Bucks County has long been the home of creative, resourceful, and caring people. The energy and the synergy that the people of Bucks County have powerfully demonstrated (for centuries now) have made our county outstanding in so many ways.

This unique human service and health needs study was fashioned to be a useful navigation tool for the present generation of creative, resourceful and caring people.

We pass this data and analysis to the leaders of thought in every Bucks County community, hoping that a fresh look at our county will, in some way, contribute to an ever-brightening future for the 600,000 people who call Bucks County home.

This study is unique in that it was collaboratively conducted by two countywide organizations that are long respected for their service and leadership:

United Way of Bucks County has been assessing and serving the needs of Bucks County since 1952. Through its network of 50 member and affiliate agencies, 95 critical human care programs are supported by the donations of thousands of residents, workers and businesses in Bucks County. These relationships and partnerships are leveraged to create real solutions to real problems faced by our community.

The Bucks County Health Improvement Project (BCHIP) is a consortium of health care providers in the county (all seven acute care hospitals, the Bucks County Department of Health and the Bucks County Medical Society) with a focused mission to improve the health status of Bucks County residents.

Building on Our Strengths confirms that this is a productive partnership. The study underscores the basic reality that no need is purely medical or purely social. Clinical issues and community ills are not only interrelated, there is a strong causal relationship that requires examination of issues with a more holistic and comprehensive vision. Life is never lived within neat silos; we have learned that the human needs in our midst form a complex web. Our goal is to avoid the high cost of fragmentation - - costly for the families affected and costly to our community.

Building on Our Strengths presents data that offer both a statistical overview of our county, as well as a penetrating look at the grassroots issues of our community, told to us in countless hours of listening to more than 1,500 Bucks County residents. Dozens of key informant sessions, focus groups, leadership meetings, and more than 1,000 personal telephone surveys, conducted with as wide a spectrum of residents as statistical science could provide, has given this report both a solid structure and a rich texture. Credit for the depth and clarity of the findings must go to our study designer and consultant, David Barton Smith, PhD., a professor at Temple University. It has been instructional and exciting to work with this distinguished national leader in community assessment. It is gratifying that David shares our optimism for the future of a Bucks County that will make information sharing and collaboration the cornerstones of progress.

This report is now yours. The more this information is discussed, used, refined and enhanced, the greater our progress will be. We will create unprecedented access to all the data, tables and findings, sharing with any group working on behalf of the people of our county. The more we encourage input and analysis, the smarter we all become. The "common ground" uncovered by United Way of Bucks County and The Bucks County Health Improvement Project is just the tip of the iceberg. We invite you to add your energy and insight to this process. When the perspectives of business, community coalitions, law enforcement, local government, volunteer and civic organizations, faith communities and others are added to the various efforts underway in every part of this county, we will accelerate progress.

Wisdom dictates that we stay in a learning mode. This assessment is a work in progress. Today is not the end of this report; we are simply sharing a "milestone" in what we hope will become a continuous effort to confront the complex issues we face with maximum coherence.

October 25, 2002

Our thanks go to the Boards of both United Way of Bucks County and Bucks County Health Improvement Project for their dynamic leadership, vision and encouragement. We thank Bucks County Government for partnering with us in this endeavor. We also thank our funding partners for their trust and support: The Grundy Foundation and the PA Department of Health. We thank the Philadelphia Foundation for underwriting the development and distribution of this report. Finally, we thank Dr. David Smith for designing the study and shepherding the process with skill and considerable generosity of time and energy; we are also grateful to the more than 1,500 Bucks County residents who contributed their time and energy.

The production of this report is yet another example of the wealth of skills, invention, cooperation and social concern that have made Bucks County a model to emulate in many of the health and community services described in this report. The financial support of the Pennsylvania Department of Health, Bucks County Health Improvement Project (BCHIP), United Way of Bucks County, Bucks County Government and the Grundy Foundation made this effort possible and is most appreciated. However, the real credit must go to the over 1,500 Bucks County residents who contributed their sweat equity to this effort, participating in focus groups, responding to the telephone survey, and going out of their way to assist in providing information or recruiting individuals who could. The board members of both BCHIP and United Way of Bucks County in particular, helped in many ways in guiding this effort and recruiting participants. Special appreciation is due the work group that assisted in guiding and reviewing progress in the project through its many stages. This group included Sally Fabian, Executive Director of BCHIP; Eric Stark, Executive Director of United Way; Madeleine Henderson and Bob Harris of Lower Bucks Hospital and the BCHIP Board of Directors; and Nathan Bosk, formerly CEO of Lower Bucks Hospital and Board Chairperson of BCHIP. I am also most appreciative of the help of Robert Uris who assisted in conducting and writing up the focus group discussions and Bob Pickard who assisted in compiling much of the statistical information in this summary report and in its supplement. I am indebted to these individuals and organizations and thank them for the special privilege of assisting in distilling their efforts.

David Barton Smith, Ph.D.

Center for Healthcare Research and Management

Temple University

July 1, 2002

Bucks County Health Improvement Project (BCHIP) and United Way of Bucks County conducted a comprehensive needs assessment for Bucks County in 2001 and 2002. This common effort joined two organizations that represent health and social services providers in the county and it builds on the previous efforts of these groups to assess needs and priorities for Bucks County. The assessment was also supported by financial assistance from Bucks County Government, the Pennsylvania Department of Health and The Grundy Foundation.

A Needs Assessment for Bucks County does for Bucks County what a physician does in conducting a comprehensive physical on an individual patient and what a business does in evaluating investment opportunities. Two hundred and ninety-one "key informants," selected to represent the diverse array of service and care providers and community leaders in the county, met in forty-one discussion groups. The information provided by these groups was then supplemented by a review of census, health and other data sources. A telephone survey helped describe the health, risk behavior, access to services and views about the quality of life in Bucks of a representative sample of a thousand Bucks County adults. The first two sections of the report summarize these results, with more detailed information supplied in the supplement to the report. The complete document provides a common information resource for providers and agencies responsible for making program and funding decisions. The final section of the report suggests the broad outlines for a common "road map" that will build on past accomplishments and address present challenges.

One of the hallmark achievements in the last decade has been an increase in collaboration throughout the county. School districts have become engaged in many innovative collaborative efforts with social service agencies. Access to day care for children has expanded, as has the range of services for seniors. United Way of Bucks County has also taken steps towards improving collaboration through its new "United Communities" initiative, aimed at strengthening and expanding services in local disadvantaged communities. A recurring theme in all of our key informant groups was the openness and willingness of service providers to collaborate as a way of coming up with creative solutions to the real problems faced by individuals and families.

The fruits of these efforts are borne out by the hard numbers. The data shows that age adjusted death rates (all causes, infant, cardiovascular, lung cancer, breast cancer, motor vehicles, suicide and homicide) have declined significantly. The percentage of births with no prenatal care in the first trimester has dropped from 13.5% to 8.2%. Residents smoke less, exercise more, use more screening services and report fewer problems in accessing health services. Ninety-five percent of Bucks County residents describe the quality of life in their neighborhood as good, very good or excellent, a rating significantly higher than a comparable assessment for the nation as a whole.

A common theme in the service provider sessions we conducted was that Bucks County often doesn’t function as a coherent whole. In addition, fragmentation of services has been exacerbated over the last decade by the exponential growth, widening income disparities, rapid aging, and growing ethnic diversity of the Bucks County population.

Service providers and their clients must work hard to overcome the fragmentation.

There is a lack of attention to some problems, many residents claim, because (1) their part of the county has very different needs from the other parts, (2) their particular community does not have mental health, drug and alcohol, domestic abuse, poverty and homeless problems and (3) their community is insulated from the problems of the larger Philadelphia metropolitan area. The statistics presented in this report strongly refute all three of these claims.

The lack of affordable housing and adequate public transportation, persistent problems in Bucks County, add to the seriousness of the looming health care and social service workforce shortages now beginning to impact the region as a whole. Bucks County emergency rooms have been overcrowded, often requiring ambulance diversions. The workforce shortages are symptoms of more complex underlying problems, which include the current medical malpractice insurance crisis, declining reimbursement for services, and the growth of an aging population that will increasingly tax all social and medical systems in the county. These and other factors hold long-term repercussions for access to services.

The final section of the needs assessment report provides a road map for residents, providers, funding agencies and leaders. This map describes both where we want to go and the best way to get there. It focuses on two broad consensus goals: (1) extend quality of life years and (2) eliminate disparities in opportunities. It proposes a "service line" approach focusing on the lives of residents during five distinct life stages (0-5, 6-17, 18-39, 40-64 and 65+). A service line approach offers promise of improving the effectiveness and reducing the five billion dollars now spent for health care, education, social services and criminal justice in Bucks County.

In refining this road map, we met with more than one hundred key people. They represented the different regions of the county and the public agencies, educational institutions, voluntary social service and health care providers serving these five different age groups. The six agenda-setting sessions (five age groups and one county-wide leadership session) laid out an agenda for accomplishing ambitious objectives over the next decade. In each area we describe (1) the key findings and conclusions of the assessment (2) who could be effective in addressing the major concerns (3) what they might focus on and (4) how their progress in achieving particular objectives will be assessed. This road map provides new fuel for the rich collaboration and innovation that has already achieved so much.

Investments in prenatal care and in the first years of life promise the greatest return in extending quality of life and reducing disparities.

Low birth weight births, associated with greater developmental challenges and medical needs, grew from 5.4% to 7.3% in the last decade. This is partly a result of continued improvements in prenatal care, resulting in the survival of babies who would have died in an earlier era. Thirty percent of women of childbearing age continue to smoke in Bucks County. Day care, a necessity for working single parents and two-wage-earner households, has become a central part of the lives of more than half of young children in Bucks County. Key informants expressed a need for better linkages between day care and schools, health care providers, and social service providers.

The Quality Child Care Coalition of Bucks County, with whatever additional representation is appropriate to assure improved coordination with public officials, legislators, employers, parenting programs, schools, health providers, and social service providers should make recommendations about how all parties can work together to improve the child care experience for all children in Bucks County.

1. Major issues to be considered should include:
1. Promotion of a new vision of high quality child care as essential for assuring healthy futures for children and communities
2. Assurance of universally accessible high quality service
1. Child care particularly for children with special needs
2. Medical homes for young children and particularly for high-risk babies
3. Pediatric mental health services
4. Full day kindergarten
3. Effective use for outreach: the use of child care sites as points of universal outreach for comprehensive services and support to families
4. High uniform standards
1. Assurance of high quality care for the more than one third of children receiving care in unregulated settings
2. A living wage, adequate professional development and respect necessary to attract and keep high quality child care workers
3. Improved universal credentialing
4. A process of continuous quality improvement that cuts across all child care settings
5. School readiness requirements that are standardized across the thirteen school districts in the county
5. Improved child care information and advocacy
1. Easily accessible, full, objective information to assist families in choosing a child care provider
2. Flexible scheduling where possible and parenting programs in work settings to assist parents of young children
3. Targeted assistance for informal, extended family and kinship care providers
4. Increased parent engagement
5. Increased public advocacy
2. Successful outcomes would include:
1. Improved access to affordable high quality day care by low and moderate-income families
2. Wage parity between preschool workers and elementary school teachers
3. Reduced turnover and enhanced professional training opportunities for child care workers
4. Quality assurance as well-ingrained a process in child care as it is in health care
5. Reduced incidence of the spread of infectious diseases in day care centers
6. Improved readiness and school performance of grade school youngsters

The at-risk behaviors of school-aged children continue to be a legitimate priority concern in Bucks County; we have some victories, and continued attention to these problems holds promise for improvement.

Collaborative programs with the criminal justice system, with conflict resolution and violence prevention groups, and with local Y’s have shown results; these programs encourage a greater openness and further collaboration. These efforts may in part account for Bucks County’s having the second lowest incarceration rate of any county in Pennsylvania. Pennsylvania as a whole has a prison incarceration rate 3.7 times as high as Bucks County.

On the top of the list of concerns of adults interviewed in our household telephone survey were teen drug and alcohol abuse and teen pregnancy. According to the 2000 Pennsylvania Youth Survey covering Bucks County, these at-risk behaviors are prevalent. These and other at-risk behaviors are higher in those who lack a sense of attachment to their family, community and school.

Create a single, visible, countywide mechanism for (1) sharing information (2) evaluating the effectiveness of existing efforts and (3) stimulating new or more coordinated initiatives to reduce risk behavior and enhance the protective attachments of school-aged children. An existing organization or combination of organizations involved with these issues, if feasible, should assume responsibility for this effort rather than creating a new structure. The task force, as it would evolve, would be composed of representatives of all the groups that work with school age children, parents and communities on these issues. It would assist in the design of the mechanism to serve these three functions and would make recommendations about the funding and staffing necessary to sustain it.

1. The major concerns of this effort include:
1. Reducing the risk of: drug and alcohol abuse, violence and domestic abuse, tobacco use, and unprotected sex
2. Enhancing the protective mechanisms that can insulate individuals from such risks as:
1. Poverty reduction within families and communities
2. Greater parental and community connectedness and sense of empowerment
3. Structured after school activities/childcare
4. Mentoring
5. Strategies to enhance trust; earlier and more seamless use of mental health and drug and alcohol treatment services
2. Methods of assessing the success of these activities should include continued use by all Bucks County school districts of the Pennsylvania Youth Survey or subsequently revised standard instruments for measuring and analyzing trends in risk behavior at a county-wide level. Measures of success should include:
1. Reduction in reported use of tobacco, drugs, alcohol and violent behavior among junior and senior high school students and an increase in protective factors as determined by the survey
2. Reduction in adolescent suicides, violent crime rates, school suspensions for violent behavior, truancy, etc.

1. Create a task force to make recommendations about how the complex problem of poverty and employment at living wages for this age group can be more systematically addressed. In essence, poverty in this age group is the county’s most costly disease. It destroys lives, undermines communities, and adds to the cost of the welfare, criminal justice, mental health, and drug and alcohol treatment systems. "Disease management," a systematic, intensive, protocol-based case management process, has proven its effectiveness in reducing the cost of many chronic diseases. A similar systematic approach is called for here. The task force should be composed of key representatives of all agencies providing services to this population as well as individuals representing major employers, the media and legislators. An existing organization or combination of organizations involved with these issues should, if feasible, assume responsibility for this effort rather than creating a new structure.
2. The major issues that should be addressed include:
1. Pre-job readiness and job training
2. Mental health counseling and support
3. Increased opportunities for living wage employment, affordable housing, child care, and an improved public transportation system
4. Behavioral risk reduction interventions (smoking, drug and alcohol use, motor vehicle accidents and violence)
5. Transitional services for released criminal offenders
3. Measures of success should include:
1. Increase in the employment rate and wages of young adults without college education
2. Reduction in reported risk behaviors in the 19-39 year old population
3. Reduced crime and incarceration rate
4. Reduction in drug overdose emergency room visits and deaths

There is a clear need for more concerted efforts in health screening and risk reduction for Bucks County’s middle age population.

Within the county, Central Bucks has higher age-adjusted heart disease death rates; Lower Bucks has higher cancer death rates; all three areas have slightly higher death rates from stroke compared to the state average. Colorectal cancer, prostate cancer and melanoma death rates, while declining in the county as a whole, are all somewhat higher than the state age-adjusted average. Only 53% of males over the age of 50 reported having a digital rectal exam in the last two years. Binge drinking is highest among adults in the central part of Bucks County. 35% of Bucks County adults are overweight; that percentage rises to 41% in the northern part of the county. 93% of adults in Bucks County have one or more cardiovascular risk factors, including overweight, lack of exercise, smoking, high blood pressure and high cholesterol. The economic and emotional stresses faced by this "sandwich generation" that provides critically important support for aging parents, children and even grandchildren, adds to the risks.

1. Expand the existing Bucks County Wellness Partnership to include representatives of major employers, health insurance providers, churches, and community organizations that interface with the 40-64 year old age group; and launch a major initiative to target cardiovascular risk reduction and cancer screening and chronic disease management in this age group.
2. The major activities should include:
1. Development of community-based stress reduction strategies
2. Development of a countywide navigational system, navigators and simplification of systems to assure more seamless referral and access to preventive and chronic disease management services and support
3. Cancer screening promotion and outreach
4. Cardiovascular risk reduction activities (tobacco cessation, weight control, exercise programs, and cholesterol and blood pressure screening)
5. Development and implementation of community-wide rather than health plan or institution-specific disease management protocol
6. Development of intergenerational strategies in risk reduction
3. Success of these activities would include:
1. Reported increases in screenings and risk reduction behaviors in this age group
2. Reductions in the death rate from cancer, stroke and heart disease in this age group
3. Reductions in the cost of treatment of heart disease, cancer and stroke

The rapid growth of this population has begun to strain resources for care and services, particularly for low and moderate-income seniors, but it also offers a rich and insufficiently tapped resource for the county.

Between 1990 and 2000, the population over the age of 75 in Bucks County grew 56%, twice the rate of statewide growth. The percent of residents over 65 living with disabilities jumped from 17.5% to 34.9%. The median age of the Bucks County population grew from 33 to 38, a rate of aging twice that of United States as a whole. Bucks County has experienced a rapid growth in retirement and assisted living development over the last decade. The need for these services continues to grow. The senior population is growing due to migration. This influx has taxed local providers and added to the difficulties in staffing for elder care.

Even the relatively affluent segment of Bucks County’s over-65 population struggles to meet the rising costs of medications, affordable home and personal care services, and assisted living arrangements. Our upper income, over-65 affluent population is not getting the flu shots and pneumonia shots they should. This is in striking contrast to the strong relationship generally observed between income and use of preventive services. Ironically, through BCHIP’s flu shot programs, the proportion of low-income seniors who reported having flu shots in the last year was higher than that of their higher income counterparts.

1. An ongoing task force should monitor what is happening in the growth of the elderly population and the development of retirement communities, assisted living facilities and nursing homes in the county; and it should assess the impact and advocate solutions. The key providers of services and representatives of the senior community should serve on this task force. Its membership will shift over time as the issues that need to be addressed change and as the initiatives that are possible to address locally and that will have the most potential impact become clearer. An existing organization or combination of organizations involved with these issues should, if feasible, assume responsibility for this effort rather than creating a new structure.
2. The major issues that should be explored by the task force include:
1. Designing an ongoing, information gathering process to monitor and anticipate the impact of the changing needs of the elderly
2. Effectively using seniors in meaningful engagement as volunteers and employees to enrich and improve the quality of life in the county
3. Designing appropriate strategies for linking people to the services they need, including awareness campaigns through appropriate media channels
4. Creating coordinated local strategies for supporting aging in place in the community, including: house sharing options, encouraging appropriate design of new housing, renovation to enhance safety, sustaining informal support networks, and assuring adequate nutrition, medication safety, transportation, exercise and social engagement
5. Local initiatives to assist in making personal care and prescription services more affordable to low and moderate-income seniors
6. Developing communication and advocacy strategies for affecting larger policy changes
7. Refining all of the above areas into a more manageable list of priorities that hold out the most promise given limited local resources
3. The success of these efforts will be measured by the development of broadly supported activities for both fully utilizing the county’s seniors as resources and addressing their needs. It will also be assessed by the growing ease by which residents can access the information and resources that they or a family member need.

Assessment: All that is lacking to make Bucks County the 21^st century’s national standard setter for increased quality of life and elimination of disparities in opportunity is greater integration of existing services and a sustained focus on what matters most in the different stages of people’s lives.

The county has the necessary financial resources, talent, and inventiveness. More than five billion dollars are expended each year for the public school education, health care, public assistance, voluntary charitable assistance and incarceration of Bucks County residents. The median family income is 1.4 times the state median and the percent of families in poverty is only 3.1%, less than 40% of the state rate of 7.8%. 31% of its residents over the age of 25 have earned a bachelor degree or higher, 1.4 times the state percentage. Between 1989 and 1999 median Bucks County household income in real dollars grew 6.2%, while income inequalities declined 31%. All of the groups we met with acknowledged the need to reduce fragmentation to better address the complex needs of the individuals and families that they serve. The schools, the criminal justice system, the mental health and health care providers, and social service agencies all work with the same families and individuals. Only sustained investment can address the problems and reap the potential savings of more coordinated and less fragmented efforts.

1. A leadership group, expanded and refined as considered most useful, will continue to meet twice a year to review progress, assist in the coordination and integration of the activities of the groups described above, and design incentives that will encourage less fragmentation and greater coordination of activities.
2. The major issues that will be addressed by the group involve the effective management of the process and the crosscutting issues that can’t be effectively addressed by the five age specific initiatives. The management issues involve acquiring and allocating sufficient resources and incentives to assure the effective functioning of the age group initiatives. At a minimum this will involve funding one full time professional staff person or "service line manager" with office support for the coordination of the activities of each group. Our discussions made clear that it was not meetings that created burn-out, only unproductive ones. One of the keys to making meetings productive is adequate staffing. The crosscutting issues that the leadership group is responsible for involve on-going evaluation of and improvement of the age-group-related initiatives and integration of these age initiatives so that they have a synergistic cumulative effect on quality of Bucks County resident lives and on reducing the cost of services.
3. The success of the efforts of the leadership group will be the combined accomplishments of the age group initiatives and their cumulative impact on enhancing the quality of life years in Bucks County and in reducing the disparities in opportunities. In addition, in the light of current fiscal realities, initiatives should also be measured against the objective of overall systems savings of between $1.00 and $1.50 for every dollar invested.

Background: In October 1994, a consortium of the seven hospitals, Bucks County Medical Society, and the Health Department in Bucks County completed a health assessment. A set of priorities emerged and the Bucks County Health Improvement Project (BCHIP) was formed to coordinate task forces focused on each of these initial priorities. The task forces and their objectives were expected to evolve over time as a result of what was learned from their efforts. It was expected that new concerns and, consequently, new task forces would come into being, facilitated by BCHIP.

In the eight intervening years, BCHIP has grown, taking on a full time executive director, expanding the representation on the Board of Directors to include United Way of Bucks County, Bucks County Community College, Lower Bucks County Chamber of Commerce and the Bucks County Assistance Office. It has also expanded its initiatives to include a work force on employment, developed a network of dental services for the children of low income families, and is in the process of expanding dental services and developing a network of clinics for low income uninsured adults. This and other efforts to assure access to care for this population are possible through the help of a 1.84 million dollar grant from the Centers for Medicare and Medicaid Services (CMS).

United Way of Bucks County, this year celebrating 50 years of serving Bucks residents, has long sought alliances to make human services in the county more effective. United Way and BCHIP were natural partners for this study.

Current Project: The BCHIP Board felt it was now time to review all of its activities and reassess the needs of Bucks County residents. The earlier assessment had relied on 1990 census numbers and now many of the 2000 census numbers were available. It had been guided, in part by the national agenda of Healthy People 2000 and now a new national agenda has been set in Healthy People 2010. The original BCHIP consortium was one of the first to bring together competing hospitals in a common community assessment and improvement initiative. BCHIP now wanted to bring together new partners, including county government, voluntary social service agencies and other groups in an expanded initiative. United Way of Bucks County was an ideal partner for such an initiative. United Way Member and Affiliate Agencies, 50 strong in Bucks County, focus on reducing the impact of income disparities and addressing social issues facing families and children. A common needs assessment would, at the very least, provide a common set of numbers and more qualitative insights.

The events of September 11^th make this effort and the focus of the federal Healthy People 2010 agenda and Pennsylvania’s State Health Improvement Plan 2001-2005 prescient. The documents offer a simple but powerful idea: provide objectives in a format that enables diverse groups to combine their efforts and work as a team. This format provides a road map that can be used by many different groups to improve health and the quality of life in the county. Although Healthy People 2010 itself includes more than 467 objectives focusing on 27 specific areas of concern, it has but two simple, overarching goals: (1) Increase quality and years of healthy life and (2) Eliminate health disparities. Large health disparities persist by race, ethnicity, gender and income. The differences are the best clue to what is possible and what are the best targets of opportunity for increasing quality and years of healthy life for everyone. Just as with the national and state effort, two overarching goals drive the Bucks County effort: (1) increase the quality and years of healthy life of Bucks County residents and (2) eliminate the disparities in health and other conditions that widen the disparities in opportunities faced by county residents. This effort envisions the same systematic approach envisioned by the national effort outlined in Figure 1.

Source: Healthy People 2010

This Bucks County Assessment embraced this blueprint and adapted it to the unique character of Bucks County and the special opportunities it provides.

As illustrated in Figure 2, this report has three parts. It is organized as a progressive filtering process. Part I provides the complex picture described by almost three hundred key informants knowledgeable about health and social service needs of Bucks County. Part II then focuses on the key statistical indicators relevant to assessing quality and years of healthy life and disparities that exist. Part III and the final section of the report digests all of this information into targeted interventions. In essence, this needs assessment blends a complete health physical on a population with the due diligence required of a business decision concerned with where one can invest scarce resources to get the best return. Part I is similar to the history taken of an individual patient during a complete physical examination. Part II is similar to the various diagnostic tests during such an examination and provides the numbers to compare the health of Bucks County’s population to that of other areas. Part III provides the diagnosis and the prescriptions. A supplement to this report that follows a similar outline, provides more detailed qualitative and statistical information and describes the methodology and data sources.

This section summarizes the key informant discussions organized by BCHIP hospitals and United Way of Bucks County. The group topics and the invited participants were carefully selected to ensure discussion of issues important to the two organizations’ goals and targeted concerns. BCHIP has focused on twelve concrete objectives whereby health status in the county could be improved.

BCHIP’s Current Objectives

1. Improve health care access for the uninsured

2. Increase access to prescription medications for low-income residents

3. Increase the number of children enrolled in CHIP

4. Expand utilization of BCHIP free dental program for uninsured children

5. Increase mental health counseling services for at-risk adolescents

6. Promote and provide ongoing immunization program

7. Develop and implement health promotion and disease prevention programs such as teen tobacco cessation

8. Counsel and refer victims of domestic violence

9. Promote careers in healthcare, including developing job opportunities and providing mentoring for people in transition from homelessness

10. Advocate for public transportation services throughout the county to remove the transportation barrier to health care

11. Promote awareness and availability of heart disease and cancer screening in every area of the county

12. Develop other task forces and projects as needs emerge

United Way has focused on nine key areas of concern addressing conditions that shape the quality of life and health of Bucks County communities and their residents. Over $2 million is allocated annually to 95 targeted programs that address the most critical needs in each of these areas of concern.

United Way of Bucks County’s Targeted Concerns 1. Empowering The Disabled 2. Fighting Substance Abuse 3. Caring for Older Adults 4. Violence Prevention 5. Responding to Emergencies (homelessness, etc.) 6. Nurturing Young Children 7. Encouraging Youth 8. Strengthening Families 9. Local Programs of National Agencies (Scouting, Disaster Relief, etc.)

The Key Informants The key informant groups that BCHIP and United Way organized to assist in the initial phase of this assessment reflected these concerns. Each chose a different strategy in selecting participants. BCHIP hospital members identified individuals they felt were key resources. United Way solicited participation of agency executive directors and key staff in a session of their choosing related to eighteen specific areas of concern. There were 44 group sessions that included a total of 291 participants. Figure 3 summarizes how these sessions were organized, describing the sponsor, focus of concern and number of participants. Figure 4 translates the groups listed in Figure 3 into something comparable to the systematic approach to health and community improvement supplied in Figure 1. Figure 4 is our model for organizing the summary of these sessions. We will summarize first the sessions that dealt with how the social context affects the health and quality of life of Bucks County residents, then those sessions assessing impact of access to supportive services, and, finally, those that assess the effect of access to health services. For each session we asked what was working, what was not working, and what could be done to better improve outcomes in terms of the quality of life and health of Bucks County residents. The dotted lines in Figure 4 that connect these three "boxes" reflect the interrelationships. The participants in the key informant groups described these interrelationships in vivid detail. Figure 3. Key Informant Discussion Groups Session Sponsor Groups Number of Participants Task Force Homeless 12 UW #1 Substance Abuse 10 Crime 5 Domestic Violence 5 Teen Pregnancy 3 Illiteracy 1 Frankford Senior Health 8 Emergency Services 9 Wellness 4 Medical Education 6 UW #2 Older Adults 7 Transportation 4 Affordable Housing 4 Job Training 4 Poverty 5 UW#3 School Superintendents 9 Doylestown Mental Health 5 EMS 3 Access 4 Senior Health 2 St. Mary Domestic Violence 14 Cultural Issues 7 Nutrition 7 Employer Responsibility 2 Grandview Mental Health 8 Older Adults 9 Access 7 Employer Responsibility 2 UW #4 Child Day Care 4 Services to Youth 8 Mental Health 12 Disabilities 6 Leadership 6 Lower Bucks Parenting 12 Early Childhood 14 Teen Issues 12 Prescriptions 8 Below Radar 9 UW #5 Substance Abuse 5 Crime, etc. 7 Teen Pregnancy 7 Job Training 3 Affordable Housing 7 Leadership 5 Total 44 291

This section of the report will provide a summary narrative distilled into three sections representing each of the boxes in Figure 4. The more detailed notes derived from all 44 individual sessions, organized in a similar fashion, are presented in the Supplement to this summary report, in Appendix I.

The key informants describe in their own words a county struggling to adjust to the changes engulfing its growing suburban population. Bucks County is not the safe, insulated haven from the troubles of the larger world that its long-term residents hoped to preserve and its many recent arrivals sought. As a growing bedroom community for New York commuters, it lost neighbors in the World Trade Center attacks. Some of its schools and neighborhoods have even been impacted by the increased availability of lower cost and purer forms of heroin, some purportedly now flowing from Afghanistan. Like other suburban areas in the United States, it struggles with an emerging "hourglass" economy that pits the needs of low-income wage earners against those of affluent but time-pressed professionals. Its new immigrant Russians, Indians, and Africans came seeking a safe haven from even more troubled parts of the world. They are concentrated in areas segregated by income, straining local resources and often embroiled in inter-ethnic tensions. Some county residents argue that Bucks County is not one county but three: Lower, Central and Upper Bucks.

Some Upper and Central Bucks residents would like to believe that they share little in common with Lower Bucks, other than the lack of adequate public transportation and poor roads that help insulate them. Yet, no matter what part of the county key informants were from, most of the needs and concerns were the same. It is, our key informants assured us, one county.

The changes and the divisions in Bucks County pose special challenges for the county’s community leaders, employers and public officials.

The challenges faced by United Way in many ways reflect those of the county as a whole. Its fund raising efforts lack the public awareness enjoyed in other communities that have not changed as rapidly. Its financial base has been eroded by the departure of some major companies that leave it with the more labor-intensive effort of raising funds from individuals and small businesses. Not surprisingly, it has had difficulty bringing the county together around a common set of goals. People in one part couldn’t even find their way to the other two parts. A lot of people who live in Bucks County work in New York or Philadelphia. In some parts of the county, the natural relationship is to the Lehigh Valley or to Montgomery County.

Community social service agencies face similar challenges made more difficult by time and resource constraints. Everybody is so busy with the day-to-day operations of their organizations that they don’t have the time to be analytical. As one key informant stated, "There used to be major speakers who came to the county. We used to say ‘let’s create something new once a year.’ We don’t do that any more."

Employers have reversed direction, trying to reduce their costs for health insurance benefits for their employees. Employers used to be interested in extending benefits for our employees and offering greater choices. Now they focus on constraining the growing costs. At the same time, some employers are troubled by the limits on coverage of prescription, substance abuse treatment, and mental health benefits that they feel are important.

Whatever the effectiveness of business and community leaders in addressing the larger challenges, a remarkable network of agencies and individuals in Bucks County have made headway in addressing the interrelated and largely hidden problems of poverty, crime, violence, substance abuse and racism in the county. These tightly interwoven problems, however, remain the largest and most intractable barriers toward the goals of (1) increasing the quality and years of healthy life of Bucks County residents and (2) eliminating the disparities in health and other conditions that widen the gap in opportunities for county residents.

Substance abuse agencies in Bucks County have been effective in collaborating in prevention and intervention programs. The sheltered housing programs for alcohol and drug abusers are working well, and the prevention programs with young people are inventive and promising. A multidisciplinary systems approach works best in matters of prevention, focusing on the whole physical and social environment that shapes the risk of drug and alcohol abuse. Such an approach means a lot of collaboration with other groups and an opening of systems. For example, prevention programs focus on schools, the family service system, and child welfare. They look at reducing risk factors and use the research to drive actions. People used to view prevention as superficial and ineffective, but the scientific evidence indicates that it does reduce risk of substance use for kids. All the services provided complement each other. Some of the schools provide a great opportunity for nontraditional kinds of education. Programs that prevent bullying, provide mediation counseling, and enhance personal decision making all help in reducing risks. More school-based services for adolescents in particular, however, are needed. There is a need right now to maintain and increase programs in the junior high schools and high schools, where kids are subjected to a great deal of peer pressure involving risky behaviors.

The stigma of substance abuse is a major barrier in addressing the problem. As one key informant stated, "We deal with what are perceived by most communities to be a very scary group of folks. The problem is that our clients are invisible when they are success stories, as most of them are. They only get in the newspapers for something that has gone wrong." This reinforces the "not in my back yard" response. Interaction with people outside the treatment system can be tough. For example, we have to be careful about the labels we use. People who need help fear being stigmatized. Many of the school superintendents, will say "their" school doesn’t have a drug problem. It can be politically risky for some schools to say they have a drug problem. It is very difficult to get consumers of substance abuse services to advocate on their own behalf. They don’t want anyone to know that they have had a problem. Until they can really speak for themselves, they will only get the crumbs in terms of resources. It’s beginning to happen though.

Care for middle-income people is often unavailable. For drug and alcohol services you have to have either limitless income or none at all. People struggling on average incomes of $30,000 a year can’t afford the care they need. It seems that many of the people seeking treatment have more chronic problems than clients in the past, but the amount of funding for these people gets less and less, resulting in increasingly shorter treatment periods. It is almost as if the private insurers won’t authorize treatment until they have chronic liver problems.

There is a gap in inpatient services for those too mentally ill to be cared for in group home settings. We heard comments like: "We use to get a mix. Now they skim off the people they feel can be treated on an outpatient basis and the people who come in to residential settings have serious problems. These are people with an extreme mental health diagnosis, chronic relapses, and often a criminal justice background. It taxes our service programs."

Staff retention is a critical problem. Often, staff members can’t get transportation to the clinics. Across the industry, people who are coming out of college are willing to work for only a brief period of time for $9-$10 dollars per hour. Salaries in the field are lower than virtually everywhere else. As one provider said, "For what we can afford to pay, you can’t get good staff. We can’t even compete with the fast food chains. We can pay in the low 30s for masters prepared people with five years of experience. I saw a sign outside McDonald’s for managers, saying they would pay in the high 30s." People may take twenty percent less pay to work in this area, but not more than thirty percent less. "Somehow we need to do something about our ability to generate income so we can pay salaries that will attract high quality people," another key informant stated.

The powerful currents of the underground economy work against the goals of prevention and treatment programs. Non-college bound 18-21 year olds who have few resources get lost. They are susceptible to drug dealing and use. An example: "How do I convince someone whose only options are making $500 a night selling drugs or working for minimum wage at a fast food chain that the fast food chain is the right choice. It’s a vicious circle that affects whole neighborhoods. The destructive impact of the economics of poverty and the disparity of opportunities it creates is phenomenal." There has been a resurgence in heroin use with increased availability of relatively pure heroin, much of it coming from Afghanistan. It’s not unusual to see kids 16-18 years old who have three, four and five bag-a-day habits. Part of the reason for the increase in heroin use among adolescents is that heroin is more affordable, and it doesn’t need to be injected. Heroin use is pervasive in the county and not limited to just one section.

Drug and alcohol abuse problems are connected to all the other problems faced by people with inadequate resources and whose lives are under stress. They have problems with affordable housing, transportation, employment and treatment. The majority of adult men are not eligible for public assistance now. They are the working poor. They have no medical care and minimum wage jobs. It’s easy for them to get frustrated and relapse. It takes a lot of strength to work their way through the treatment system. The restrictions on the length of stay in inpatient treatment programs make these entire infrastructure issues more of a problem. It’s particularly difficult in caring for adolescents. To be effective, you have to change the people, the place and the things that have created the problem. We heard: "In the good old days we had 18 months to do this. Now we have just so many days. Lengthy, intense interventions can make real differences in the lives of people with serious substance abuse problems. It takes time to get people to see things differently, change behavior, and detoxify the brain so it processes information differently."

The Bucks County Correctional Facility is considering recommendations for improving services for women who are incarcerated. Yet, it is perhaps more open to volunteers than any other jail in the state. There are more than four hundred community volunteers in the correctional facility. About two hundred are faith based and most of the rest provide one on one tutoring.

The placement of juvenile probation officers within some of the Bucks County schools helps. Their presence has reduced recidivism by 50%. The officers came to be seen more as positive supports for these individuals at risk rather than as punitive threats. They provided quick interventions. They are now perceived as a friend and helper, a part of the school’s support staff.

The failure to provide adequate support to parolees feeds a high recidivism rate. People are recycling through the system. There are tremendous and often unrealistic demands put on parolees. According to one of the key informants, "Some just don’t have the skills. A tough guy in prison is afraid to lift up the phone and call someone. Probation officers don’t have the time to help. There are no special funds for parolees."

Sealed off pockets of need provide breeding grounds for crime. There is one neighborhood where no one will make pizza deliveries. It is a neighborhood that will not reach out and has tremendous mistrust of the mainstream. It is mostly Section VIII housing, a low income neighborhood first housed in Quonset huts left over from the World War I war effort. Another area is experiencing much turnover and new immigrants. There is little stability in the school population and a lot of racial and ethnic tensions. It’s a working poor area, a border town with some moving there to escape New Jersey Children and Youth or fleeing the reach of the law. In another low-income area a ten-foot chain link fence surrounds it and seals it off from the rest of the community. What kind of message does that give the children growing up there? Trailer parks scattered through the more affluent areas of the county house the more hidden working poor.

Lack of good data blocks accountability and stalls innovation. Record keeping is not uniform. There is under-reporting, and often a lot of pressure not to report. For example, school drop out rates tend to be kept artificially low. You are able to keep state funds if they are transferred to an "alternate setting." We are operating blind in the criminal justice system; "there are no effective ways to measure outcomes." Uniform crime reports from the 40 local police departments are a euphemism. It is hard, for example, to measure the extent of domestic violence or how effective the programs have been in addressing it.

A Women’s Place set up a medical advocate project with funding from BCHIP in 1999. All the hospitals and clinics run by hospitals, Planned Parenthood, the Health Department and volunteer groups such as HealthLink have access to a Medical Advocate who builds awareness and counsels victims of domestic abuse without charge.

The legal system is responding more quickly and there is more outreach and earlier intervention. Legal Assistance handles between eight hundred and one thousand domestic abuse cases a year. There are no financial eligibility restrictions for those seeking help with domestic violence problems. There is more vigorous prosecution. The District Attorney endorses the domestic violence protocol and all forty of the police departments in the county have at least formally implemented the protocol. A Women’s Place gets referrals from hospitals, law enforcement, and schools. A Women’s Place runs intervention programs for batterers. Referrals have now doubled into these programs.

School-based and long-term intervention programs hold promise. Small, focused, well designed and targeted school programs work. A peer mediation training in one elementary school reduced the number of fights from three to five a week to less than three a month. A bullying prevention program in another school district increased sense of attachment. We know that the more attachment children have to their family and school, the less likely they are to get in trouble. The long-term group programs can be highly effective also. They start in group sessions and over time they begin to see things differently. We heard: "sometimes there is a level of violence that is taken for granted which they don’t see. Then there will be one event that will take them over the edge." Groups work well; it’s a gradual process. The support worker can point things out but it doesn’t always register. Over time the group members often point it out to each other. Verbal abuse is an example of something they don’t think of as abuse.

There has been a lack of headway with domestic abuse issues in the new immigrant communities. Cultural differences slow progress. The Russian or Islamic women need a more culturally sensitive approach. It’s more than just informing them and distributing materials. One provider said it this way: " I don’t know how to do it. You can’t make them a pariah in their own community. The cost is too great." The downside of the new protocol is that some are more reluctant to report domestic violence.

Growing economic and social stress may mute the effectiveness of all the community efforts to reduce domestic violence. "Hurt people hurt people." Domestic violence does not operate in a vacuum. We have been seeing more domestic violence and stress since September 11th. It has to do with general anxiety and the economic downturn. As the financial situation faced by families becomes tougher, domestic violence increases. Three women in Bucks County were killed last year as a result of domestic disputes. Hopefully it’s an aberration. Domestic abuse cuts through all economic levels. Services for victims of violent crimes are very comprehensive, with Network of Victim Assistance (NOVA) playing a key role. NOVA was asked by the Federal Government to run the Pennsylvania September 11^th Victim Assistance Program and worked very closely with United Way of Bucks County to assist the 17 Bucks families who lost loved ones.

The effort has to be sustained and it has tended to lose momentum. It burns out the judicial system. There is little uniformity on these issues across police jurisdictions in the county. The entire system needs to be continuously sensitized.

Some low-income housing resources have been added in the county but they fall far short of the need. There is an excellent program of foster care for adults, for people 18 years and older who can’t live independently but don’t need skilled care. It’s a small program now, partly because only $800 per month is available to be paid to foster families, and not many families can be recruited to care for people for that amount.

There is now a permanent year round homeless shelter. Many clients receive subsidized housing through the Section VIII program. The emergency shelter program has been valuable in paying up to $750 to help people avoid eviction. Interfaith Housing of Bucks County has been building housing so people can get out of shelters and motels. "For every one we put up there are 10-12 people who are waiting to get into the program. Many people are still living in motels and shelters because there aren’t facilities for them."

The cost of most housing in Bucks County is more than people of moderate means can afford, and the traditional cycle from apartment to starter house to larger family house is blocked. The average price for a 1-bedroom apartment is $650 per month. There is an even greater problem if people need more than a 2-bedroom apartment, which is typical for people who have more than two children. Since large apartments are virtually unavailable for people receiving assistance, this means that larger families have to be located in a house. But finding a landlord willing to take Section VIII payments for a rental is very difficult. It’s often suggested that they go to Philadelphia, but they don’t want to leave the county. People who can’t afford to buy their first house don’t move out of rental apartments. This means, in turn, that apartments don’t open up for new residents.

One current bright spot in this otherwise bleak picture is the 37-unit townhouse development being built in Trumbauersville by Habitat for Humanity. This one-of-a-kind project includes two tiers of low-income housing (the Habitat and Interfaith Housing models) and a third of the homes available to open market buyers. The quantity of affordable units represents a huge departure from the typical one or two a year approach in Bucks County.

The "not in my backyard" fear of low-income housing persists, undermining the creation of viable communities. Such housing is often equated with "those people," minority groups. Fear is a big issue here. There is fear of lower property values in the community, fear of drugs coming into the neighborhood and other fears. Rather than admit their fear, people pretend the need for low-income housing doesn’t exist. Or they support open space rather than affordable housing. People don’t understand that if you don’t have affordable housing you can’t have a viable community. Communities need gas stations, fast food restaurants and other services. Yet, the people who work in these places can’t afford expensive housing.

Providers of health and social services have struggled to accommodate to the growing ethnic diversity of some sections of the county. There is a problem in getting information out about the Children’s Health Insurance Program (CHIP) and school lunch programs to people who don’t speak English: primarily Russian and Hispanic families. Training is needed for medical interpreters. Such training is now occurring in Philadelphia. The Mother Bachmann Center in Bensalem provides maternity care for people who don’t have any health coverage. Among other groups, there is a large Turkish and Indian community being served. Many of these people come back and volunteer after they have their babies. Some people have no idea how the health system works in this country. "We had a man come in last week with a handful of money because he thought that was the only way to get service."

Immigrants are often reluctant to use services because of legal concerns, lack of familiarity and cultural predispositions. People who are in the United States illegally are often afraid that if they come for health care they will get reported to the Immigration and Naturalization Service. One provider stated, "We tell them we don’t care what their status is, but they may not believe it. They don’t understand that the registration process is primarily intended so people can be placed on a sliding scale." People can come in to the country legally and still have to wait to get Social Security cards. In the interim, they aren’t eligible to take jobs, get health insurance or secure other routine benefits. For Russians, it’s not part of the culture to attend a support group. Doing so means you are bringing your problems outside of the house. There’s a lack of materials in multiple languages and virtually no information in doctors’ offices about how to make appointments and handle other routine matters. People are not noncompliant. They just need some simple instructions in a language they understand. Domestic abuse and dealing with it can be a special problem for immigrants from different cultures. For example, there’s a strong stoic quality in Korean and Cambodian cultures. It’s hard for them to understand that abuse is something to deal with and report. The Russians can’t believe that an HIV test can be confidential. Many have taboos and cultural biases about reproductive health. The women won’t get pap smears from male doctors.

The schools in some communities face special challenges in addressing the shifting ethnic make up of their students and their families. "We had little girl in school from Liberia. She asked if she could sharpen her pencil. She did it with a penknife and was suspended for carrying a concealed weapon." African Americans, Island people and those from Liberia are all thrown together. Add the language barrier and you have problems. How does the school go about even getting permission forms signed? How do you deal with ringworm?

English as second language programs build bridges. "In the English as a second language program we work with people with thirty-two different native languages in the same classroom. The warmth, the love and respect of the teachers is amazing. There is sweetness and eagerness and it is unbelievable. Immigration is a good thing. It has been a marvelous gift for our country."

Some saw a subtle undercurrent of racism shaping social policies and some African Americans had experienced its less subtle sting first hand. Many of our clients are minorities, but much of our staff is not minority. Part of the problem is having overwhelmingly white staff serving clients who are often members of minority groups. Why aren’t there more qualified minorities on staff? We could do a better job of recruiting minorities. We don’t advertise in papers read by minorities. "We had a client one time. She was white. One of the skills this client discussed was that she was white. In her mind, her being white alone afforded her something that was not available to the nonwhite."

Families of color are largely shut out of new housing simply because they make 25% less than white families in the county. Also, there is little affordable rental housing in the county. There’s not a broad range of housing being developed in the county. Whether it’s covert or overt, minority families don’t have the option to move into the housing that is being built. There are rarely discussions of race in the county. "A middle age woman I know who has been here for 30 years said it’s hard to live in this county. She said that when she walks into a store people follow her. When she leaves, they check her bag. Especially in the northern part of the county, there are hate groups. I grew up in Upper Bucks. I had a gun shot into my living room last Christmas. The hate messages that keep getting spray-painted onto my house aren’t coming off after 20 years. The police have never addressed it. I question why minorities live here. I want to work in Bucks County, but I could be much better off if I took a job in the city. A good friend of mine was arrested and the policeman said in court, I wouldn’t have arrested you except you looked suspicious. You’re black."

There are very few programs in the schools to deal with racism. Racism among teenagers is disturbingly common. Some of the racism problem is related to total ignorance, but part is choosing not to see it.

Head Start serves as catalyst for low-income families to learn about community resources. We have Head Start programs in most parts of county, but not in some areas that are more affluent but which have pockets of poverty. Head Start provides transportation, but this service is limited to a one-hour bus run.

The BCHIP Health Care Jobs Project for the homeless has made a significant difference in the lives of some families There is seamless collaboration between the shelters and other sources of applicants, job readiness programs, and the hospital employers. The task force has worked hard at assuring this coordination. Those that are employed have families with children whose lives have changed for the better. Intensive, sustained interventions with one on one mentoring work.

The poor face many barriers beyond just job skills. The barriers include transportation, affordable housing, affordable child care, and their health problems and those of other family members. For example, many health providers reserve their evening hours for their private pay clients and offer time for their Medicaid and CHIP patients during the day, since they are assumed to be not working. If people are healthy and can help themselves and they are on welfare, they are being handled reasonably well. But the people a level above that aren’t served. If they lose their jobs and use up their unemployment, they will have a problem. What welfare gives them won’t be enough to pay the rent. Section VIII subsidized housing is a good program, but it has a one year waiting period. What are families to do during that year?

There is a tension between pressures to demonstrate results by moving people off the public assistance rolls through any form of low wage employment and providing the more extensive training that helps people move out of poverty. The Healthcare Jobs Project is a resource-intensive effort that can’t demonstrate big numbers or quick results.

Success requires intensive mentoring, but mentoring in the absence of support services to solve the problems of clients can’t succeed. Transportation, health needs, child care needs and housing needs have to be met.

The working poor, just a step above eligibility for public assistance, have the fewest programs available to them and are often blocked from advancing beyond bare subsistence. It doesn’t make sense to have the deck stacked against people who can easily tumble into poverty. It is critical to have a safe place for school age children after school until their parent gets home. There are programs like this, but they cost too much for people with limited resources. How can people who are making minimum wage afford to rent these apartments? "The positions we train for won’t pay $16-$20 per hour, the amount that is needed to live at a reasonable level in the county. We want people to get training that will at least lead to that level of income. For example, registered nurses can get $25-30 per hour after a two-year associate degree. We need people to get training that will get them into a career ladder such as one that leads to becoming a registered nurse. We can get more creative with job training. Training services have already been working with the hospitals. They could do more with other employers. And training doesn’t always have to be at the community college. It could be on-site at the job. "

Among poor people surveyed in Bucks County, 68% said they didn’t have enough food for their families to last out each month. There is a big problem of communication between agencies responsible for nutrition programs and the rules regarding eligibility. People in the agencies themselves often don’t know the rules. It’s understandable, then, that the poor wouldn’t know them. Usage of food in the 28 food pantries in Bucks has increased this year. This probably relates to the downturn in the economy. Overall it’s hard to be poor in Bucks County. It’s especially hard to be poor in Central Bucks. Some schools don’t have school breakfast or lunch programs because there are only a few children from poor families.

Literacy programs work, and employers need to play more of a role in literacy and skill development programs. "People learn to read and write and whole worlds open up. They read to their children, they read a menu, they write a birthday greeting to their mother and they get their GEDs. When I was in one of the local hospitals, a nurse’s aide, came in. When she heard I was part of the literacy program she hugged me and started to cry. ‘My husband did not allow me out of the house and I did not learn English or how to read. Then he died and I was alone and had no way to support myself. Your program made the difference,’ she said." Businesses want skilled workers who can read but won’t pay for it. The expectations are often unrealistic. It takes about 50 hours to go one grade level in literacy. It takes time. They all want workplace programs but we can’t afford to do it without support from employers. They would have to be half on the clock. Perhaps some kind of consortium involving the Workforce Improvement Board and the Chamber of Commerce and the Workforce Literacy program would work. The business sector expects a welfare system to support them but complains about the one that exists.

The supportive services people need are shaped by the social context. Access to those services affects their quality of life and health status. These "services" include the informal care given to children by parents and to aging parents by their adult children. The key informant groups summarized in this section focused on how people’s lives from birth until death in Bucks County were shaped by the care they received from friends, family members and/or social service agencies.

There can be no access to services without transportation. Transportation in Bucks County, as noted in the last section, has long been a persistent problem and it is more of problem for those who are poor or disabled.

Significant progress has been made over the last eight years. A Bucks County Transportation Management Association has been formed to try systematically to address the problem. The Pennsylvania Lottery fund continues to help subsidize more than 300,000 trips a year for Buck County Transport. SEPTA has added bus routes in Lower Bucks and the county has been helping to provide transportation for people coming off welfare to get jobs.

The disabled and the frail elderly still face many difficulties. The services are "door to door rather than door through door." The transportation system is equipped to handle the additional help that handicapped people require. Typically two days notice for medical appointments is required for Bucks County Transport (BCT) for seniors, and this leads to excessive use of ambulances and emergency rooms. The unpredictable nature of the schedule means that seniors have to be waiting as long as thirty minutes outside in all kinds of weather. Taxi service, even with BCT subsidies, is unavailable in many areas of the county.

The automobile "dependency habit" has proved difficult to break. There is a public perception that mass transportation is a second-class way of getting around. The mentality of Bucks County is, you have a car. This means that even when you set up a public transportation program it can fail from lack of use. Bucks County’s road system and development are not conducive to buses. The roads are too clogged. More parking at the train stations would benefit those who use the trains to go into Philadelphia for health care. The county doesn’t accommodate well to pedestrians. The lights aren’t long enough and often there are no curb cuts for wheel chairs or sidewalks. There is little accommodation for bikes. Some have made a convincing argument that simply subsidizing the purchase of automobiles for low-income families would be cheaper than expanding public transportation. Lots of people drive without licenses because they don’t have public transportation alternatives.

The shift toward outpatient care exacerbates transportation difficulties. Health Maintenance Organizations (HMOs) frequently change their lists of providers and the location of these new providers and specialists can impose unanticipated burdens on patients. In-home care sometimes relies on aides who may not have reliable cars. Few pharmacies provide delivery services.

Schools can link people to services. "We are the infrastructure." Monday through Friday between the hours of 8:30 and 3:00, one-fourth of the entire Bucks County population is in our schools either as pupils, teachers or support staff. In many districts buses stop at almost every household twice a day. School buildings are empty all but a third of the day and could house many services now offered at more fragmented and less visible locations. The state sets elaborate construction requirements for school nurses’ units; perhaps they could use them for clinics. The problem is how to marshal the resources to do it well without sacrificing their primary mission.

Schools are transforming, acknowledging their role as social service provider and forming new partnerships. There are lots of collaborative ventures and, within the limits of funding, there is a strong collaborative philosophy in the county. There are good resources for drug and alcohol referrals. The Big Brother and Big Sister programs and the Y in one township have helped in supporting school programs. The Y came and asked the principal, "What can we do for you?" He wanted to teach students rail and water safety. They helped to secure funding to get the swimming instruction and our students are now bused to the Y for this. The Big Brother and Big Sister Program trained the high schools students to be Big Brothers and Big Sisters to the elementary school students and that was a wonderful idea. Some schools do a lot of after school and summer programs with the Y’s and other agencies. The Head Start program purchased one of the school’s buildings and they worked to merge educational programs to provide a daylong program for kindergarten students. A lot of agencies are looking for partnerships and trying to find ways to stretch their funding. "If I go back a few years, I don’t think I had a clue about what these other agencies did. There is still frustration, tension and battles about who is going to do what, but I think there is much more openness, discussion and knowledge about what other agencies do throughout the county." It has to do with trust and building relationships and that takes time. There is a greater degree of trust and perception of the professionalism of these agencies among school districts in the county. Success breeds success.

We must strengthen the infrastructure to support people with mental health issues in the county. In physical health you keep taking the prescriptions until you’re cured; in mental health you’re done after three days of treatment. That impacts the kids and it impacts the families. There is lack of realistic levels of support. Mental health providers have mandates without resources. "I’ve been involved personally with one elementary school child and his family with Children and Youth and juvenile court. We tried to get care with the Bristol Bensalem Unit and then with Northwestern. The turnaround of Northwestern staff was so slow the mother got so frustrated she took the child to Penndel. This district ended up hiring a 1:1 personal assistant for the student to help control his behavior and emotional issues. Every time I turned around another agency was involved. Children and Youth is understaffed. It gets so frustrating, you end up trying to do it yourself. We go to the agencies and they say, ‘we’d like to help but we can’t.’ As a result, we have had to become our own mental health team. We have hired a lot of social workers, psychologists, physical therapists, and occupational therapists. We have to develop all of these related services and it has become a large drain on our resources. Even when there is collaboration with other agencies, it’s discretionary for them but it’s not discretionary with us. We have the child seven hours a day. I’m beginning to wonder whether United Way should be supporting the school districts. The schools can do it, and probably well with more resources, but we divert a lot of dollars now from the reading, math, and science to address the mental health issues. I support it but it’s not our major mission. "

There are clear limits to what schools can be expected to address on their own. Family problems and parenting are not things that schools should or can address on their own. The faith community and others need to work together. Sometimes we find out things indirectly and can work with pastors to get people the counseling that they need.

Politics gets schools caught up in contradictions. For example, it is a state requirement that schools provide AIDS prevention education but not pregnancy prevention and some school boards balk at providing such education when it is not mandated by the state.

There is the growing problem of the latch key children. They have two working parents or a single parent. It is a problem that pervades all income levels in the county. The only difference is the size of the key and the size of the empty home.

Bucks County parents have become more self conscious about parenting and more willing to seek help. Parents are thinking more about what they should do. They are more reflective, willing to seek out services and more willing to ask questions. Parents are willing to seek out resources to help them. There isn’t the stigma associated with seeking help that there used to be. If you get help now you’re a "good" parent. They are taking a more sophisticated approach to discipline. Far fewer resort to physical discipline. Now discipline is more likely to involve withholding privileges. It takes the form of not allowing use of the Sony Play Station for a week instead of a swatting.

There are more resources available to parents now. Parenting classes are widely available. Our parents didn’t have these services. They learned what they learned from their own parents. The grandmother was there to help out. Now, the extended family is too dispersed to play any effective role. Parents have developed their own support groups and more are springing up all the time. It gives the parents a forum, a network and engenders a sense of self-respect. It helps give parents more of a sense of authority.

Schools, Y’s and other community services have been more self-conscious about involving parents and supporting the development of strong bonds with their children rather than serving as a substitute. " I work with the elementary students and we have The 100 Book Challenge. The school gives prizes for every 25 books they read but you have to have an adult "coach" that signs off on your accomplishments. That forces the parents and the grandparents to be involved more." There are also library programs and YMCA programs that seek to involve parents more with their children. There are groups such as Jack and Jill that meet monthly and organize family outings and organize special recognition celebrations for graduating seniors. There are also special efforts now to fund programs to support teen fathers.

Too many parents and children live time pressured lives. The kids are not the number one priority. They say they give the kid anything it needs, but they don’t give them a parent. Love is just not enough. Parents have to spend the time. We have created a generation of latch key children and higher incomes have not insulated children from the impact. Too many kids are dealing with adult issues. The parents are working two jobs. Sometimes the kids are caught in the middle in blended families. When they come to kindergarten, they don’t know any nursery rhymes. All they know about is World Wrestling Federation body slams. The kids now have more responsibility and have become parents to their younger siblings in the absence of the real parent. Many parents are isolated and haven’t been reached by services or the more informal supportive networks. As a result, too many children are falling through the cracks. It’s the village thing. You can’t parent just your own kids; you parent the other children as well. It used to be that everybody in the neighborhood looked out for all the kids. If a child had to walk somewhere, there were always other parents watching along the way to make sure they crossed the street safely and so forth. Now you can’t say anything to another kid. Yet, community members have to be involved. The growing cultural diversity of Bucks County poses new challenges both for parents and agencies caught between the expectations of immigrant and mainstream cultures. The cultural differences in how parents discipline is a major problem. They know what they learned from their parents. If they attempt to try more widely accepted approaches to discipline, their relatives and neighbors reject it. They say, "What are you doing?" They are laughed at then. Some cultures will not allow the women to go out at night. Language has becomes an additional barrier. The Sept 11^th events have not helped with Buck’s growing Moslem community. The Arabic women were scared to go outside and had to be picked up for the parenting class.

For those struggling with basic survival, attention to parenting is often a luxury beyond their grasp. If people don’t have adequate food, clothing, and shelter, you can’t deal with parenting. The bottom line is that as parenting service agencies we adapt. We have a food pantry in the community. The major problem, however, is housing. We can get them food and furniture. All we have is the shelter. The kids can’t get their homework done because of the lights out curfew in the shelter. All a parent and their kids can focus on are "three hots and a cot." We still have kids that are living in the back seat of cars in Bucks County. Some are stuck in the motels on Route 1. The family loses their home because they can’t make the payments and they don’t have the money for the security deposit for an apartment or the apartments have limits on the number of children they will accept. There is no extended family to fall back on. Many just don’t have the educational skills for making anything more than minimal wage. These are not parents that access the parenting programs. They give up.

Childcare services have expanded in the county. There is less of a waiting list for childcare. There are support programs for parenting teens and day care. As childcare services for preschoolers have become the norm in childrearing, it has produced a more open and public involvement in early childhood development. More parents are working, and the welfare to work program has encouraged this. Even non-working parents want to send their kids for socialization as the informal opportunities for peer play shrink. Early childhood development and parenting have become more of a public discussion rather than a private family matter. As a consequence, parents are more willing to get involved in such formal support activities and are more aware of the resources that exist for them. Fathers are also becoming increasingly involved. There is new attention and state resources available for involving teen fathers in child raising and more parenting.

Staying at home to care for your preschool children is no longer valued or supported. There is no support for fathers and moms that stay home. It’s the " What do you do?" and the "Oh..." that follows the answer to that questions that says it all. Peer pressure chastises them for staying home. Mothers feel guilty about not bringing in that extra paycheck. We have become too materialistic. "We should try to give our children what we had when you were growing up not what we didn’t have."

The inability to provide child care workers with a living wage threatens to undermine day care and the futures of the children it cares for. Many college age kids want to work with young children but their parents won’t let them stay in the field. They say, "You would be better paid at McDonalds." The turnover creates a terrible problem. The kids form attachments and the childcare workers have to leave in order to find work that pays a living wage. How many times can children go through that in one year? They feel shunted around and get angry with those teachers. They feel abandoned. If you add some children with special needs that require more training and staffing to deal with it, that adds to the difficulties. Kids spend their whole day in some kind of day care center. Day care workers make $12,000 and high school teachers make $60,000. We are not putting our money where it makes the most difference for kids. It reflects values that don’t coincide with research evidence about the importance of these early years. Unlike with free public education, there are no subsidies for childcare for most parents so you can’t have less than a one to ten staffing ratio and keep the tuition affordable for them.

Schools lack the day care centers that would fill an obvious need for both teen parents and school staff. We encourage teens to breast-feed their kids but there are no day care centers in the schools. School day care centers would help not just these teens; they could help the teachers with pre-school age kids. It would make a big difference in stress levels and reduce the transportation problems. It’s more a philosophic issue and an issue of values than of space. Schools use modular units all the time and this would work fine for day care. When push comes to shove, the schools have become the extended family.

Child development services are still too fragmented, and the gap between early childhood development and the schools has yet to be closed. Everything is separate. There needs to be more collaboration. The mental health component has gotten worse. There are a lot of examples of what is possible to accomplish. A YMCA program provides a safe place for kids to go after school. Schools say they are willing to do whatever they can and my peers say frequently that the schools are empty most of the time and the ideal place for after school hour programs, but the system of education is so fragmented. There is still a big gap between early childhood education and the schools. It’s like strip malls. You discover that you need zoning only after they’ve been erected. The schools seem to have a lack of respect for an early childhood educator. There is a divide between these two systems. Where is the communication? If you ask the schools about kindergarten readiness, they say, "What do you want to do that for?" There isn’t the dialogue that’s needed.

Businesses are often indifferent and sometimes even hostile toward the child welfare concerns of their employees. Some restrict "personal calls" at work. "If it’s a call about your children, it’s not a personal call; it’s everybody’s call! Employers have to do more." They provide their employees with exercise programs and other benefits. Why not childcare and parenting support groups? They are a critical part of the overall equation.

Schools and childcare centers are beginning to be overwhelmed by the illness and health problems of the children of working parents that used to be cared for at home. Schools are being forced to take more responsibility for the illnesses and health problems of children as the work demands of their parents and the difficulties in getting timely appointments with physicians increase. Parents are taking their sick child to day care or to school. They have to work. It used to be that when a child had a fever you kept them home for 24 hours after the fever had ended. People learned after September 11th that Bucks is a bedroom community of New York City. By the time the parent gets back to pick up a sick child, it’s time to go home anyway.

Health professionals lack the time and ability to effectively communicate with parents about the health problems of their children. The medical profession knows what’s needed but many lack the ability to talk to parents. Physician’s sensitivity in talking to parents about the serious chronic illnesses of their children is sometimes atrocious.

A variety of innovative programs have succeeded in breaking down the barriers that have traditionally existed between teens and professional counseling services. The Teen Center at Oxford Valley Mall, which grew out of the last assessment, provides a comfortable contact point. There are knowledgeable people there and we see all the problems faced by often-alienated teens. A daytime curfew program in Bristol has raised school attendance to ninety-two percent. The TRACK (truancy reduction and curfew for kids) has forced us to deal collaboratively with the problems creating truancy. It has involved working with the police, school, drug and alcohol and mental health programs and Children and Youth. Planned Parenthood has created on-going programs that build strong relationships with the goal to eliminate teen pregnancy and delay the onset of sexual intercourse among teens. Many community-based programs such as the Platinum Steppers drill team have effectively connected with teens. The YWCA and YMCA run pre-employment training programs in three school districts. In another school district, high school students act as counselors for at-risk elementary schools kids.

Some school districts have been transformed. They have had to change. We have three social workers in our school district. When kids are removed from schools, the problem is how do they come back. There are new counseling programs in schools. There are NA and AA and smoking offenders and anger management programs at night at school. Attending the smoking offenders program will excuse the fine. AA and NA programs involve self-motivation. The anger management program grew out of peer mediation of fights in the schools. Combined collaboration with other community agencies has had an impact. With the mediation program the number of fights has decreased while the number of mediations has increased. There is a collaborative effort with TODAY, Inc. to prevent bullying in elementary schools. The Juvenile Justice Program put probation officers in the school. There are three probation officers and a social worker located in the schools in one district. Some schools won’t let them in because they are afraid of the stigma, but it works.

New collaborative efforts are emerging in reducing teen pregnancies. The doors have opened and some schools are providing a full array of preventive and supportive services. Several school systems have well-developed programs of both prevention and care.

New innovative approaches have helped to better connect to teens. Teen parent awareness programs with empathy bellies for the guys, an annual teen peer conference and teen day camp for moms have provided ways to more effectively involve and connect to teens. Educational programs have found ways to provide their messages in schools in ways that have overcome some of the resistance in some school districts.

Many troublesome problems remain in assuring safe and healthy transitions into adulthood. Date violence is pervasive. Many suffer from sleep deprivation from combining jobs with school. Kids are spending too much time working. Some are working full time to pay tuition to parochial school but are failing. Parents are sometimes disengaged. These are not parents that come to school conferences or attend parenting discussion groups. They struggled themselves in school and the last thing they want is to be reminded of it. How do you reach them? The lower down the social economic level the more the parents disengage. It’s difficult to engage resistant parents and kids and work the system at the same time.

We know more and have more programs to support individuals with chronic illnesses in the community. We know more about how to educate and help those with diabetes and those with congestive heart failure. People live longer and, as a result, have more chronic diseases they have to deal with. They need more help in managing those diseases. We can also provide more preventive care that helps stop the accumulation of chronic problems.

Transitional care units help. A transitional care unit is post acute. In-patients are referred to the transitional care unit. We have team meetings with the patient, family members and staff to help prepare for the discharge. "We talk about every patient for a half hour each day. Some families don’t realize what their insurance doesn’t cover, such things as durable medical equipment and medications. We do a lot of problem solving." When people fail to get the resources they need after discharge we see them back in the hospital. PT and OT tend to decide discharge date. It’s a team effort involving nursing and social services.

Skilled home care works well as long as people have the insurance to cover it and resources to take care of their less skilled care needs. Skilled home care is available from Medicare and some supplemental policies. There is less coverage of the unskilled services. The Area Agency on Aging helps provide some additional personal care and transportation, but there are long waiting lists. You can wait up to a year in some cases. We work to determine needs at home, and plug them into the Area Agency on Aging that provides personal care and transportation. Lots of seniors don’t know about it. The hospital also provides meals on wheels, but there are not enough volunteer drivers to deliver the meals.

Services are available but often seniors are unfamiliar with them. There are many agencies providing care for seniors. Finding out who does what can be confusing even for a professional. It’s even harder for vulnerable populations. It would be very helpful for there to be case managers to help work out the needs of individual clients. Home based long-term services used to cover only a few weeks. Now, with funds available from the lottery, at least for low-income people, there is continued access to personal care services at home (with aides who come to the home, help with personal care and do errands.) There is a care registry of people who can provide home care, but many people aren’t aware that it is available. The Bucks County Area Agency on Aging manages the directory and it’s a fine idea. "I hesitate to provide names from the directory. People will call 5-6 people and find they aren’t providing these services any more." Managing this list could be an easy thing to do on a community-by-community basis. Unfortunately, those who maintain such lists can face liability for any misdeeds performed by the individuals who are hired or procedural failings by those hiring them. For example, most families hiring these individuals don’t deal with Social Security, Workers Compensation and other programs required to be provided for employees. Also with no screening of those on the list, old people can be put at risk.

Good discharge planning is available in the hospitals. But after people leave the hospital, they don’t know whom to turn to. Day care programs for seniors tend to work very well. There are sufficient spaces in facilities around the county. Unfortunately, many people don’t know these programs are available to them.

Many seniors require short, intermittent visits but travel times make this costly. If someone needs just an hour of care, their families will be paying not just for that care but also for the time people drive to and from their homes. If you are paying for these services through a commercial provider, the fee is typically $18 per hour. With all of the time coming and going, that can be a big bill for a little bit of care. Also, many people say, "what? $18 an hour for someone to go to the grocery store for me?"

Middle-income seniors are unable to afford or fear using up their savings for the services available free to the poor and for a fee to the affluent. The Bucks County Area Agency on Aging can provide excellent services. But for those above that income eligibility level there is a real problem in getting comparable services. Seniors save for a rainy day, but they don’t realize it’s finally raining. It’s common for the daughter of a person to call and say she needs help persuading her parents to use some of their savings at a time when it is totally appropriate for them to spend it. Many excellent services are provided in continuing care retirement communities. But many people, even if they can afford these facilities, don’t want to move from their homes. We all believe in aging in place, but we need someone to provide people with the kinds of services they would otherwise get in the retirement communities.

Independence is a characteristic of people living in this area. They are proud and they don’t want to admit they have problems. It’s particularly difficult to organize services to help people who won’t tell you they have needs. Many people can’t afford the prescription drugs they need. Even the Program of All-Inclusive Care for the Elderly (PACE), serving low-income people, only exists for those 65 or older. There is a problem with seniors taking unnecessary drugs or those that have adverse reactions with each other. "The list of prescription meds they are on is sometimes so long. Do they need to be on all of them?"

Families are often overwhelmed by the care needs of their aging relatives. Two income families hardly have time to care for themselves and their children. In addition, parents who retired to warmer climates are far away. How can distant caregivers function effectively? Caregivers absorb a tremendous physical and emotional cost in providing care. Most people don’t recognize what a big strain is placed on the primary caregiver. There are short-term placements to provide respite, but they typically require the person using the service to pay about $150 per day. Moreover, at all these facilities, advance planning is required to make a reservation. It is, in fact, very difficult to do such planning because facilities use respite care to fill empty beds. It’s usually not possible to know in advance when and where a bed will be available. Some of the support groups that have sprung up for caregivers have been very helpful. A group called Children of Aging Parents helps people who are starting to have problems with their parents and it works well.

Isolation can delay getting the help they need. Doctors, visiting nurses, pastors, senior centers, and the children of seniors can recognize that a person needs help. But many people are isolated and don’t have this kind of help. " I have a case of a man who is disabled, in a wheelchair, and still trying to care for a wife who is demented. He is trying to care for her because he doesn’t know what else to do." People are often isolated in their own apartments. In some apartment houses with senior residents there can be nine floors of people, all isolated in their own apartments. Many of Bucks County’s seniors are lonely in their home settings.

There is not enough health education for seniors. For example, how many know to put your meds in a brown bag and bring them to all your doctor visits so they can see what you are taking. Seniors should use all the help that a pharmacist can provide and get their prescriptions filled at the same place. Preventive health is at least as important for seniors as it is for others. Hospitals can do more, such as partnering with senior programs, in keeping these individual healthy. Proper nutrition is another key health issue for seniors.

Mental health services for seniors are inadequate. Among other issues, older people don’t tend to seek them out. There is still a lot of stigma attached to looking for help. They say, "Do you think I’m crazy? Are you going to put me in a nuthouse?"

Preventive Services