Health Access Assessment Update

Health Access

Accessing Primary Preventive Health Care

Information related to access and utilization of primary preventive health care in Archuleta County has been collected by various agencies in the community. The following are the sources of information that have been collected in the community:

Healthy Archuleta Health Care Provider Survey, conducted during May 2022 with 10 health care agencies responding. The following definition of primary preventive care was given to providers in the survey: Routine healthcare that includes screenings, check-ups, and patient counseling to prevent illness, disease, and other health problems as well as response to acute illnesses or to coordinate care among specialists.
Healthy Archuleta Health Care Access and Utilization interviews, conducted during October and November 2022, with a total of 32 participants. The demographics of this group were 90% (29/32) Adults (26-64) and the remainder (3/32) had representation from Older Adults (65+) and Young Adults (18-25), 50% (18/32) of respondents were White (Non-Hispanic), 41% (13/32) Hispanic/Latin-x and the remaining 9% (3/32) were Indigenous/Native America and Black/African American. Additionally, 37.5% (12/32) respondents did not have health insurance and of the 62.5% (20/32) who had some form of health insurance, 60% (12/20) had private insurance (Blue Cross Blue Shield, Friday Health Plans, Rocky Mountain Health Plans, and United), 20% (4/20) had Medicare, and the remaining 20% (4/20) other insurance types Medicaid, cost-sharing program, or had military coverage.
Pagosa Springs Medical Center Quality Improvement Survey, conducted during August and September 2022 with 28 respondents
San Juan Basin Public Health Community Survey, conducted during the Spring of 2023 (results pending)
Aspire Community Survey, conducted during Spring of 2023 (results pending)

Additionally, information from public datasets was compiled related to primary preventative health care at the County and State level. These data sources included:

County Health Ranking (2020)
KFF, Statewide Medicare enrollment (2020)
CDC Nutrition Physical Activity and Obesity Data: Colorado (date varies by data)
CDC Behavioral Risk Factor Surveillance System (2021)
National Low Income Housing Coalition (2022)

What are the motivators and barriers to accessing primary preventive care from individual perspectives?
Where is the data available?

Healthy Archuleta health care interviews (Oct-Nov 22)
PSMC Quality improvement survey (Aug-Sept 22)

What does the data say?

Healthy Archuleta Health Care Interviews
- Most interviewees reported annual visits as important to very important. For those getting annual check ups, the reported motivation was health and wellness.
- Follow-up Question for Community:
  - How important is it that you receive a primary care check up annually? Not very important, Not important, Important, Very Important
- In response to the question "Which of these best describes the barriers you face in accessing preventative/primary care services?" interviewees select barriers from a multiple selection list. Their selections included:
  - Finding a provider they want to see (n=17)
  - Not knowing what insurance covers and having to pay out of pocket (n=13)
  - Finding a provider who they can establish a relationship with (n=11)
  - Cost of service even with insurance (n=10)
  - Cost of services (n=9)
  - Having/making time to see a provider (n=9)
  - Transportation issues (n=4)
  - Finding a provider that speaks their language (n=3)
  - Not having family/community support to help when they need see a provider (n=3)
- Additionally, interviewees were asked to share "what other barriers/challenges have you faced in accessing primary care services (physical, dental, and mental health)?" They reported:
  - Lack of understanding of what their insurance covers
  - High Deductibles
  - Cost of services and having to pay up front for care
  - Transportation to services
  - Speciality services
  - Spanish-speaking community members reported being disrespected
  - Availability of appointments
- Interviewees who reported not getting annual checkup were asked "what prevents you from getting these annual check ups?" Respondents indicated:
  - Not knowing what insurance covers
  - Cost
  - Difficulty in taking time off to go to an appointment
  - Finding a provider
  - Lack of appointments
  - Lack of trust
  - Wanting to be treated holistically
- In response to the question "what difficulties have you encountered when trying to find primary/preventive services for your annual check-ups and for your family?" Interviewees reported the following difficulties:
  - Finding female providers for women's health
    - Follow-up Questions for Agencies:
      - Which one of the female providers at your facility offer women's health services - please describe the scope of the services that they offer?
      - Who/how many among these providers are taking new patients?
      - What is the wait time for getting established as a patient with these provider?
      - What is the wait time for annual visits with these providers?
      - How much do the patients that are seeking women's health services have the option of choosing female providers?
      - From your experience, when it comes to seeking women's health care services at your agency, which of these are patients looking for in the provider: nurse practitioner, family practice doctor, physician assistant, obstetrician and gynecologist, female provider, other
    - Follow-up Question for Community:
      - When it comes to wanting to get women's health care in Archuleta County, which of these are you looking for in the provider: nurse practitioner, family practice doctor, physician assistant, obstetrician and gynecologist, female provider, other
  - Waiting time for appointment
  - Lack of pediatricians
  - Lack of information in Spanish
  - Cost without insurance
PSMC Survey
- Respondents to the PSMC Survey were able to select from a multiple selection list in response to the question "What prevents you from seeking an annual check up?" Responses included:
  - Out of pocket costs or lack of insurance coverage - 43%
  - My schedule conflicts with accessibility to clinic appointments - 36%
  - I currently do not have a healthcare provider - 14%
  - I do not find value in having an annual checkup - 7%

What action steps emerged?

Advocate for women and pediatric providers in Archuleta County by communicating with providers
Find out from pediatric providers outside of Archuleta how many patients are from Archuleta county (volume of patients who get care)
Connect with PPOS to learn about their student school health efforts
Make video to show the process of engaging/navigating the health care system for the different services offered in the County (in both Spanish and English)

What are the issues and opportunities related to accessing primary preventive care for the residents of Archuleta County?
Where is the data available?

Healthy Archuleta health care interviews (Oct-Nov 22)
Healthy Archuleta health care provider survey (May 22)

What does the data say?

From among the Healthy Archuleta health care access/utilization Interviewees some issues related to accessing primary preventive care emerged, including:
- Cost of service, both for those without insurance and those with insurance was mentioned as an issue by interviewees
- For those with insurance, many indicated an issue was no knowing what their insurance covered when it came to primary preventive care
- Interviewees also mentioned finding and connecting with a provider was an issue, especially related to women's health, pediatric providers, and those looking for more holistic care
- Interviewees also mentioned time as an issue for accessing care, both related to being able to personally find the time to go to an appointment and the length of time it takes to get an appointment
- Additionally, for those who Spanish is their primary language, they reported lack of information in Spanish.
Health care providers were asked to describe their ideal primary preventive health care system in Archuleta County would be. Respondents described integrated care for patients and to be able to provide care regardless of insurance or ability of community to pay. They also described team-based approaches, collaboration, partnerships, and the importance of having community access to primary care and annual visits to manage and prevent disease.
Some opportunities related to accessing primary care that were mentioned by the providers in the Health Care Provider Survey included:
- Coordination and collaboration among providers and agencies
- Having community health advocates at the clinics
- Exploring the idea of food prescription programs at clinics
- Increased referrals
- Patient education related to where services are provided in Archuleta County
As part of the Health Care Provider Survey, providers were asked a series of questions about who and how they refer to in the community. From the responses, six organizations emerged as key players in the network having a high number of connections. These organizations included:
- Authentic Solutions Consulting
- Pagosa Springs Medical Center
- San Juan Basin Public Health
- Archuleta Integrated Health Care (Axis)
- Aspire, pregnancy center
- Department of Human Services
Additionally, survey respondents indicated the nature of their referral processes:
- 54% (100/186) of referrals between organizations were described as informal
- 27% (50/186) of referrals between organizations were described as formal
- 15% (28/186) of partnerships do not need a referral process
- 4% (8/186) of potential connections between organizations should have a referral process but one does not currently exist

What primary preventive services are available in Archuleta County?
Where is the data available?

Healthy Archuleta health care provider survey (May 22)

What does the data say?

Primary Care Services Provided to children 0-5
- Follow-up Questions for Agencies:
  - Does the child and/or family need to be an established patient in order to receive childhood immunization?
  - Can non-established patients walk-in to receive childhood immunization?
  - What services are you currently offering in collaboration and/or in support of SJBPH (MOU, contract, unmet need, grant funding)?
  - How long have you been offering this service?
  - What is the patient load for this service?
  - Are you planning to continue to offer this service and what would it take?
  - Standard Immunizations
    - Follow-up Question for Community:
      - If you have a 0-5 year old child, are you aware that your child needs the following services: standard immunizations, standard well child checks, developmental behavioral assessment, vision screening, hearing screening.
    - Hearing Screening
    - Vision Screening
    - Developmental Behavioral Assessment (Ages and Stages or other)
    - Standard well child checks
    - Follow-up Questions for Agencies:
      - Does the child and/or family need to be an established patient in order to receive childhood immunization?
      - Can non-established patients walk-in to receive childhood immunization?
      - What tracking and/or reporting system do you use and to whom?
Primary Care Services Provided to youth 6-18
- Follow-up Questions for Agencies:
  - Does the child and/or family need to be an established patient in order to receive childhood immunization?
  - Can non-established patients walk-in to receive childhood immunization?
  - What services are you currently offering in collaboration and/or in support of SJBPH (MOU, contract, unmet need, grant funding)?
  - How long have you been offering this service?
  - What is patient load for this service?
  - Are you planning to continue to offer this service and what would it take?
    - Annual Health Check-up
    - Standard Immunizations
      - Follow-up Questions for Agencies:
        Does the child and/or family need to be an established patient in order to receive childhood immunization?
        Can non-established patients walk-in to receive childhood immunization?
        What tracking and/or reporting system do you use and to whom?
    - Vision Screening
    - Hearing Screening
    - Reproductive Health
      - Follow-up Question for Community:
        If you have a 6-18 year old child, are you aware that your child needs the following services: annual health check-up, standard immunizations, vision screening, hearing screening, reproductive health.
Primary Care Services for Adults
- Pneumonia Immunization
- Herpes Booster
- Blood Pressure Screening
- Blood Glucose Test
- Coronary Screening
- Cholesterol Screening
- Skin exam
- Colorectal Screening
- Colonoscopy
- Fecal Occult Blood Test
- Thyroid Stimulating Hormone Test
- Bone Density Testing
- Testicular Exam (yearly)
- Prostate Exam
- Pap Smear (every 3 years)
- Pelvic Exam (yearly)
- Reproductive Health
- Mammogram
- Ovarian Screening

If low barrier services such as health fair or easy to access screening are offered through the public health department or private health agency would that increase primary care? And what level of screening would people be willing to participate in? And how often?

Are the location of services in AC a barrier to accessing healthcare?

What services do people want to access outside of the current traditional healthcare delivery facilities for non-medical follow up? Would getting access to these services outside of a medical setting make a difference in accessing care? Examples of these services include education for diabetes after diagnosis with the chronic disease.

What is people's level of insurance and adequacy of insurance to cover needs of primary care?
Where is the data available?

Healthy Archuleta health care interviews (Oct-Nov 22)
San Juan Basin Public Health Community Survey (Spring 23)
County Health Ranking (2020)

What does the data say?

Those that participated in the Healthy Archuleta interviews were asked if they had health insurance, 11 of the respondents did not have insurance and 20 of the respondents did have insurance.
For those with insurance, most knew it covered an annual exam and limited blood work and some did not know what their insurance covered.
In 2020, 16% of Archuleta County residents under the age of 65 were uninsured according to County Health Ranking data.

What action steps emerged?

There is a need for education related to understanding and using health insurance, helping individuals understand what primary preventive care is covered by insurance and where they can access care (in-network vs out-of-network)
Understanding from providers how they are interacting with insurance companies
Public messaging with language that aims to build community capacity to advocate for themselves
Investigate inviting some of the bigger payers (insurance companies - Medicaid, Friday) to talk to the community, have a session for community members and one for providers
There is a need for community advocates - who is the ombudsman for the public when health insurance does not cover a service? Go to payers and ask them how do we solve this issue?

What insurance types are accepted among providers in Archuleta County?
Where is the data available?

Healthy Archuleta Health Care Providers Survey

What does the data say?

Respondents to the survey reporting accepting the following insurance types in Archuleta County:
- Medicaid
- Medicare
- Rocky Mountain
- Anthem
- Cigna
- Bright
- Friday
- United
- Aetna
- Humana
- TriCare (for the military)
- IHS
Additionally, 7 out of 10 respondents also offered a sliding scale. These sliding scales are primarily advertised through the websites of the primary care providers and the mental health providers primarily share the information with patients through individual conversations.

What is the Medicare Enrollment in Colorado?
Where is the data available?

What does the data say?

The total Medicare enrollment in Colorado in 2020 was 938,949, of which
- 56% was traditional Medicare enrollment and
- 44% was Medicare Advantage or other health plan enrollment.
In 2020, Medicare beneficiaries were 16% of the Colorado population.
Additionally, 122,088 individuals (or 13% of all Medicare beneficiaries) were enrolled in both Medicare and Medicaid, of which
- 83,790 had full benefits and
- 38,297 had partial benefits.

How do people with limited access to transportation manage their health care needs?

How important is it that primary care services are free or on a sliding scale before you consider using them? How important is it for people to be able to visit the agency's website to learn the cost of service before people decide to visit?

Do people have problems understanding insurance and need help figuring out what they have in terms of coverage?

What systems do we need in place so everyone has access to timely and responsive primary preventative healthcare services? What system changes are needed to create access for everyone?

Where are people accessing primary health care services? Offer SJBPH as one of the options?
Where is the data available?

Healthy Archuleta health care interviews (Oct-Nov 22)
Healthy Archuleta health care partner survey (May 22)

What does the data say?

Interviewees who participated in the Healthy Archuleta health care interviews (n=16) who had said they got annual check-ups in the last year reported going to the following providers:
- Pagosa Medical Group (n=7)
- Pagosa Springs Medical Center (n=4)
- Alpine Medical & Specialty Practices (n=2)
- Out of the county (n=1).
  - Follow-up Questions for Community:
    - In 2022, did you receive an annual primary care check up with a health care provider? Yes/No,
      - If not, tell us why?
      - If yes, which of these places did you visit to get your care (Aspire, Axis, PMG, PSMC, SJBPH, Alpine Medical and Specialty Practices, Out of County [describe}? Which of these factors influenced you in deciding to get your care from this place (in-network provider for my insurance, easy to get an appointment, referred/suggested by someone I know, they offer payment methods that I can use, they offer specific services that I was looking for, they offer appointments and/or walking option that best fit my schedule, I have an established relationship with a provider at this facility, other)
In the Healthy Archuleta healthcare partner survey, agencies were asked how many patients they provide primary care to per quarter, the following number of patients were reported by each agency:
- Pagosa Springs Medical Center - 4,000
- Pagosa Medical Group - 2,500
- San Juan Basin Public Health - 715
- Alpine Medical & Speciality Practices - 500
- Archuleta Integrated Healthcare - 400
  - Follow-up Questions for Agencies:
    - In 2022, how many patients received an annual primary care visit at your facility? Please provide a breakdown of the annual visits by age [0-5, 6-18, adults (19-29, 30-40, 41-50, 51-64, 65+)] and gender?

What action steps emerged?

One action step that emerged related to continuity of care is to have health care facilities to find ways to support patients with seeing the same provider to build relationships for ongoing care (organization policy change to recommend).

Are people interested in women's care - mammogram and cancer screening?
Where is the data available?

Healthy Archuleta health care interviews (Oct-Nov 22)

What does the data say?

In response to a question about what difficulties respondents have faced in finding primary/preventive services, finding a provider for women's health was mentioned.
Additionally, in response to a question about what primary/preventative services need to be offered in Archuleta County women's health was mentioned by respondents.

What action steps emerged?

Communicate with health care providers that there is an interest and demand for women's health providers
Explore the issues with providers as to what are the barriers to women's health provider services in the county. What can the community do to help with this (need more space and/or more providers)?

What are community members' experiences and perceptions of healthcare?
Where is the data available?

Healthy Archuleta health care interviews (Oct-Nov 22)

What does the data say?

Interviewees reported generally an average experience with health care in Archuleta County, noting that access to specialty care is limited and for those without insurance the cost is expensive.
Some interviewees reported have difficulty navigating health insurance.
Additionally, interviewees reported that dental and mental health care is also limited in Archuleta County.
Some things interviewees mentioned that they like about health care included:
- Being able to get care locally
- Knowing they are healthy
- The technological advances of medicine
- Their relationship with their provider
Some things interviewees mentioned that they did not like about health care included:
- Navigating insurance coverage
- Cost
- Fragmented care
- Being told conflicting information
- Language barriers

What action steps emerged?

One action step is for the health assessment team to invite speakers to come and talk about health insurance to help with the development of educational materials related to (invite community partners), representative from the office of health equity,
- Durango broker, SJBPH, RMHP - Colorado Medicaid.
System level action - invite the agencies to see what elements of their system support this, do a reflection with staff on what nurtures relationships and kindness and bring back the care studies to the advisory group.
Keeping the relationship with the provider, being able to see the same provider for the visit each time. (are there examples of practices that do this well that can share their experiences with the group).
Care Coordination
- What can we learn about pediatric care coordination that can inform family practice?
- Model for care coordination for preventive and acute cases.
- Have the care coordinator for PSMC come and talk to the group.
- Have agencies share at advisory meetings what they have for care coordination and navigation for ancillary health care (if any).

Utilizing Primary Preventive Health Care

For the uninsured, what does it take for them to access primary care? Where do they go to get services that are available to them?
Where is the data available?

PSMC Quality improvement survey (Aug-Sept 22)

What does the data say?

One comment from the "Additional Comments" section of the PSMC survey reported, “I think if people knew the prices of routine things, bloodwork, exams and x-rays it would promote more “low income” people to come. It would also be nice if there was some sort of “working class” middle income program or discount for people who don't qualify for Medicare and can't afford insurance.”

What day of the week and time of day would you be able to attend a health fair?
Where is the data available?

PSMC Quality improvement survey (Aug-Sept 22)

What does the data say?

One comment from the "Additional Comments" section of the PSMC survey reported, “Why not have a ‘Health Fair’ where diagnostics can be done for people who are reluctant to seek treatment.

Telehealth and the ability to participate in services? Reliable internet, computer. Experience with the service if they have used it? Would you access telehealth services in another facility? Do they ve reliable transportation to access telehealth services from a facility?
Where is the data available?

HA health access interviews (Oct-Nov 22) (what do you know, your experience and interest)
PSMC Quality improvement survey (Aug-Sept 22)

What does the data say?

Interviewees were asked what they know about telehealth services and their experience with them.
- Not many had experience with tele-health, mentioned a need to be a bit tech savvy to use, and that tele-health misses the personal connection with a provider.
- Saw the convenience during COVID for things like prescriptions and mild symptoms. Potential for use with mental health providers.
One comment from the "Additional Comments" section of the PSMC survey reported, "need telehealth access to more specialists, dermatology, endocrinology, and rheumatology."

What action steps emerged?

Skills needed by providers for effective telehealth service delivery - investigate successful models and those with higher ratings that offer services in Spanish and how they can get it covered by health insurance; research and catalog tele-health services that can be shared with providers across the health organizations.

Do people have a Primary Care Provider and/or regular primary caregiver that you they see regularly?
Where is the data available?
HA health access interviews (Oct-Nov 22)
What does the data say?

Some interviewees reported using multiple providers for their annual care over time due to scheduling and cost.
Additionally, insurance may drive where people get annual care and may change with changing insurance.
Interviewees who had had an annual visit reported going to Pagosa Medical Group (n=7), PSMC (n=4), Alpine (n=2), and out of the county (n=1).

What action steps emerged?

Health care facilities to find ways to support patients with seeing the same provider to build relationships for ongoing care (organization policy change to recommend)

What makes people comfortable in their access to primary care? What does establishing a relationship with a Primary Care Provider mean to them?
Where is the data available?

Healthy Archuleta health access interviews (Oct-Nov 22)
Healthy Archuleta Health Care Providers Survey (May 22)

What does the data say?

In response to a question about what interviewees would like to see in a Primary Care Provider respondents mentioned
- having more time to connect and build relationship,
- speaking the same language,
- having more specialists like pediatrics and women's health,
- being open-minded, and
- more consideration of non-prescription options for care.
Respondents to the health care providers survey, agencies were asked to share what learning opportunities they provided related to cultural responsiveness and cultural competency. The majority of providers offer some sort of training for their staff through virtual sessions and some larger organizations have DEI committees.

What action steps emerged?

A place to come meet providers - organize a health fair where providers can meet the community.

What are people's experiences with timely annual primary care in Archuleta County?
Where is the data available?

Healthy Archuleta health access interviews (Oct-Nov 22)
Healthy Archuleta health care providers survey (May 22)

What does the data say?

Interviewees were asked how long it took them to get an appointment for annual care in the last year.
- Responses ranged from over a month to a couple of weeks for primary care with specialists taking longer and that acute issues could be seen at urgent care immediately.
- Dental appointments had a similar time of over a month to a couple of weeks.
Health care providers reported their perceptions of timely access to care, sharing how long they thought it should take to access care:
- Mental Health Care - About 1 week
- Primary Health Care - About 1 week
- Dental Care - About 1 week
Additionally, providers were asked if they though care was accessible in a timely manner for the three types of services:
- Mental Health Care - 3 out of 10 responded care could be accessed in a timely manner
- Primary Health Care - 8 out of 10 responded care could be accessed in a timely manner
- Dental Care - 2 out of 10 responded care could be accessed in a timely manner

What action steps emerged?

Share with the providers that the community has this as a concern and explain the timeline for scheduling visits.
Share best practices with scheduling from other organizations. Being proactive in scheduling.
Sending reminders to patients for annual care - do agencies have practices that they can share? Timeline for sending out reminders. Organizational policy for reminders - letter to patients. Organizational policy for scheduling with returning patients and acute care with seeing the same provider.

What are people's expectations of providers and services in AC?
Where is the data available?

Healthy Archuleta health access interviews (Oct-Nov 22)
Healthy Archuleta Health Providers Survey (May 22)

What does the data say?

When asked what primary/preventive services interviewees wanted offered in Archuleta County, responses included
- more alternative health services,
- women's health,
- pediatrics,
- dental care,
- mental health and
- more specialists.
- Also in response to a question about what interviewees would like to see in a Primary Care Provider respondents mentioned
  - having more time to connect and build relationship,
  - speaking the same language,
  - having more specialists like pediatrics and women's health,
  - being open-minded, and
  - more consideration of non-prescription options for care.
Health care providers were asked in the survey if they had bilingual staff, 6 out of the 10 respondents said they did have bilingual staff. These staff hold various positions at the agencies, including clinic director, registration and discharge, therapist, physical and other roles.
In the providers survey, 6 out of 10 agencies reported being fully staffed at the time of the survey.

What action steps emerged?

A place to come meet providers - organize a health fair where providers can meet the community.
Communicate with health care providers that there is an interest and demand for pediatric and women's health providers
Explore the issues with providers as to what are the barriers to pediatric and women's health provider services in the county - what can community do to help with this (need more space and/or more providers)?

How many people get annual check ups?
Where is the data available?

HA health access interviews (Oct-Nov 22)
HA health care partner survey

What does the data say?

In the health access interview, 11/23 indicated they get annual check ups.

In the Healthy Archuleta healthcare partner survey, agencies were asked how many patients they provide primary care to per quarter, the following number of patients were reported by each agency:
- Pagosa Springs Medical Center - 4,000
- Pagosa Medical Group - 2,500
- San Juan Basin Public Health - 715
- Alpine Medical & Speciality Practices - 500
- Archuleta Integrated Healthcare - 400

What mental and dental services are available in Archuleta County and what are people's experience with mental and dental health?
Where is the data available?

Healthy Archuleta health access interviews (Oct-Nov 22)
Healthy Archuleta Health Care Providers Survey (May 22)
PSMC Quality improvement survey (Aug-Sept 22) for mental health

What does the data say?

Providers Survey
- Mental health services provided in Archuleta County include:
  - Individual psychotherapy/counseling
  - DBT
  - EMDR
  - Group Therapy
  - Medication
- Dental Health services provided in Archuleta County include:
  - Child/youth teeth cleaning
  - Child/youth exam including x-rays
  - Adult teeth cleaning
  - Adult exam including x-rays
  - Fluoride treatments
  - Sealants
- The following providers listed the number of mental health clients they see each quarter:
  - Archuleta Integrated Healthcare: 200
  - Pagosa Springs Medical Center: 175
  - Alpine Medical & Speciality Practices: 123
  - Authentic Solutions Counseling: 200
  - Private Mental Health providers see an average for 20-100
In the health access interviews:
- Dental Health
  - Interviewees had mixed reviews on local care, some were going out of Archuleta for care due to cost and/or insurance coverage.
  - Limited Medicaid providers locally. Some felt there were being upsold locally by providers.
- Mental Health
  - Interviews asked what people thought about access and use of mental health services in Archuleta - Generally, interviewees described services as
    - hard to access due to limited providers, especially in Spanish and
    - expensive without insurance.
    - Issues of stigma and confidentiality in a small town were also brought up by interviewees.
PSMC Survey:
- In response to the question. "We know that behavioral health needs are as important as physical health in promoting a sense of wellbeing. What mental health resources do you believe are lacking in our community? (check all that apply)" respondents selected:
  - 33% Accessibility to local outpatient behavioral health services.
  - 28% Lack of adequate community support groups.
  - 22% Lack of behavioral health services that address ethnic and cultural diversity.
  - 17% Lack of coordination of health services between primary care and mental health providers.
  - Comments:
    - “Don’t know if any lacking because I never had to look for any resources.”
    - “Lack of utilizing an important volunteer services available in certified pet therapy! National groups are covered by liability insurance and free of charge.”
    - “Not sure.”
    - “Not aware of behavioral health issues- pro or con.”
    - “N/A”
    - “I have never been in need of mental health services, so I am unsure.”
    - “Lack of knowledge concerning this area.”
    - “Translators in the hospital”
- What resources do you mostly rely on for mental health and support? (check all that apply)
  - 56% Friends or family members
  - 19% Religious organizations/ clergy members
  - 13% Local support groups
  - 6% Behavioral Health outpatient services (e.g., mental health clinics)
  - 6% Helplines or internet self-help services
  - Comments:
    - “Prayer.”
    - “Not much need for mental health support.”

What action steps emerged?

Dental health:
- If we can get a dentist to the space, share the information we are learning from community members.
- Meet with the dentists separately to let them know what we're hearing from the community.
- Host a gathering.
Mental health:
- Distinguishing between the community perception that mental health care services may not be confidential in a small town and the reality of what accessing these services is actually like and communicating this through gateway partners and health care providers
- Emphasize integrated health as a model of service for patient care
- Learn about the care coordination of the different health orgs and share with the community.
- Continue to encourage and find resources/follow-through for mental health providers who are Spanish speakers.

1) Which of these services do you get on an annual basis? 2) If you get these services, from which of these locations do you get the service? 3) If you don't get these services, tell us which of these best reflects why you don't get the service? 4) If this service was available through the local public health department would you access this service? 5) If yes, which of these factors would influence you to get the service at the health department.

How many people have high deductible health insurance? Does it deter them from accessing an annual visit? Are they aware that their insurance should cover an annual visit and certain blood work? What prevents them from getting their blood tested?

Community Wellness

What kind of support do people need to make lifestyle changes?

What are the current practices related to substances such as marijuana, diet, exercise, supplements, and alternative therapy?

How important is it that someone is able to speak your native language?

How do people rate the overall health of the community?
Where is the data available?

SJBPH

What diseases are people facing in their families? How are they coping with it in terms of access? What are they concerned about considering these conditions?
Where is the data available?

PSMC Quality improvement survey (Aug-Sept 22)
Healthy Archuleta Health Providers Survey (May 22)

What does the data say?

Of the 28 respondents to the PSMC survey, those that answered that they had been diagnosed with one of the listed medical conditions (n unknown) reported the following diagnoses -
- 39% hypertension,
- 23% diabetes,
- 15% heart failure,
- 15% athma, and
- 15% COPD.
For those that indicated that they had one of the above conditions, they were asked how well their disease was being managed
- 75% indicated working with their health care team to manage their disease and they are making progress towards improving their health;
- 25% indicated their illness is partially under control, having exacerbations a few times a year that sometimes results in being hospitalized or going to the Emergency Department.
Some comments included:
- “I believe that the patient needs to do the most work.”
- “I manage it myself” (referencing diabetes and hypertension).
- “Have to go to Denver for this; need telehealth” (referencing diabetes mgmt.)
- “N/A.”
- “I do take a blood pressure medication.”
Additionally, respondents were asked if they were suffering from a chronic health condition, what they believe would be the most helpful in managing their condition.
- 60% indicated having a healthcare professional who they could reach out to regularly for questions or information regarding their disease and how to improve their health,
- 40% indicated easier access to regular follow up care and checkups with their health care provider, and
- 20% indicated additional or ongoing education and information for their disease.
In the Healthy Archuleta Health Providers Survey, providers were asked to share if they are seeing diabetes, heart disease, and cancer more prevalent in certain populations in Archuleta County.
- Providers described seeing diabetes in Native American populations and in older populations (over 50 years old) seeing all three diseases with more advanced cases among minority groups.
- Some ways that providers are addressing these diseases among their patients include:
- Connecting with patients early through well-child visits and continuing to connect with them through annual visits and screenings and assisting with disease management.
- Follow-up Questions for Agencies:
  - What are the top 5 health conditions you are seeing in your facility?
  - In 2022, how many individuals did you see for each of these 5 conditions?
  - Besides treatment and referral, do you have any education programs that are offered for any of these conditions?
  - For each of these conditions, describe the services that you offer in your facility and those that you refer out and to whom?
  - Which of these conditions have a tracking and/or reporting system and to whom?
  - What needs do you see public health and/or community agencies address in supporting your patients with the prevention and/or management of these conditions, such as cancer support groups, diabetes prevention program, lactation support, nutrition classes, food pantry services, and others?
  - What services are you currently offering in collaboration and/or in support of SJBPH (MOU, contract, unmet need, grant funding)?
  - How long have you been offering this service?
  - What is the patient load for this service?
  - Are you planning to continue to offer this service and what would it take?

Which social determinants of health are major concerns in the community?
Where is the data available?

Healthy Archuleta Health Providers Survey (May 22)
PSMC Quality improvement survey (Aug-Sept 22)
SJBPH
Aspire survey

What does the data say?

Respondents to the health care providers survey reported the following challenges to recruiting a qualified workforce:
- Lack of housing for applicants
- Lack of childcare for applicants
- Overall cost of living
The PSMC survey asked respondents which conditions from a list negatively affect the quality of life and health promotion in the community.
- 31% indicated transportation issues,
- 29% indicated need for assistance with housing,
- 20% indicated food security,
- 11% indicated need for help with utilities, and
- 9% indicated interpersonal safety.
Other things mentioned in the comments included
- “Inflation, social media, education on how to save money and how to budget.”
- “Drug and alcohol abuse”
- “Addiction issues.
- “Transportation issues from our rural location for specialists.
- Specialists are only in Durango or Denver.”
- “Current County Commissioners do not support anything for local residents, from recycling to their attacks on San Juan Basin Public Health, to grand lack of knowledge and care to learn anything.”

If you felt depressed, anxious, or having problems with drugs or alcohol and realized you couldn't handle it with yourself, who or what organization in Archuleta County would you turn to?
Where is the data available?

PSMC Quality improvement survey (Aug-Sept 22)

What does the data say?

The PSMC survey asked if respondents knew where individuals could seek treatment for opioid addiction,
- 84% responded "no" and
- 16% responded "yes."
- One respondent commented, “Yes in Durango, no in Pagosa Springs.”

What are the state level trends in nutrition, physical activity, and obesity?
Where is the data available?

CDC Nutrition Physical Activity and Obesity Data: Colorado

What does the data say?

In 2021,
- 25% of adults had obesity and
- 35.5% of adults had an overweight classification.
In 2019
- 10.3% of students in grades 9-12 had obesity and
- 11.7% had an overweight classification.
In 2020
- 8.6% of WIC children (2-4 years old) had obesity and
- 14.7% had an overweight classification.
Also in 2020,
- 6.3% of WIC children aged 3-23 months had a hight weight-for-length.
In 2019,
- 94% of infants were ever breastfed,
- 66.1% were breastfed at six months,
- 39.6% were breastfed at 12 months,
- 62.8% were exclusively breastfed through 3 months,
- 32.1% were exclusively breastfed through 6 months,
- 9.6% were supplemented with formula within 2 days of life,
- 18.5% were supplemented with formula before 3 months, and
- 28.5% were supplemented with formula before 6 months.
In 2020, the average maternity practice in infant nutrition and care (mPINC) score among hospitals and birthing facilities was 85.
In 2021, 35.1% of births occurred at facilities designated as "baby friendly" by the Baby Friendly Hospital Initiative (BFHI).
In 2021,
- 38.3% of adults reported consuming fruit less than one time daily and
- 18.8% reported consuming vegetables less than one time daily.
In 2019,
- 44.9% of students grades 9-12 reported consuming fruit less than one time daily and
- 33.4% reported consuming vegetables less than one time daily.
In 2017, Colorado had 2.8 farmers markets per 100,000 residents and
in 2019, 21.7% of farmers markets in Colorado accepted SNAP benefits.
In 2017, 5.1% of farmers markets accept WIC coupons.
In 2018, Colorado had 16 local food policy councils and a state-level food policy council.
In 2002, Colorado had a state-level farm to school/preschool policy.
In 2020, Colorado state child care regulations DID NOT align with the national standards for serving fruits or vegetables.
In 2021, 16.7% of adults did not engage in leisure time physical activity.
In 2019,
- 59.3% of adults achieved at least 150 minutes a week and
- 37.% achieved at least 300 minutes a week of moderate-intensity aerobic physical activity or 75 minutes a week of vigorous-intensity aerobic activity or an equivalent combination.
Additionally, in 2019:
- 39.3% of adults engaged in muscle-strengthening activities on 2 or more days a week and
- 27.4% engaged in muscle-strengthening on 2 or more days a week and at least 150 minutes a week or 75 minutes a week of vigorous-intensity aerobic activity.
For youth, in 2019:
- 25.4% of 9-12 graders achieved 1 hours or more of moderate and/or vigorous-intensity physical activity daily and
- 15.7% participated in daily physical education.
In 2019, 3.8% of adults in Colorado usually biked or walked to work in the last week.
In 2016, 61.3% of youth had parks or playground areas, community centers and sidewalks or walking paths in their neighborhoods.
In 2015, 73.8% of Coloradans lived within 1/2 of a park.
According to 2020 data, Colorado has adopted some form of a complete streets policy, however, the state child care guidelines did not align with the national standards for moderate to vigorous intensity physical activity for preschoolers.
In 2011, 23% of students in grades 9-12 drank regular soda/pop at least one time per day.
In 2014,
- 16.8% of secondary schools allowed students to purchase soda pop or fruit drinks from one or more vending machines or at the school store, canteen, or snack bar and
- 35.4% allowed students to purchase sports drinks.
In 2020, the state child care regulations did not align with the national standards for avoiding sugar, including concentrated sweets such as candy, sodas, sweetened drinks, fruit nectars, and flavored milk.

How does Archuleta County rank for health outcomes and health factors as compared to the state of Colorado?
Where is the data available?

County Health Rankings & Roadmaps

What does the data say?

In 2023, Archuleta County ranked 20 out of 59 counties in Colorado and ranked in the high middle range health outcomes and health factors.
- For quality of life, Archuleta County has 10% poor or fair health as compared to 10% in CO;
- 2.8% poor physical health days as compared to 2.7% in CO,
- 4.3% poor mental health days as compared to 4.3% in CO, and
- 8% low birthweight as compared to 9% in CO.
For health behaviors,
- the adult smoking rate is 14% in Archuleta County vs 13% in CO,
- the adult obesity rate is 23% in Archuleta County vs 24% in CO,
- the food environment index in 7.6 in Archuleta County vs 8.5 in CO,
- the physical inactivity is 18% in Archuleta County vs 17% in CO,
- the access to exercise opportunities is 91% in Archuleta County vs 90% in CO,
- the excessive drinking is 22% in Archuleta County vs 20% in CO,
- the alcohol-impaired driving deaths is 30% in Archuleta County vs 34% in CO,
- the sexually transmitted infections is 206.7 vs 453.9 in CO and
- the teen birth is 18 vs 16 in CO.
The uninsured rate is 16% in Archuleta County vs 10% in CO,
Archuleta County has
- 1,180:1 primary care physicians vs 1,200:1 in CO,
- 2,300:1 dentists vs 1180:1 in CO,
- 440:1 mental health providers vs 230:1 in CO,
- 1451 preventable hospital stays vs 1730 in CO,
- 32% mammography screenings vs 35% in CO and
- 40% flu vaccinations vs 51% in CO.
For social and economic factors -
- Archuleta County has a 94% high school completion rate vs 92% in Co,
- 59% have some college vs 73% in Co,
- unemployment in Archuleta County is 4.9% vs 5.4% in CO,
- 20% of children are in poverty vs 12% in CO,
- Archuleta County has a income inequality rate of 3.6 vs 4.3 in CO,
- 12% of children live in single parent households compared to 22% in CO.
In Archuleta County there were 9.2 membership organizations per 100,000 people.
In Archuleta County there were 95 deaths due to injury per 100,000 people.
In 2020-2021 51% of children in Archuleta County public schools were eligible for free or reduced price lunch.

What are the Behavioral Risk Factors in Colorado?
Where is the data available?
CDC Behavioral Risk Factor Surveillance System
What does the data say?

Cholesterol: In 2021,
- 84.4% of adults have had their blood cholesterol checked within the last 5 years,
- 4.3% have not had it checked in the last 5 years, and
- 11.3% have never had it checked.
- 31.6% of adults who had their blood cholesterol checked were told it was high.
Arthritis: In 2021,
- 9.4% of coloradans have arthritis and have limited usual activities,
- 14.2% have arthritis with no limit to usual activities, and
- 76.5% have not been told they have arthritis.
- 7.4% of coloradans have arthritis and have limited work activities,
- 15.9% have arthritis with no limit to usual activities, and
- 76.6% have not been told they have arthritis.
- 23.7% of adults in CO have been told they have arthritis.
Asthma: In 2021,
- 10.4% of adults in CO have been told they currently have asthma and
- 15.4% have ever told they have asthma.
Cardiovascular Disease: In 2021
- 2.5% of coloradans had ever been told they have angina or coronary heart disease,
- 2.6% had ever been told they had a heart attack,
- 2.2% had ever been told they had a stroke, and
- 4.1% reported having coronary heart disease or myocardial infarction.
COPD: In 2021,
- 5.1% of Coloradons had ever been told they had COPD.
Depression: In 2021,
- 20.4% of Coloradans had ever been told they have a form of depression.
Diabetes: In 2021,
- 7% of Coloradans had ever been told they have diabetes,
- 0.9% pregnancy-related diabetes,
- 2.3% prediabetes or borderline diabetes, and
- 89.9% have not.
Kidney disease: In 2021,
- 2.6% of Coloradans have ever been told you have kidney disease.
Cancer: In 2021,
- 6.7% of Coloradans were ever told they had skin cancer and
- 6.4% of Coloradans were ever told they had other types of cancer.
Vision: In 2012,
- 13.7% of Coloradans had ever been told they had a vision impairment.
Colorectal Cancer Screening: In 2020,
- 9.2% of Coloradans aged 50-75 had a blood stool test in the past year,
- 24.9% had not had one in the past year, and
- 65.9% had never had a blood stool test.
- In 2018,
  - 63.4% of Coloradoan aged 50-75 had a colonoscopy in the past 10 years and
  - 2.1% had a sigmoidoscopy in the past 5 years.
Healthy Days: In 2021,
- 67.2% of coloradans had 0 days when physical health was not good,
- 23.3% had 1-13 days when physical health was not good, and
- 9.5% had 14 or more days when physical health was not good.
- Additionally, 55.6% had zero days when mental health was not good,
- 30.2% had 1-13 days when mental health was not good, and
- 14.2% had 14 or more days when mental health was not good.
E-cigarettes: In 2021,
- 6.8% of coloradans used e-cigarettes, of these
  - 3.7% use every day and
  - 3.2% use some days.
- Additionally, 22.4% are former e-cigarette users.
Fruit and Vegetables: In 2009,
- 24.8% of coloradans consumed fruits and vegetables five or more times per day.
- In 2021,
  - 38.1% of coloradans consumed fruit less than one time per day and
  - 18.6% consumed vegetables less than one time per day.
Health care costs: In 2021,
- 9.5% of Coloradans needed to see a doctor in the last 12 months but could not because they could not afford it.
Health Insurance: In 2021,
- 90.25% of Coloradans had some form of health insurance.
Last Checkup: In 2021,
- 67.4% of Coloradans had visited a doctor for routine checkup within the last year,
- 16.4% within the last 2 years,
- 9.2% within the last 5 years,
- 6% five or more years ago and
- 0.9% had never been.
Health Status: In 2021,
- 86.9% of Coloradans had "good or better" health and
- 13.1% had "fair or poor" health.
Physical Activity: In 2019,
- 27.4% of Coloradans participated in enough Aerobic and Muscle Strengthening exervises to meet the guidelines,
- 72.7% did not.

How does the high cost of living in Archuleta County impact people's access and use of primary health care?

Where is the data available?

National Low Income Housing Coalition

What does the data say?

In 2022, Archuleta County had 5,736 households, of which 26% (1484) were renters as compared to 34% in CO.
The housing wage to afford
- a 1-bedroom was $17.33,
- 2-bedroom was $22.79, and
- 3-bedroom was $29.40.
The fair market rent in Archuleta county in 2022 for a
- 1-bedroom was $901,
- a 2-bedroom $1,185, and
- a 3-bedroom $1,529.
The annual income needed to afford
- a 1-bedroom was $36,040,
- a 2-bedroom $47,400,
- a 3-bedroom was $61,160.
In 2022, the minimum wage in Archuleta was $12.56 and an rent that is affordable to a minium wage worker was $653.
A minimum wage worker in Archuleta would have to work
- 55 hours a week to afford a 1-bedroom,
- 73 hours a week to afford a 2-bedroom and
- 94 hours a week to afford a 3-bedroom.
The median renter household income in Archuleta was $49,191.

Assessment Update

Health Access

Acknowledgments