DELAWARE RURAL HEALTH INITIATIVE DELAWARE RURAL HEALTH PLAN PROGRESS REPORT JANUARY 2004 LIFECYCLES & SERVICE AREAS Compiled by the: Delaware Rural Health Initiative DELAWARE RURAL HEALTH PLAN PROGRESS REPORT JANUARY 2004 TABLE OF CONTENTS I. Lifecycles Needs of the Infants and Perinatal Population ........................... 2 Needs of the Child and Adolescent Population ............................ 7 Needs of the Adult Population ........................................... 10 Needs of the Geriatric Population ....................................... 12 II. Service Areas Primary Care ............................................................ 14 Dental Care ............................................................. 16 Mental/Behavioral Health ................................................ 18 Hispanic Population Needs ............................................... 20 Lifecycle #1 – Needs of the Infants and Perinatal Population Key outcome indicators of infant and perinatal health care effectiveness are the neonatal/infant mortality and low birth weight (LBW) rates. In Sussex County, infant mortality and neonatal mortality dropped during the last two 5-year periods. Low Birth Weight has continued to rise from a favorable level (pre-1995) to approach the higher state rate. The Sussex County infant mortality rate (8.1) is higher than the US (7.1), but lower than Delaware (8.4) and New Castle County (8.5).1 See Table 1. Kent County has the highest infant mortality rate (8.6). Infant mortality rates represent the number of deaths to children under one year of age per 1,000 births. Table 1 Infant Mortality Rates - US vs. DE vs. Counties (Not shown) The Sussex County neonatal mortality rate (5.3) is higher than the US (4.7), but lower than Delaware (5.9), Kent County (5.9) and New Castle County (6.0).2 See Table 2. Neonatal mortality rates represent the number of deaths to children under 28 days of age per 1,000 live births. Causes are usually very low birth weight or congenital anomalies. Table 2 Neonatal Mortality Rate - US vs. DE vs. Counties (Not shown) The Sussex County postneonatal mortality rate (2.8) is higher than the US (2.4); Delaware (2.5); Kent County (2.7); and New Castle County (2.4).3 See Table 3. Postneonatal mortality rates represent the number of deaths to children 28 to 364 days of age per 1,000 live births. Table 3 Postneonatal Mortality Rates - US vs. DE vs. Counties (Not shown) The Sussex County low birth weight percentage (8.3) is lower than the state (8.6) and New Castle County (8.8) but higher than the nation (7.5), Kent County (8.1).4 See Table 4. Table 4 Percentage of Low Birth Weights Births (<2500 Grams) - US vs. DE vs. Counties (Not shown) The Sussex County percentage of live births to single mothers (44.7) is higher than the nation (32.8); the state (37.1); New Castle County (34.8); and Kent County (38.0).5 See Table 5. Table 5 Percentage of Live Births to Single Mothers - US vs. DE vs. Counties (Not shown) The Kent County percentage of mothers receiving prenatal care in the first trimester (69.4) is lower than the nation (80.5); the state (83.1); New Castle County (88.7); and Sussex County (76.1)6. See Table 6. Table 6 Percentage of Mothers REceiving Prenatal Care in the First Trimester - US vs. DE vs. Counties (Not shown) Black women in Kent and Sussex Counties are less likely to receive adequate prenatal care. The Sussex County percentage of births to Black mothers beginning prenatal care in the first trimester (67.4) is lower than the state (76.9); New Castle County (81.7); and Kent County (67.5).7 See Table 7. The Sussex County percentage of Hispanic mothers receiving prenatal care in the first trimester (45.7) is lower than the nation (71.4); the state (69.4); New Castle County (81.3); and Kent County (60.1).8 See Table 7. Table 7 Percent of Live Births to Mothers Receiving Prenatal Care in the First Trimester by Race and Hispanic Origin (Not shown) 1 Table E-4, Delaware Vital Statistics Annual Report, 2000, page 196. 2 Table E-5, Delaware Vital Statistics Annual Report, 2000, page 199. 3 Table E-6, Delaware Vital Statistics Annual Report, 2000, page 201. 4 Table C-37, Delaware Vital Statistics Annual Report, 2000, page 100. 5 Table C-17, Delaware Vital Statistics Annual Report, 2000, page 79. 6 Table C-49, Delaware Vital Statistics Annual Report, 2000, page 117. 7 Table C-51, Delaware Vital Statistics Annual Report, 2000, page 119. 8 Table C-52, Delaware Vital Statistics Annual Report, 2000, page 120. Lifecycle #1 Update Access to Care: The La Red Health Center opened in Georgetown in 2001 and is providing primary care and maternity services. The Kent Community Health Center in Dover received federally qualified health center status in 2002 and is planning to add maternity services in the future. Monitoring: The Delaware Vital Statistics Annual Report is used to monitor the reported indicators. The infant mortality rate is rising – initiatives are underway between the Division of Public Health and the Perinatal Board to research causes and implement strategies to reverse this trend. Lifecycle #2 – Needs of the Child and Adolescent Population While meaningful county specific data is lacking in younger childhood needs, extrapolation of state level data suggests that asthma and childhood obesity are areas that may require attention. In Delaware, asthma affects almost 14,000 children. Nationally, childhood obesity has reached epidemic proportions. Of the state’s three counties, Sussex has the highest overall injury death rate at 39.8 per 100,000.9 This figure is 36 percent higher than the Kent County rate and over 79 percent higher than the New Castle County rate. The high motor vehicle-related death rate in Sussex County contributes to the overall increased injury death rate for the county and the entire state. See Table 8. Table 8 Leading Causes of Injury Deaths by County Kent County, 1979-1998, Ages 0-19 Manner of Injury/Poisoning Number Percent Rate Motor Vehicle Traffic 105 51.5 15.1 Fire/Burn 22 10.8 3.2 Drowning/Submersion 20 9.8 2.9 Firearm 17 8.3 2.4 Suffocation 11 5.4 1.6 All Other Injuries 29 14.2 4.2 TOTAL 204 100.0 29.3 Sussex County, 1979-1998, Ages 0-19 Manner of Injury/Poisoning Number Percent Rate Motor Vehicle Traffic 139 56.0 22.3 Fire/Burn 25 10.1 4.0 Drowning/Submersion 24 9.7 3.9 Firearm 20 8.1 3.2 Suffocation 11 4.4 1.8 All Other Injuries 29 11.7 4.7 TOTAL 248 100 39.8 As articulated in Delaware’s Maternal and Child Health Block Grant application, the following needs are apparent in Sussex County for special needs children: 1. Insufficient services for occupational therapy (OT), physical therapy (PT) and speech therapy needs. 2. Quality childcare needs for the population is insufficient. 3. Care coordination is insufficient for children >3 with special needs. 4. Culturally compatible specialty care access is insufficient. 5. Not enough service providers for the socio-emotional needs of young children and even less preventative services available. The Sussex County live birth rate to mothers 15-19 years of age is 73.8, which is higher than the nation (51.0); Delaware (50.7); New Castle County (44.1); and Kent County (55.2).11 See Table 9. Teen live birth rates in several census tracts (Bridgeville, Selbyville and Laurel) stand out as extraordinarily high. Table 9 Live Birth Rates to Mothers 15-19 Years of Age - US vs. DE vs. Counties (Not shown) For White teen mothers, the Sussex County rate is 58.4, which is higher than the nation (45.5); Delaware (37.7); New Castle County (29.9); and Kent County (50.6)12. For Black teen mothers, the Sussex County rate is 124.5, which is higher than the nation (84.5); Delaware (94.9); New Castle County (98.5); and Kent County (66.4).13 See Table 10. Table 10 Live Birth Rates to Mothers 15-19 Years of Age, By Race (Not shown) All high schools in Sussex County have a School Based Health Center (SBHC); all but one in Kent County has a SBHC. Based on interviews and SBHC data, teen primary health care needs are characterized as “largely unmet.” Teen mental/behavioral health needs are also not adequately met due, in part, to a lack of providers serving this population. In addition, for both primary care and mental health needs, transportation is inadequate and conflicts with access and confidentiality needs. Self-reported substance use in older Sussex County adolescents exceeds state rates. The need for improvement is particularly apparent for the increase in use reported between grades 8 and 11, which greatly exceed the state. The Kent County rates are lower than the state in the area of marijuana use.14 See Table 11. Table 11 8th v 11th Grade Self Reported Substance Use Grade 8 Grade 11 % % Cigarettes Sussex 13 24 Kent 12 20 Delaware 12 20 Alcohol Sussex 25 49 Kent 25 43 Delaware 24 43 Marijuana Sussex 13 28 Kent 10 21 Delaware 14 25 9 Delaware Health and Social Services, Division of Public Health, Childhood Injury in Delaware, 2001 10 Rate per 100,000 11 Table C-6, Delaware Vital Statistics Annual Report, 2000, page 64. 12 Table C-7, Delaware Vital Statistics Annual Report, 2000, page 65. 13 Table C-8, Delaware Vital Statistics Annual Report, 2000, page 66. 14 Center for Drug and Alcohol Studies, University of Delaware, 2002 Lifecycle #2 Update Access: There are efforts statewide to improve access to behavioral and mental health services. See mental health behavioral service area #3. Lifecycle #3 – Needs of the Adult Population Delaware cancer mortality rates are the second highest in the US. Mortality from prostate, colorectal, cervical, and lung cancers are extremely high in state. County rates are indistinguishable from state in vital statistics data for individual cancers due to small population numbers. African-American men (lung, prostate, colorectal) and African-American women (cervical) predominate in excess mortality. Hospitals have been instrumental in developing integrated cancer care and support programs. The leading causes of death for persons in Kent and Sussex County are heart disease, malignant neoplasms, cerebrovascular diseases, chronic lower respiratory diseases, accidents, influenza and pneumonia, and diabetes mellitus. Lifestyle and controllable risk factor issues predominate as predisposing factors.15 (see Table 12): 1. Smoking 2. Overweight 3. Hypertension 4. No Seat Belt Use 5. Operating under the influence of alcohol Table 12 Delaware Adults at Risk from Selected Behavioral Risk Factors (Not shown) The Burden of Diabetes Report (2002) estimated the prevalence of diagnosed and undiagnosed diabetes at 8,521 cases in Sussex County and 7,721 cases in Kent County. Sussex County rates for STDs, such as syphilis, gonorrhea, and Chlamydia, exceed state rates, which are high compared to US rates. 15 Delaware Health and Social Services, Division of Public Health, Behavioral Risk Factor Surveillance Survey,2002 Lifecycle #3 Update Access: Primary care provider numbers appear adequate for the population when federal shortage area criteria are applied BUT this may not result in operational access if practices are closed to new patients, certain payer types or do not have accessible hours or geographic sites for special populations. Dental access is limited, even for populations able to pay. The Delaware Institute for Dental Education and Research (DIDER) in conjunction with the Delaware Health Care Commission is attempting to improve dental access. Lack of transportation infrastructure is a long-standing problem. Managed care networks limit access to some physicians. Referral: Referrals are most problematic for mental health. There are no inpatient mental health facilities in Sussex County and only one facility in Kent County. Lifecycle #4 – Needs of the Geriatric Population As a result of both the aging of the population and an increasing retiree population, the Sussex County elderly population is anticipated to grow rapidly through 203016. The greatest growth rate will be in the over 85 age group. See Table 13. Table 13 Elderly Population Growth Estimates - DE vs. Counties (Not shown) Other than basic mortality data, despite an anticipated explosive geriatric population growth, there is a striking lack of data to support the identification of needs for this population. This data is required for a thorough understanding of needs and for resource development. Anecdotal and qualitative data suggests needs in the following areas: 1. Primary care 2. Geriatric medical specialists 3. Home care 4. Transportation 5. Social activities Coordinated and long range planning for this population needs to be emphasized at the county level. 16 Delaware Population Consortium, September 2003 Population Projection Lifecycle #4 Update Access: Access to prescription medication is a problem. The Delaware Prescription Assistance Program (DPAP) has increased access to prescription drugs for low income. Vans are available to assist in alleviating transportation problems for the geriatric population, but individuals requiring multiple services or living in low population density areas continue to experience transportation related limitations. Direct service: Home health is an important support and is in short supply. Geriatric medical specialists are not readily available in Kent or Sussex County. Infrastructure: State directory of geriatric services indicates many resources are present but sufficiency is unknown. Senior centers are important resources (e.g., focus for day activity, housing, recreation). Assisted living sites are increasing, but it is not clear if demand supports an increase in housing units. Service Area #1: Primary Care Needs Sussex County is currently designated as a Medically Underserved Area (MUA), and as a Primary Care Low Income Health Professional Shortage Area (HPSA). Designation is based in part on the overall number of full time equivalent (FTE) physicians. According to the Primary Care Physicians in Delaware Report (PCP Report, 2001), which was compiled by the University of Delaware’s Center for Applied Demography and Survey Research: -There is one FTE primary care physician per 1,231 people in Delaware; 1:1,318 people in Sussex County; and 1:1,678 people in Kent County. -The number of FTE primary care physicians has increased in each of the counties between 1998 and 2001: 1998 2001 Delaware 610 636.5 New Castle 429 442.2 Kent 72.3 75.5 Sussex 108.7 118.8 Eight percent of the primary care physicians in Sussex County are of Hispanic origin, which is higher than the state (4.3); New Castle County (3.9); and Kent County (1.3). The estimated need for additional primary care providers differs when taking a “by the numbers” view versus documenting the experience reported by individuals related to “limited practical access or availability” of numerically adequate providers. Access may also be compromised due to the following factors: -Practices may be closed to new patients. -Practices may accept limited insurance (public health insurance, such as Medicaid and State Child Health Insurance Program (SCHIP), as well as commercial). -While the federal criteria for FTE (hours of practice per week) are met, productivity is not considered (i.e., low productivity would effectively reduce capacity). -Typical hours of operation (no evenings or weekends). -Lack of knowledge or skill in the care of special populations (e.g., disabled, child/adolescent, AIDS, and geriatrics. -The primary care capacity is clustered around hospitals, especially for OB/GYN services, thus making access geographically difficult for some citizens – particularly those lacking private transportation. This geographic problem is institutionalized, to some degree, by hospital credentialing rules requiring physicians to live within 30 miles of the hospital. -Cultural accessibility (Hispanic population) and multi-lingual capacity are limited. The University of Delaware, Center for Applied Demography and Survey Research compiled the most recent Delawareans Without Health Insurance report in 2001 (DWHI Report). According to the DWHI report, approximately 10.9% of Sussex County residents are uninsured. This is slightly higher than New Castle (10.5%), and lower than Delaware (11.3%) and Kent (15%). According to the DWHI report, approximately 88,000 Delawareans are without health insurance. Of that, 16,000 are from Sussex County, 20,000 are from Kent County and 52,000 are from New Castle County. Service Area #1: Primary Care Resources Summary of Findings: Primary Care Gap Analysis Awareness: Hospitals make medical staff directories available and provide information on available primary care practices. DPH developed and distributed a Health Care in Delaware brochure, which provides information on available resources statewide (including Sussex County). Access: Improvements have been made to access/intake. Sussex County has numerically adequate capacity, but problematic geographic distribution. Fewer than 37% of PCP sites have Spanish bilingual capacity. 26% of Sussex County PCPs do not participate in a managed care network. Primary care access for special population is problematic. Providers treat 92.4% of Medicaid patients with 70.2% accepting new Medicaid patients. Providers treat 88.8% of Medicare patients with 74.5% accepting new Medicare patients. Recruitment of health individuals to provide primary “well care” remains problematic. Direct Service: Primary care services are available through private providers, hospital based providers and community health centers. La Red Health Center opened in 2001 and is serving approximately 3,000 customers annually. The Kent Community Health Center (Delmarva Rural Ministries) provides primary care services in Dover. Referral: Linkages with behavioral health, geriatric specialists, and dental services remain questionable. Monitoring: The 2000 Consumer Assessment of Health Plans in Delaware measures quality and accessibility to primary care and gave Sussex County a quality rating of 7.9 (out of a possible 10) while managed care organizations received a quality rating of 7.7 (out of a possible 10). Infrastructure: Hospital bylaws require physicians to reside within 30 miles of hospital. Leadership: Delaware Rural Health Initiative (DRHI) will provide a leadership role. Hospitals, the Division of Public Health, the Delaware Health Care Commission (including DIMER), and physician organizations have taken a leadership role in increasing primary care access. Planning: The Delaware Health Care Commission (DHCC) has taken a coordinating role in recruiting health care professionals and having data available. Communication: Communication across all provider networks has improved. Service Area #2: Dental Care Needs Sussex County is a designated Dental Health Professional Shortage Area (HPSA). Designation is based in part on the overall number of full time equivalent (FTE) dentists. There continues to be a capacity deficit in Sussex County dental services for treating both insured and non-insured populations. Shortages are particularly acute in western Sussex County from Bridgeville to Laurel. There is also a shortage of culturally compatible dentists for certain populations (Hispanic and African-American). Many dental practices are closed to new patients. Further, the capacity of dentists is likely to deteriorate due to planned retirements. In 1998, one in five dentists in Sussex County were uncertain if he/she would be in practice in five years. Sussex County dentists reportedly have heavier workloads than industry standards. Improved access may require a change in office hours, but this is difficult to reconcile with their current workload. Because dental access is more limited, more patients do not benefit from preventive services and end up receiving urgent care that could be prevented with routine visits. Employers report an increased cost of dental coverage resulting from the need to allow network access outside of the local (Sussex County) area. It is not uncommon for insured patients to travel to Kent County or Wilmington for dental care. Most uninsured travel to Wilmington for care at one of the dental clinics. There are a number of ongoing initiatives focused on attracting dental resources to Sussex County. These have been associated with some success to date. The response to the dental crisis indicated a capacity for effective crisis planning. The Delaware Dental Access Improvement Committee (DDAIC) report (Spring 2000) articulated a coordinated approach to improvement. As proposed, activity intended to attract dentists to Sussex County has begun and includes a recruitment campaign, indicating that proactive planning to address the dentist shortage has begun. Current efforts are focused on addressing infrastructural issues (including licensing regulations) that constitute barriers to additional recruitment: -Training and licensure requirements are restrictive -Delaware has is own testing program and does not grant license reciprocity to other states -Dental hygienists are not permitted to practice preventative dentistry other than under the direct supervision of a dentist -There is no dental school in Delaware. The General Practice Dental Residency Program and dental hygiene education programs are both located in New Castle County. Although there has been substantial effort to focus on and improve the dental issue, there continue to be gaps in service. Service Area #2: Dental Care Resources Summary of Findings: Dental Care Gap Analysis Awareness: There is no organized way for the population to know if there is a new provider or resource. Little or no prevention related education gets to the general population. Access: Of the few practices available, many are closed to new patients. Strategies to improve access by expanding office hours are difficult to reconcile with current workload. There has been a substantial increase in the number of providers accepting Medicaid clients (only children are covered for dental services under Medicaid). Medicaid children have limited access through public health clinics, with less than one-third of eligible children receiving services each year. Children above the Medicaid threshold and adults have problematic access, with affordability being a primary barrier. Direct service: Sussex County dentists reportedly have heavier workloads than industry standards. Improved access may require a change in office hours, but this is difficult to reconcile with their current workload. Referral: There is a lack of dental sub-specialists located in Sussex County. Monitoring: Preventative care is not a high priority, many practices do not send reminders for regular care and checkups. Dental health status to date has not been measured on a population basis. Infrastructure: Sussex County is under-served. Shortages are particularly acute in western Sussex County. One in five dentists was uncertain if he/she would be in practice in five years in Sussex County. Efforts are underway to attract dental resources to Sussex (e.g., recruitment campaign, training programs). State licensing regulations are a barrier in increasing the number of dentists (e.g., training requirements are restrictive, Delaware has its own testing program, no reciprocity with other states, etc.). Leadership: Efforts to get water fluoridated in under-served communities have been successful. Nine of thirteen municipal water supplies in Kent County and eight of 18 municipal water supplies in Sussex County are now fluoridated. This represents access to fluoridated water for 48,102 residents in Kent County and 31,953 residents in Sussex County. Planning: The response to the dental crisis indicated orientation toward crisis-focused planning, and the beginning of proactive planning. Planning has resulted in effective policy advocacy (e.g., allowing hygienists limited practice outside of dentist’s office). DIDER/DDAIC are providing leadership. A recruitment campaign is underway. A survey was done in 2003 of 3rd graders statewide to assess dental care needs. A report is being compiled. Communication: Little communication between dentists and other health care providers. Few newspaper articles describing needs or calling attention to problem. Service Area #3: Mental/Behavioral Health Needs Behavioral health needs were characterized and documented in the 1999 Delaware Institute for Medical Education and Research (DIMER) reports as inadequate. DIMER found a “severe shortage” of mental health practitioners in Sussex County. However, Sussex County lost its federal Mental Health Shortage Designation Area (HPSA) in 1998. Data analysis is underway at DPH to determine if HPSA designation can be reinstated. Based on interviews and a review of limited Sussex County data available from the Division of Substance Abuse and Mental Health (DSAMH): -Ambulatory chemical dependency and substance abuse services (CD/SA) appear to be insufficient. Capacity has increased over the past few years to include more outpatient providers. There is a plan to develop a methadone program this year. -Child and adolescent services are insufficient. -Specialty geriatric mental health services are virtually non-existent. -SBHC staff report significant access problems to mental health services for children and adolescents: 1. No formal process is available for adolescent behavioral health referrals or for linkages between primary care and behavioral health resources. 2. There are 0.5 FTE child psychiatrists in eastern Sussex County. 3. Sussex County has no pediatric or adolescent behavioral health inpatient units or hospital services. 4. Knowledge of, and linkages between, resources (communication) in the child and adolescent population are lacking. 5. Transportation/data from schools confirm that access for adolescents is a real problem. 6. Although small in absolute numbers, needs data reveal high suicide rates among the teen population. Hospital personnel report a significant proportion of emergency room use is directly related to behavioral health needs and that providers do not feel they can provide optimal care for these problems in the emergency room setting. Sussex County has no involuntary admission capacity. Most involuntary admissions are taken to St. Jones Center in Kent for acute hospitalizations, although this capacity is limited and some may be taken to NCC acute hospitals if St. Jones doesn’t have any beds. Individuals are transported to these hospitals by “peace officers” as defined in State code (transported in police cars by on duty officers). -Managed care organizations as well as other payers are emphasizing outpatient treatment -Credentialing limitations limit use of non-physician providers There are cultural issues driving a hesitancy to use mental health and substance abuse services for many Sussex County individuals. Leadership, planning, and communication (for targeted populations) needs to be improved, especially addressing dual diagnosis; isolation and depressions; and stigma associated with seeking mental health care. There is a stigma about mental health and mental health treatments that must be addressed. Stigma against mental illness and its treatment is found throughout the country and for all age groups. Service Area #3: Mental/Behavioral Health Resources Summary of Findings: Mental/Behavioral Health Awareness: Geriatric population barriers are cultural and related to the stigma associated with mental health treatment. Differences in awareness may be related to geography (closer to hospitals = higher awareness). Access: Sussex in not classified as a HPSA for mental health care. One part-time child psychiatrist in Lewes is the only one in the county and is involved mostly in crisis work. Significant barriers to access to specialized child, adolescent and geriatric providers was consistently reported. Transportation from schools complicates access for adolescents. Direct service: A significant portion of emergency room use is directly related to behavioral health needs. Reimbursement levels for providers are well below average and may impact access. Referral: No formal process for adolescent referral or linkages between resources. For the adult population, many know what is needed, but it may take multiple calls to arrange for services. Monitoring: External outcomes measurement is beginning (United Way, Managed Care, Delaware Health and Social Services (DHSS)/Division of Substance Abuse and Mental Health (DSAMH). Burden of “non-institutionalized” mental health is not well understood at the county level. Mental Health Parity Law passed in 1999 and substance abuse coverage was added to the law in 2001. Money was never appropriated by the legislature to implement the bill (as mandated in the bill’s language). Infrastructure: Sussex County has no involuntary admission capacity. Transportation of involuntary patients in inadequate. Licensing and health plan credentialing regulations problematic for non-physician providers. Inadequate chemical dependency/substance abuse services. Leadership: The Delaware Health Care Commission's Mental Health Issues committee will issue a draft report Spring 2004. This Mental Health Issues committee has four subcommittees: Data Gathering; Treatment Protocols; Training and Employer Education; and Public Awareness. Planning: Need more focus on outpatient care. Looking more at parity in mental health benefits for adult population. More focus on geriatric population, especially in the areas of dual diagnosis, isolation, mental health stigma. Communication: Linkages among providers serving adolescent population are lacking. Interagency Council is helping increase communication. Special Considerations: Hispanic Population Needs Hispanic Population The identifiable and rapidly growing Hispanic population in Sussex County prompted a specific focus on needs in that community. In the first large-scale attempt to characterize Hispanic population needs, DPH in conjunction with La Esperanza/La Red, conducted a survey in 1999. The Delaware Health Statistics Center released a formal report “Health Status of Hispanics in Delaware” in July 2001. While there have been multiple initiatives and efforts to provide health services for the Hispanic community in the past several years, concern remains regarding the level of health care services accessible to Hispanics in Sussex County. Between 1990 and 2000 the Hispanic population in Sussex County has grown by 368.5%. The three census county divisions with the fastest growing Hispanic populations were Georgetown, Selbyville/Frankford and Millsboro. Most of the Hispanic population is resident rather than migrant. Most respondents have been in the area for less than five years but more than one year. Most of the population is single, but live in a group environment with household income of less than $20,000. Most of the employed Hispanic population works in a high-risk environment for occupational injuries, such as farming and poultry industries. In order to enroll in financial and medical assistance programs, individuals must present evidence they are “legal”. The need to verify “legal” status adds a layer of complexity to accessing many services. The opening of the La Red Health Center has provided an access point for primary health care services for the Hispanic population.