2President and CEO, Howard County General Hospital Victor A. BroccolinoPresident and CEO,Howard County General Hospital
3Director Office of Population Health Improvement, DHMH Madeleine SheaDirectorOffice of Population Health Improvement, DHMH
4Hospital PerspectiveLisa Hillman Senior Vice President, Legislative Affairs, President, AAMC FoundationKathleen McCollum Senior Vice President, Business Development and Ambulatory Services
5We have one foot in the boat and one on the dock.
6Healthy Anne Arundel Coalition Coalition NetworkSteeringCommitteeCommunity Outreach SubcommitteeCo-Occurring Disorders SubcommitteeCommunity Health Needs Assessment SubcommitteePromotion and Publicity SubcommitteeObesity Prevention SubcommitteeAcademiaExisting Boards, Committees & CoalitionsGovernment AgenciesFaith-Based OrganizationsCommunity-Based OrganizationsHealth Care ProvidersPhilanthropyBusinessesLeadership & Finance Subcommittee
7Department of Health Steering Committee Member Organizations: Anne Arundel County Office of the County ExecutiveAnne Arundel Co. Dept. of Aging and DisabilitiesAnne Arundel County Department of DetentionsAnne Arundel Co. Dept. of HealthAnne Arundel Co. Dept. of Recreation & ParksAnne Arundel Co. Dept. of Social ServicesAnne Arundel Co. Public SchoolsAnne Arundel Co. Mental Health Agency, Inc.Anne Arundel Co. Chapter of the NAACPAnne Arundel Community CollegeAnne Arundel Community Development ServicesAnne Arundel Economic Development CorporationCare First Blue Cross Blue ShieldCity of Annapolis Mayor’s OfficeCity of Annapolis Dept. of Recreation and ParksCommunity Foundation of Anne Arundel CountyHousing Authority of the City of AnnapolisMEDSTAR Harbor HospitalNorthrop GrummanPeople’s Community Health Centers, Inc.Rite Aid CorporationSchool of Public Heath, University of MarylandWalmart
8OpportunitiesWorking more collaboratively with the Department of Health and key players who play a role in the prevention, care and management of patients we commonly serve.To develop consensus on primary health improvement targets and address allocation of resources.Examining how the system of care - both prevention and public health - can work seamlessly together.Sharing information on high utilizers of care together in order to examine prevention efforts that can minimize their utilization for better health outcomes.Joint Community Health Needs Assessment.Provides local health data and community input into the community benefit planning process.
9Challenges Assuring representation from key stakeholders and partners. Transition in hospital focus to population health and community benefit.Hospitals have different primary service areas that may or may not overlap and each with their own unique needs.Developing an implementation structure (5 sub-committees) that works and is manageable without being burdensome.The Coalition's focus areas of obesity prevention and co- occurring disorders are complex health issues that will take substantial amounts of resources and time to improve.
16Executive Director Institute for Healthiest Maryland Renee FoxExecutive DirectorInstitute for Healthiest Maryland
17Institute for a Healthiest Maryland Presentation to Statewide LHIC Leadership MeetingOctober 10, 2012Renee Ellen Fox, M.D.Executive DirectorInstitute for Healthiest Maryland
18Mission: To measurably improve the health of Maryland citizens, the Institute will support community transformation efforts, translate public health research into practice, and provide technical assistance to local health departments and community organizations.Vision: Be a guiding resource for transforming Maryland communities into healthy environments for all.
19Initial Funding for IHM Funding from DHMH via CDC Community Transformation Grant (CTG) from the Public Health Trust Fund of the ACA.address obesity, tobacco use, hypertension and health disparitiesPartially funds Executive Director and AssistantOffice of the President UMB to partially fund Executive Director and Assistant for 5 yearsLong Term Goal: Self-sustaining through external funding.
20MOU from DHMH to UMBProvide Technical Assistance to Local Health Departmentsthrough Academic PartnersUMB Law, Pharmacy, Medicine and NursingUMBC Tobacco Quit ProgramUMCP SPHJHU Bloomberg School of Public HealthDr. Shell will present the specific goals of the CTG in a few minutes.
22IHM Role in CTG Conduct Local Health Departments’ needs assessment Compile, develop, disseminate resources and best practicesCommunication strategiesTraining and technical assistanceUse the existing evidence based interventionsContribute to the knowledge base.I want to frame how the CTG works with IHM and after the next few presentations, will come back to discuss the goals of the Institute and get your feed back and suggestions on these goals and their implementation.
23Contact InfoRenee Ellen Fox, MD, Executive DirectorPhoneGreer Huffman
24Asst. VP, Quality Policy & Advocacy Maryland Hospital Association Nicole StallingsAsst. VP, Quality Policy & AdvocacyMaryland Hospital Association
25Supporting Policy Innovation to Improve Population Health Statewide LHIC Leadership Meeting October 10, Nicole Stallings, MPP Assistant Vice President, Quality Policy & Advocacy Maryland Hospital Association
26Quality & Patient Safety Population HealthPreventionCare CoordinationQuality & Patient Safety
27Population Health Management in the ACA Community Health Needs Assessment requirementsExpansion of prevention and wellness servicesHospital Readmissions Reduction ProgramCommunity-based Care Transitions ProgramAccountable Care OrganizationsPatient Centered Medical HomesIncreased funding for health centers
28Opportunities for Hospitals to Explore Quality of CareEfficiencyAccessPhysician TrainingHealth Information TechnologyPhysician EmploymentCare Integration and CoordinationBehavioral Health AccessDisparitiesCultural and Linguistic AccessDisease ManagementProvider Supply
29Example: Total Patient Revenue Hospitals Sources: HSCRC 2012
30Source: HFMA. Value in Health Care: Current State and Future Directions. June 2011.
31Hospitals’ State of Readiness Focus on population health is already occurring; variation in level of investmentPartnerships are essential for successPhysicians and other cliniciansPost-acute care providersEmployersGovernment and commercial payersSocial and community servicesPublic Health agenciesLocal, State and Federal Policy
33Reducing Readmissions and Medicare Opportunities Fredia WadleyCEO, Delmarva Foundation
34Chief Medical Officer DHMH Laura HerreraChief Medical OfficerDHMH
35Overview of “State Innovation Models” Grant Proposal Laura Herrera, MD, MPHChief Medical OfficerMaryland Department of Health and Mental Hygiene
36State Innovation Models (SIM) Grant Solicitation Released by Center for Medicare & Medicaid Innovation (CMMI) at CMSPurpose: Develop, implement, and test new health care payment and service delivery models at the state-level2 tracks:Model Design: Planning grant to fund the development of a comprehensive state innovation plan; $1-3 million over 6 monthsModel Testing: Funds implementation and testing of an existing state innovation plan; $20-60 million over 3.5 yearsMaryland applied for Model DesignFunding period: December 2012 – June 2013Opportunity to apply for Model Testing in 2013
37Proposed Model: Community-Integrated Medical Home Integration of a multi-payer medical home model with community health resources4 pillars:Primary careCommunity healthStrategic use of new dataWorkforce developmentTwo parallel stakeholder engagement processesPayers and ProvidersLocal Health Improvement CoalitionsAll-stakeholder summit to form policy recommendations and develop plan for Model Testing application
38Proposed Model: Community-Integrated Medical Home
39Payer and Provider Engagement Process Develop a governance structure for medical homesEstablish a public utility to administer payment and quality analytics processesSet programmatic standards, such asCriteria for practice inclusionQuality assessmentAnalyticsShared savingsHilltop and its contractor will conduct actuarial modeling of health costs to demonstrate savings expected from CIMH
40Local Health Improvement Coalition Engagement Process Complement medical care by linking high-need patients with wrap-around community-based health servicesCapacity of LHICs will be strengthenedWill be asked to help develop new models to carry out CIMH activities (e.g., 501(c)3, integration with LHD, etc.)Community health workers may play role of coordinating with practicesLHICs will be asked to help define responsibilities and required skills/education for CHWsUse new data and mapping resources to “hot-spot” high utilizers and bring them into CIMHLHICs will review prototypes of these resources
41New Data Resources and Workforce Data for “hot-spotting:” Real-time hospital admissions dataData for population health monitoring: Health status, claims, administrative, and survey dataWorkforce developmentMaryland Learning Collaborative will develop resources and help prepare practices for community integrationMLC will partner with AHECs for training, especially in southern MarylandExample of hot-spotting with admission data
42Senior Research Analyst Hilltop Institute Michael AbramsSenior Research AnalystHilltop Institute
43Coordination of Care for Persons with Substance Use Disorders under the Affordable Care Act Maryland State Local Health Improvement Coalition Leadership MeetingHoward County General HospitalOctober 10th, 2012Michael T. Abrams, M.P.H.Funding: Baltimore Substance Abuse Systems, Inc.
44Even smart people are unclear about what’s in the ACA
45The ReportAffordable Care Act (ACA) review (U.S. Public Laws and )Literature reviewExisting program review (Behavioral Health Integration)Opportunities and barriers in the recently passed federal health care law (the ACA) regarding the development of overall health care coordination for persons with SUD?Patient-centered medical home
46Essential Health Benefits (A) Ambulatory patient services(B) Emergency services(C) Hospitalization(D) Maternity and newborn care(E) Mental health and substance abuse services, including behavioral health treatment(F) Prescription drugs(G) Rehabilitative and habilitative services and devices(H) Laboratory services(I) Preventive and wellness services and chronic diseases management(J) Pediatric services, including oral and vision(ACA § 1302(b)(1)(E) – p. 59)
47A health home provider is… “a physician, clinical practice or clinical group practice, rural clinic, community health center, community mental health center, home health agency, or any other entity or provider (including pediatricians, gynecologists, and obstetricians) that is judged by the State and approved by the Secretary to be qualified to be a health home for eligible individuals with chronic conditions on the basis of documentation showing that the physician, practice, or clinic – (A) has the systems and infrastructure in place to provide health home services; and (B) satisfied the qualification standards established by the Secretary”(ACA § 2703(a)(h)(5)(A and B) – p. 232)
48Medicaid Subgroups: Health Home Targets Latent Class GroupingVariableAdult - High Somatic MorbidityAdult - High Psychological MorbidityN3,7323,258Mean Age (stdev)46 (11)38 (12)Alcohol Dependence30%38%Opioid Dependence44%47%Cocaine Dependence12%28%Anxiety disorders10%63%Tobacco use9%71%Schizophrenia spectrum1%67%Depression3%85%Cardiovascular97%61%Gastrointestinal/Hepatic96%53%Hematologic72%15%Musculoskeletal93%74%Neurologic90%65%Renal80%29%Respiratory94%51%Source: Abrams et al., 2012,
49BarriersPayment reform (Finkelstein et al., 2011; Lindly et al., 2011; Croze et al., )Burden of new data monitoring and collection (Medical Directors Council, 2005)Avoid “double-billing” for the same service (Integrated Care Resource Center, 2012)Essential benefits too vague (Buck, 2011; Garfield et al., 2010; Takach, 2011)Inertia (Croze et al., 2011)
50Barriers continuedMedical culture (Kunins, Sohler, Roose, & Cunningham, 2009; Davidson & White, 2007)Stigma (Davidson & White, 2007; Edlin et al., 2005)For substance use disorders especiallyConfidentiality (Lindly et al., 2011)
51OpportunitiesSocial justice argument (Boyer & Indyk, 2006; Edlin et al., 2005; Secker et al., 2006)TechnologyFQHC expansion/leveraging (Abrams et al., 2011)ACA language and grant supportIncludes many types of efforts, venues, provider typesStrong leadership (Lindly et al., 2011)
52Contact InformationMichael T. Abrams, MPHSenior Research AnalystThe Hilltop InstituteUniversity of Maryland, Baltimore County (UMBC)
55Director, Community Wellness Calvert Memorial Hospital Margaret FowlerDirector, Community WellnessCalvert Memorial Hospital
56Community Health Improvement Roundtable Calvert County’s Local Health Improvement CoalitionLHIC Leadership MeetingOctober 10, 2012
57BackgroundCMH has coordinated the Community Health Improvement Roundtable since 1995.Membership: Calvert Memorial Hospital, Calvert County Health Department, Calvert County Government, Calvert County Public Schools, Hospice, Department of Social Services, Clergy, Health Impact Council, Oral Health Task Force, Tobacco/Cancer Coalition, Health Ministry Network, IPOPIntegrated SHIP objectives into Community Health Needs 2011.
58Transforming Calvert County to A Culture of Wellness LOCAL HEALTH IMPROVEMENT COALITION (LHIC)Transforming Calvert County to A Culture of WellnessGoals, Objectives & Action PlanCommunity Health Needs Assessment (CHNA)State Health Improvement Process (SHIP)Local Health Improvement Coalition (LHIC)
59SHIP Target Area Priority Area #1 Smoking Priority Area #2 Obesity Objective #32Objective #33Priority Area #2 ObesityObjective #30: Increase health weight of adultsPriority Areas #3 & #4 Death RatesObjective #25: Reduce Heart Related DeathsObjective #26: Reduce Cancer Related DeathsPriority Area #5 DisparitiesObjective #27 Reduce ER Utilization for DiabetesObjective #28 Reduce ER Utilization for HypertensionObjective #39 Access to Care2 FormsNew activity form for more details about new services or programsUpdate activity form for ongoing programs and serivces
60Disparity Addressed ER Utilizations for Diabetes Related Visits 4.5 times the rate of CaucasiansWhy?ER Utilization for Hypertension Related Visits4.75 times the rate of Caucasians
61New Initiatives Data Analysis Creation of education tools Diabetes Boot CampDiabetes Survival GuideA1c ScreeningHealth LiteracyCommunity Coordination Care Team
62Previous Care Coordination PATIENTEmergency Room VisitCare Transition CoachPCP Care CoordinatorAccess To Primary Care Physician (PCP)Health Ministry Team NetworkLiving Well ProgramDiabetes Self ManagementMental Health ServicesSubstance Abuse Services
63Community Coordination Care Team PATIENTEmergency Room VisitCare Transition CoachPCP Care CoordinatorAccess To Primary Care Physician (PCP)Health Ministry Team NetworkLiving Well ProgramDiabetes Self ManagementDiabetes Boot CampMental Health ServicesSubstance Abuse ServicesDiabetes Care Coordinator
64Health Officer, Worcester County & Lower Shore Coalition Lead Debbie GoellerHealth Officer, Worcester County & Lower Shore Coalition Lead
65Prevention Program Model for Lower Shore Tri-County National DiabetesPrevention Program Model forLower Shore Tri-CountyHealth ImprovementDeborah Goeller, R.N., M.S.N.,Health OfficerWorcester County10/10/12[Start speaking on next slide]
66Lower Shore Maryland14.3% of Lower Shore residents have been diagnosed with diabetes , almost double the State of Maryland at 8.3%. (2009 Community Health Assessment)2010 HSCRC data revealed Lower Shore rate for emergency department visits due to primary diabetes diagnosis exceeded the State of Maryland (565.5 vs )2009 Community Health Assessment by Professional Research Consultants found Lower Shore citizens being diagnosed with diabetes at an alarming rate of 14.3% vs. Maryland’s 8.3%.The high prevalence poses a burden on both patients and the health care system, especially emergency department use.2010 HSCRC data, lower shore rate for emergency department visits was per 100,000 which was higher than the state rate (347.2)
67History of Worcester County Health Department Experience with NDPP Preventive Health and Health Services (PHHS) Block Grant funding to focus on Diabetes“ Lifestyle Balance”Utilized NDPP curriculum and evaluation toolsGroup Intervention- Education + ExerciseTeam Taught- Registered Dietitian, American College of Sports Medicine Certified Clinical Exercise Specialist, Health Educator[Don’t read the slide out loud]Our pilot used the full curriculum and most of the evaluation tools required by the NDPP for certification.
68Implemention in Worcester 16 Week Program“ Coaching”Food/Activity JournalsLocations- Workplaces, Recreation Centers, Community Sites, YMCANotice the intensive staff time involved over a full year of training, coaching, and tracking
69OutcomesJuly May 2012, 344 individuals have participated in the program219 (64%) individuals have completed the program (attended at least 75% of classes)17 sixteen-week programs have been completedOffered at 13 different locationsI’ll just flash thru these slides: by multiple measures NDPP is successful
70Fruit and Vegetable Intake Improvement in food choices
73COOP Quality of Life Assessment Dartmouth COOP (Primary Care Cooperative ) Charts were used to evaluate health-related quality of life. Each chart consists of a simple title, one question, and five response choices. Each possible response is described in words and presented graphically , as a caricature, along a five-point ordinal scale. There are nine scales, each of which are used to measure a different aspect of patient functional status (physical activity, feelings, daily activities, social activities, pain, change in health, overall health, social support, and Quality of Life)
74National Diabetes Prevention Program Somerset, Wicomico, and Worcester Counties received CDC “partial recognition” for NDPPGrant funding used to sponsor “Lifestyle Coach” training conducted by DTTAC , Emory University, in June 201210 Local Health Department Staff from 3 lower shore counties completed the trainingWe’ve completed trainingOne of the requirements for a program to become a CDC “Recognized” provider, is for coaches to complete “Lifestyle Coach” Training provided by Emory University DTTAC Staff.Cost of the training was $13, The price to send a staff to Atlanta, Georgia for training is $1200/per person for training alone (does not include travel or lodging).
75NDPP Implementation in Tri County Grant Funding will support one full year (16 core sessions and 6 post-core monthly)of the NDPP in each of the 3 Counties.20 individuals will complete the program which will be offered in each of the 3 counties (60 participants total)Somerset, Wicomico, and Worcester County Health Departments collaborate to market the program through Local News Media, Tri County PIOs, Websites, Social Media, News Releases, and Local Public Television.[Mimi note the #] The first cohort of 31 participants began 7 weeks ago and already have lost a combined total of 142 pounds.
76Recognition Leads to Billing and Sustainability All 3 LHDs will pursue “Full Recognition” from the CDC for the National Diabetes Prevention Program requiring data reports every six months for the next 24 months.Full Recognition allows billing and program sustainability as fee for service.The best part of the NDPP is the potential for sustainability as a fee for service prevention program.
77Reducing Behavioral Health ED Visits Amy BakerProgram Director, Care Coordination UnitCarroll County Health Department
78Deputy Director, Community Services Harford County Sharon LipfordDeputy Director, Community ServicesHarford County
79Harford County Local Health Improvement Plan Behavioral Health:Emergency Room DiversionSusan Kelly, Harford Co. Health Dept.Health OfficerSharon Lipford, Harford Co. Dept. Community ServicesDeputy Director/ LHIP Behavioral Health Chair
80Demographic Indicators Baseline Data (per 100,000):Demographic IndicatorsHarford CountyMarylandCounty 2014 TargetBehavioral health-related admissions to E.R.1,243.71,206.31,183.4Suicide rate11.79.611.2Drug-induced death rate14.913.413.91,235.7Harford County’s rate of ER visits for a behavioral health condition.3rd HIGHESTHarford County’sdeath rate from intoxication was thein Maryland19.0%12.8%AnxietyDisorderRatesHARFORDMARYLANDSource: Health Services Cost Review Commission; CDC Behavioral Risk Factor Surveillance System; Office of the State Medical Examiner
81Behavioral Health Workgroup Strategic DirectionDevelop mechanisms to integrate mental health and substance abuse treatmentImprove the delivery of behavioral health servicesProgress to DateYouth Behavior Survey ~170 parents across Harford CountyParents believe substance abuse is a problem among youth, with alcohol being a primary concern, followed by drugsAnxiety is also of concern among parentsFocus group with Emergency Room Staff from Upper Chesapeake Health and Harford Memorial HospitalBazelon Center for Mental Health Law Behavioral Health/Criminal Justice ReviewPrescription Drug Take-Backs
82Next Steps: Prevention, Intervention, Recovery Focused Use Primary Care/Urgent Care Doctor as a first line of intervention - depression/suicide screeningExpand training for Law Enforcement- EP/ED DiversionMulti-disciplinary ~information sharing and cross-training of addiction and mental health servicesPromote recovery and support through peers, families and faith-based communities
83Health Officer Allegany County Health Department Sue V. RaverHealth OfficerAllegany County Health Department
84Allegany County Health Planning Coalition Partners:Allegany County Health DepartmentWestern Maryland Health SystemAllegany County Board of EducationTri-State Community Health CenterWestern Maryland Area Health Education CenterCounty United WayAllegany County Human Resources Development Commission
86Breathalyzer Project Purpose: To reduce alcohol related crashes through educational awareness initiatives.Funding:Community Health Resources Commission (CHRC) GrantPartners:Western Maryland Health SystemACHD Prevention ProgramMaryland State Police
87Consultation Legal Issue: The Network for Public Health Law – University of MD“The education benefit (e.g. knowing what being over the limit ‘feels like’) seems to trump the legal risks.”Maryland State Police in Garrett County
88What We Do Personnel: DRE Maryland State Police Officers Drug Resistance Education (DRE)ACHD Prevention StaffLocation:Large public events where alcohol is served/purchasedProvided Services:Non-threatening educationVoluntary breathalyzer (Maryland State Police)Alcohol consumption informationDangers of driving under the influenceFacts and myths about alcohol
89VOLUNTARY PARTICIPANTS Events To-DateEVENTVOLUNTARY PARTICIPANTSOVER LEGAL LIMIT (0.8)Friday After Five196Frostburg Block Party93F-Bar in Frostburg* (10/2)3224Frostburg Homecoming (10/12)Not yet available* Funded through Strategic Prevention Framework (SPF) Grant. Some initiatives undertaken by the F-Bar include the addition of food to their menu, Tuesday trivia night, and TIPS (Training for Intervention ProcedureS) training for employees (to recognize potential alcohol-related problems and intervene to prevent alcohol-related tragedies).
90CommentsInterested to know how drinking affected BAC (blood alcohol content) levelInterested to know what factors are involved:SexWeightFood ConsumptionTime Frame of ConsumptionPrevalent Myth:Drinking coffee can make one sober
96National Data Source: Healthy People 2020, National Child Abuse And Neglect Reporting System Maryland Data Source: Maryland Department of Human Resources (DHR)
97National Data Source: Healthy People 2020, National Center for Education Statistics Maryland Data Source: Maryland State Department of Education (MSDE)
98Data Source: Maryland Health Services Cost Review Commission (HSCRC)
99Maryland SHIP 2012 Update County-level data Data Source: Maryland Youth Tobacco Survey (MYTS)
100Maryland SHIP 2012 Update County-level data Data Source: Maryland DHMH Vital Statistics Administration
101Maryland SHIP 2012 Update County-level data Data Source: Maryland Health Services Cost Review Commission (HSCRC)IMPORTANT: Only visits made by Maryland residents to Maryland hospitals were used for the analysis; emergency department visits made by Maryland residents to out-of-state hospitals were not included. Data are coded by patient’s county of residence.
102Maryland SHIP 2012 Update County-level data Data Source: Maryland Health Services Cost Review Commission (HSCRC)IMPORTANT: Only visits made by Maryland residents to Maryland hospitals were used for the analysis; emergency department visits made by Maryland residents to out-of-state hospitals were not included. Data are coded by patient’s county of residence.
108The Partnership Mission Connecting people, Inspiring action, Strengthening community Track and interpret health data to “check the pulse” of our community/results.Current structure includes eleven Core Health Improvement Areas (e.g., Prevention and Wellness, Elder Health, Access to Health Care etc.)Established in 1999 by Carroll Hospital Center and CC Health Department.Collaborate to build the capacity of individuals and organizations to improve the health and quality of life in our community.Influence policies, form leadership teams (mini coalitions), drive change, promote engagement/ accountability , measure results and advance a healthy community vision.
109Purposes driving the 2012 CHNA: Provide information needed for development of a CHC Community Benefit Plan in compliance with their charitable organization Mission and elements of the 2010 Affordable Care ActCHC Strategic planningThe Partnership's operational and organizational strategic planningInform the CHC Cancer Committee ongoing accreditation processSHIP/LHIP compliance expectations
110Components of the 2012 Community Health Needs Assessment Common ThemesPrevalent IssuesHigh Impact IssuesComponents of the 2012 Community Health Needs Assessment1. Community Health Surveys and Key Informant Surveys2. SHIP/LHIP and Secondary DataAnalysis3: Focus Groups, Carroll County Health Rankings, CC Transit Development Plan
111Targeted Populations Focus Groups Five focus groups conducted:African American (Completed with NAACP )Hispanic (Completed with CCC ESOL Program at B.E.R.C.)Low Income (Completed with CC Head Start of Taneytown and with Human Services Program of Carroll County)Older Adult Providers (Completed with Elder Health Leadership Team)Online profile collected, sessions recordedFor Hispanic program, Interpreters provided by CCHD
112Information from Key Informant Survey Obesity most frequently identified concern, but not listed as most urgent concern to be addressed.Health care access was not listed as a primary concern.Goal was a 70% return rate or about 95 Key Informant responses.136 persons, ranging from private practice doctors to law enforcement to private business owners.Geographies were considered.
113Integrating the SHIP - LHIP with other Carroll County Specific Secondary Data