Health Care, Mental
Health Care and Dental Health Care in
Kitsap County – 2009-2011
By
The League of Women Voters/Kitsap
Table of Contents
IntroductionPage 3
Primary Health Care Survey AnswersPages 4-12
Peninsula Community Health Services UpdatePages 13 -15
Kitsap Public Health District UpdatePages 13-15
Kitsap Public Health Strategic Plan 2011-2012 Pages 16-17
Mental Health Care Survey AnswersPages 18-26
Kitsap Mental Health Services Update Pages 26-30
Dental Health Care Survey Answers Pages 31-35
Additional Information:
LWVUS and LWVWA Health Positions Page 36
Suggested WebsitesPages 36-37
Suggested ReadingPage 38
Glossary of AcronymsPage 38
Introduction to the LWVK Health Care Survey Project - 2011
At the annual meeting in May 2009 the League of Women Voters of Kitsap County decided to do a survey on the adequacy and accessibility of primary health care services in Kitsap County including mental and dental health. This is a report on that effort. We particularly want to acknowledge Dr. Scott Linquist, Director of the Health District and his epidemiologists Beth Lipton and Siri Kushner, and Program Manager, Health Information Resources Chris Craig ; Barbara Malich, Director of Peninsula Community Health Services and Rochelle Doan, Director of Development and Community Relations at Kitsap Mental Health services for their help and guidance. Of the more than 174 contacts made, a total of 120 surveys were returned; 55 primary health care, 46 mental health care and 19 dental health care. At the beginning of each survey there is a breakdown of the specific categories of the responders. At the end of the primary health care and mental health care surveys the Health District, Kitsap Mental Health Services and Peninsula Community Health Services have provided a short summary of the status of their services due to the funding cuts over the two year period of collecting information. Additional information, websites and a suggested reading list is at the end of the report. Anyone wishing more detailed information on the report may contact the League of Women Voters Kitsap.
Many thanks to those League members who helped in this effort, especially, Ann Smith, Connie Waddington, Sue Hughes, Ann Rudnicki, Joyce Maddock, Shawn Northrup, Judy Friedberg-Nerf and Lucy Johnson.
The Health Committee of the League of Women Voters Kitsap
Pam Hamon, Chairman
(360-598-3508)
Primary Health Care
Introduction
TheLeague of Women Voters Kitsap'shealth task force distributedthe primary health care survey to 77 individuals including doctors and nurses, administrators of medical services and government agencies such as the Kitsap PublicHealth District (KPHD)and Department of Social and Health Services (DSHS), Harrison Medical Center, Hospice, Planned Parenthood, Urgent Care facilities, Peninsula Community Health Services (PCHS), Olympic Internal Medicine Associates, and theKitsap County Health District (KCHD). We also included representatives from agencies such asBainbridge IslandandSouth KitsapHelpline, Mary and Martha Children and Adult Services, Holly Ridge Center,North KitsapFishline, United Way, fire and law enforcement departments, school health officials, advocates for the aging, and for the homeless, pharmacists and some members of the alternative health community. We distributed surveys to members of the African American, Hispanic and Native American communities as well. From these sources we received 55 responses; 11 from doctors and nurses, 7 from administratorsof local medical services, 7 from the Health District, 14 from community service agencies, 3 from pharmacists, 3 from fire and law enforcement, 1 school counselor, and 9 from advocates or users of the health system. Any opinions or conclusions expressed in this report solely reflect the responses received to the survey questions, not those of the League of Women Voters.
The surveys were dispersed and collected over an 18 month period. Both Peninsula Community Health Services and the Kitsap County Health District have experienced drastic cuts in funding over this time period. A summary of the resulting changes for both providers is at the end of this section of the report.
LWV Primary Health Care Survey Answers #1
- What types of gaps, if any, do you see in primary health care for the citizens of Kitsap County?
It is clear from the majority of responses received that lack of health care for low income individuals and families including the uninsured and underinsured is the most significant gap in health care in Kitsap County. Some physicians accept Medicare and Medicaid but limit the number of these patients due to the low reimbursement rate for services. In addition there is a shortage of family practice and internal medicine doctors. The number of these primary care doctors has decreased due to retirement and the difficulty in recruiting replacements. Specifically, primary care physicians are in short supply due to the low income generated for their services compared to other specialties. (This is a national problem).Two responders noted the lack of OB/GYN physicians especially for low income women without insurance. PCHS and its two satellite clinics in Poulsbo and Port Orchard provide health care services to many underserved but they are increasingly having to limit the number served due to funding cuts. Urgent Care clinics are available in many locations in the County but there are upfront fees for services that prove prohibitive for many. Even the small fee of $25, $15 or $10 is too much for some people. As a consequence an increasing number are turning to the Harrison Medical Center Emergency Room(ER) for primary care. The ER is always available but also the most expensive way of providing outpatient care.
Three responders particularly specified the age groups lacking access to primary care. These are the uninsured working young adult, and a growing number of elderly. Most children seem to have a primary care provider. Other responders addressed the lack of Spanish speaking providers or qualified interpreters for all non-English speaking groups, the shortage of prevention care,the need for school based clinics and the lack of access to mental health care, dental services and vision services. Transportation was also viewed as a problem for persons living in outlying areas of the County. Finally a few responders felt there was a need for a better outreach effort to educate the general public on where and how to access services.
LWV Primary Health Care Survey Answers #2
- Do you feel that all geographic areas of the county have adequate availability of primary health care services?
Approximately half of the responders found there is sufficient coverage for those with public or private insurance particularly in view of the current economic climate. For the most part, those responders that found inadequate availability were responders who are directly involved in the health care or social services systems. Noted was the lack of transportation in Kingston, Seabeck, Hansville, Indianola, Suquamish, Port Orchard, Burley, Olalla and North Mason. PCHS has clinics in Port Orchard and Poulsbo but access to these clinics was still difficult for those persons living in the far south and far north because of the lack of public transportation. Compounding the problem is the fact that rural areas are not fiscally viable areas for physicians to locate a practice. The concentration seems to be in Bremerton and an increasing number are locating in Silverdale. Kingston does have one full-time internal medicine doctor and another internist who works there a couple of days a week.
Seven survey participants did not respond to this question or indicated they did not know the answer. Some responders addressed the gap in services rather than addressing geographic availability.
LWV Primary Health Care Survey Answers #3
- Are there any referral specialties lacking in Kitsap County?
Eleven responders indicated that there was a shortage of rheumatology specialists in the County. Seven participants noted a need for more OB/GYN physicians especially those that accepted Medicaid beneficiaries. Many women go without care and consequently develop otherwise preventable complications. According to one respondent, there are no primary care providers delivering babies and midwives do not have hospital privileges at Harrison Medical Center. Five responders stated there is a lack of breast specialists and those who perform female surgeries such as breast augmentation.
Neurological services are lacking in Kitsap County according to eight responders. Most trauma cases have to be sent to Harborview Hospital in Seattle. This practice of referring individuals to Harborview was not necessarily viewed as a negative as Harborview, the designated regional trauma center, is an excellent.
A need for endocrinology specialists and a need for providers of pediatric sub specialties were noted by seven responders and six responders respectively. Other referral shortages are orthopedics including pediatric and spine, pain management, urology and dermatology. One person found a need for reconstructive surgery for cleft pallet; another stated a need for providers who treat diabetes, the developmentally disabled and one mentioned the need for services for Fetal Alcohol Syndrome Disease. The need for inpatient services for children was noted in one survey response.
Several responders continued to raise the concern that not enough providers accept Medicaid and that more people need to know about PCHS 211 phone service. Eight survey participants did not respond to this question and another eight stated they were unaware of the lack of any referral providers.
Mental health services (psychiatric and psychology services, especially pediatric) were mentioned by 12 respondents. These responses also included the need for parenting classes for new mothers, substance abuse treatment for youth and domestic violence treatment specialists. This matter is more fully discussed in the mental health services portion of this report.
LWV Primary Health Care Survey Answers #4
- Do you feel that uninsured and underinsured patients in Kitsap County have access to recommended primary health care prevention services and medically necessary treatment services?
The clear answer to this question is no. First, physicians who do accept Medicaid and Medicare must limit their numbers as the reimbursement received for services rendered is insufficient to cover the doctors’ cost. It was noted that Washington’s Medicaid reimbursement is particularly low. Second, the low income, uninsured and underinsured have access to PCHS but the clinic is stretched due to funding cuts and can only accept a certain number of patients. There is also a patient co-pay for services that many cannot afford and consequently they do not receive these services. Many eventually end up in the ER at Harrison Medical Center often late in the development of the problem or for non-emergent care. The need for a universal health care system was noted by the Director of the Kitsap Public Health District. The Group Health Home model was praised by the Juvenile Detention responders for the coordination and provision of services to those detainees enrolled in Group Health. The Detention Center is even contacted when detainees need updates on their immunizations.
LWV Primary Health Care Survey Answers #5
- What prevention approach(es) to improving health of Kitsap County residents would you suggest and support?
For Children:
Nineteen responders stated that full funding for services at the District Public Health District would clearly improve health care for children. The services listed as most important were well child clinics that need to be reinstated and the continued need for low cost/free immunizations. One respondent felt strongly that parents should not be allowed to refuse immunizations for their children as this puts others at risk. Other services mentioned were family planning, sexually transmitted disease testing, clinics for the homeless which provide follow-up care and public health nurse services including home visits, parenting information and support for new mothers. One District Health representative said the Apple Health for Kids program needs to be maintained at current levels. The Apple Health for Kids program is Washington State’s Children’s Health Insurance Program (S-CHIP). Another District Health employee recommended that the standards of health plan developed by the Health District in collaboration with other members of the community needs to be resurrected and moved forward.
The increase in child obesity was a significant concern noted by sixteen responders. Several indicated that prevention measures such as education and support groups should be available in weight control, exercise and nutrition. Schools should be encouraged to offer healthy lunches and physical education programs for all students. Promoting a healthy community was another suggestion such as having bicycle and hiking paths, safe swimming areas and sidewalks. Eating disorders prevention was also mentioned as an important issue.
Every child in the County needs to have a primary care physician and full financial coverage for services. Twelve responders noted the importance of prevention services for children, improving the payment rates to physicians and better funding for PCHS as steps thatwould greatly improve health care for children.
Seven recommended improving access to dental services and six responders said increasing the availability of mental health care was important. Specifically mentioned were fluoridation of water supplies and dental clinics in schools. Increased mental health services should include smoking, drug and depression prevention. One person felt that every child in the County should be tested for brain development.
Six responders saw a need for more and better distribution of information on health care issues. Recommended vehicles for this effort included health fairs that offer wellness checks, information to Head Start and a list of resources provided to schools and child care centers. One responder stated that services were available but not used and another found that special needs children were well served.
Some participants pointed out the need for expanding family support programs including prenatal care and parenting classes for parents of children of all ages. The need for adequate housing was brought up by one survey participant. Schools could improve access to needed services and provide a health care safety net for children with dysfunctional parents. Finally, other ideas expressed were the need to provide vision care, decrease the exposure to environmental toxins and screen all infants at birth for Fetal Alcohol Syndrome Disease.
For adults:
The major step which must be taken to improve the health care status of all Kitsap County residents is increasing access to services. Everyone needs a medical home so they don’t resort to the hospital ER for non-emergency services. PCHS needs to be fully funded and Medicare/Medicaid reimbursement rates for primary care services should be increased so that physicians are more able financially to serve this population. The State’s Basic Health Plan must be improved and services reinstated and prescription drugs must be more affordable. One doctor suggested that individuals should take more responsibility for his/her own health care and be given a greater degree of control over the financing of their health care.
Nine participants noted the huge role played by the Public Health District in preventive care and emphasizing the importance of sufficient funding to carry on the District’s effort. Basic prevention services noted were immunizations, family planning, sexually transmitted diseases testing, and more public health nurses for mother/child services. The District used to have conveniently located clinics in the County but these clinics no longer exist.
Other prevention services for adults was screening for the low income residents for potential problems such as colon, prostate and breast cancer, diabetes, hypertension, vision and dental needs. Additionally, more classes need to be offered on weight control, nutrition, the benefits of exercise and a healthy life style. Obesity in adults as with children needs to be more strongly addressed according to eight responders. A suggested activity is to conduct a countywide campaign to promote a healthy life style through proper nutrition, exercise and weight control. More bicycle paths and side walks were also mentioned.
Other ideas pertained to improving the environment through decreased exposure to toxins, and establishing public policies in this regard. Also mentioned were the need for advocacy services to help people navigate the health care delivery system, increased support services especially at more convenient hours for the working population, improved transportation and better chronic disease management.
Servicing persons with a mental illness in a timely manner was also noted as critical to prevent the problem from escalating and becoming more severe. Dental care is almost non-existent for the low income and this lack of care can be a serious barrier to those looking for employment. The ER only prescribes antibiotics for those suffering with a dental problem. Otherwise comprehensive dental services are available only for those who can pay or have dental insurance. (Mental Health and Dental Services are discussed in more detail in subsequent sections of this report.)