City of Wrangell Senior Services Needs Assessment€¦ · PROJECT PARTNERS Wrangell Community...

City of Wrangell Senior Services Needs Assessment

Prepared by

Alaska Center for Rural Health University of Alaska Anchorage

3211 Providence Drive Anchorage, Alaska 99508

December 2001

City of Wrangell Senior Services Needs Assessment

PROJECT PARTNERS

Wrangell Community Planning Group

Marge Byrd Marlene Clarke

Jim Culley Betty Keegan John Martin

Dave McCandless, MD Lurine McGee Alice Rooney

Carol Rushmore Harriet Schirmer, MD

Janet Strom, PHN

Alaska Center for Rural Health, UAA

Denny DeGross Jan Harris

Beth Landon Jenny Louden Janice Troyer

Institute for Circumpolar Health Studies

Sanna Doucette Todd Malinick Stacy Smith

University of Washington School of Medicine

Peter House

Wrangell Senior Services Needs Assessment i December 2001 Alaska Center for Rural Health

EXECUTIVE SUMMARY The City of Wrangell, Alaska contracted with the Alaska Center for Rural Health (ACRH), UAA to conduct an assessment of community senior services needs. The assessment included four distinct pieces, as follows:

1. A mail-out survey measuring community opinions about local health and social and other support services for seniors, including their expected utilization;

2. A list of existing senior services; 3. Focus groups discussing services for seniors and their needs, and key

informant interviews addressing similar topics, as well as potential resources; 4. A community-wide goal-setting meeting.

A group of organizations and individuals collaborated on this project. The Alaska Center for Rural Health acted as the lead agency. Their colleagues in the Institute for Circumpolar Health Studies (ICHS), UAA assisted in development, implementation, and analysis of the survey instrument. Peter House of the University of Washington School of Medicine�s Program for Healthy Communities led the community-wide goal-setting meeting, assisted by ACRH staff. A local planning group is a key component of any successful community assessment. The Wrangell Community Planning Group directed the assessment team�s activities and guided the overall project. Specifically, ACRH staff worked closely with the Wrangell Planning Group to develop the assessment plan, to develop and disseminate the survey instrument, to carry out focus groups and interviews, and to conduct the community-wide meeting. For a small town, Wrangell has a good variety of health and social services available for its senior citizens, and most are widely praised. It is the quantity of services that appears to be limited. Coordination of services was also identified as an issue, as was cost. Considering results obtained from the various assessment methods, ACRH staff found that there was substantial agreement in the community about service deficiencies, as well as preferences for new or expanded services. As is true elsewhere, the senior population of Wrangell is growing and is anticipated to more than double in size in the next twenty years. A large percentage of Wrangell seniors want to stay in the community as they age, and to remain independent for as long as possible. Pressure on existing facilities and services for seniors will increase significantly. At the same time, seniors bring economic resources to a community (usually in the form of medical insurance and retirement income), as well as provide a depth of knowledge and experience of benefit to all generations. A comprehensive and collaborative strategic planning effort for senior services will be an important step in preparing for the growing demand, and for further integration of seniors into the fabric of the community.

Wrangell Senior Services Needs Assessment ii December 2001 Alaska Center for Rural Health

RECOMMENDATIONS I. Collaboratively determine what level of senior services the community would like

to establish, and how services should be configured. II. Improve coordination of and expand senior services and activities.

• Develop an ongoing Senior Services Coalition to meet regularly, share information and ideas, and coordinate services.

• Establish and maintain a Senior Services Coordinator position in the community.

III. Develop a master plan for facilities in Wrangell to meet the needs of seniors at

all levels of care, now and in the future. IV. Inventory existing funding sources for senior services, activities, and facilities;

identify unfunded need; develop a financial plan; and seek additional funds.

Wrangell Senior Services Needs Assessment iii December 2001 Alaska Center for Rural Health

TABLE OF CONTENTS

EXECUTIVE SUMMARY.................................................................... i

RECOMMENDATIONS .................................................................... ii

TABLE OF CONTENTS .................................................................. iii

I. BACKGROUND.......................................................................... 1

A. Aging Population............................................................................................. 1 B. City of Wrangell, Alaska.................................................................................. 2 C. Health and Other Senior Services.................................................................. 3 D. 2001 Senior Needs Assessment..................................................................... 3 E. 1991 Community Needs Assessment ............................................................ 4 F. 1998-99 Senior Citizens Needs Assessment Survey--Catholic Community

Services ............................................................................................................ 4

II. METHODOLOGY ....................................................................... 6

A. Introduction...................................................................................................... 6 B. Survey .............................................................................................................. 6 C. Focus Groups and Key Informant Interviews ............................................... 8 D. Community-Wide Goal-Setting Meeting ........................................................ 8

III. RESULTS .............................................................................. 10

A. Local Senior Services ................................................................................... 10 1. Wrangell Medical Center............................................................................ 10 2. Public Health Center .................................................................................. 11 3. Emergency Medical Services..................................................................... 11 4. Center for Community................................................................................ 11 5. Community Connection.............................................................................. 12 6. Wrangell Community Services (WCS) ....................................................... 12 7. Catholic Community Services .................................................................... 12 8. Loan Closet................................................................................................ 13 9. Dental Services.......................................................................................... 13 10. Wrangell Volunteer Hospice...................................................................... 13 11. Positive Approach to Community Health (PATCH) ................................... 13 12. AVENUES................................................................................................. 13 13. Chiropractor .............................................................................................. 13

Wrangell Senior Services Needs Assessment iv December 2001 Alaska Center for Rural Health

14. Massage Therapy ..................................................................................... 14 15. Senior Apartments .................................................................................... 14 16. Assisted Living Homes.............................................................................. 14 17. Salvation Army.......................................................................................... 14 18. Churches and Other Organizations........................................................... 14

B. Survey – Senior Services.............................................................................. 15 1. Respondent Demographics ....................................................................... 15 2. Location ..................................................................................................... 16 3. Types of Care ............................................................................................ 18 4. Services Required in the Next Ten Years .................................................. 19 5. Independent Living..................................................................................... 21 6. Nursing Home Services ............................................................................. 22 7. Open-Ended Questions ............................................................................. 23

C. Focus Groups and Key Informant Interviews ............................................. 24 1. Wrangell Medical Center Services ............................................................. 25 2. Community Health Services....................................................................... 25 3. Senior Center Services .............................................................................. 26 4. Senior Housing .......................................................................................... 27 5. Other Community-Based Services............................................................. 27 6. Coordination of Services............................................................................ 28 7. Concerns ................................................................................................... 28

D. Results of the Community-Wide Goal-Setting Meeting.............................. 29 1. Long Term Care Unit Expansion................................................................ 29 2. Assisted Living ........................................................................................... 30 3. Senior Housing .......................................................................................... 30 4. Senior Services Coordinator ...................................................................... 30 5. Respite Care.............................................................................................. 31 6. Hospice Care ............................................................................................. 31

E. Wrangell Medical Center Community-Wide Goal-Setting Meeting ............ 31

IV. DISCUSSION AND RECOMMENDATIONS............................... 32

Appendices Appendix A: Wrangell Community Health Care Needs Assessment Survey Report Appendix B: Focus Group and Key Informant Interview Questions Appendix C: Thematic Analysis: Focus Groups Appendix D: Thematic Analysis: Key Informant Interviews

Wrangell Senior Services Needs Assessment December 2001 Alaska Center for Rural Health

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I. BACKGROUND A. Aging Population In conformance with the national experience, Alaska�s population is aging. In a report commissioned by the Alaska Commission on Aging, the number of those age 65 and older, as a percent of the population, is expected to grow from 8% in 2000 (35,658 seniors) to 20% (124,303 seniors) by 2025. This is an astonishing 249% increase, as compared to an expected 30% growth rate in the overall Alaskan population. The City of Wrangell, Alaska is participating in this trend. Census 2000 data reveal that 12% of Wrangell�s population is age 65 or older. As a result of this phenomenon, communities across Alaska are struggling to develop a service infrastructure that supports the health and social needs of senior citizens. This is complicated by the rising incidence of Alzheimer�s Disease and other forms of dementia in the elderly. By 2025, it is estimated that there will be about 15,700 individuals at risk for Alzheimer�s Disease (13% of the projected population). The infrastructure can take many forms but, out of necessity, will involve collaboration between organizations, volunteerism, and development of new funding streams. Recognizing that seniors want to live independently for as long as possible, and that they prefer to stay in or near their homes close to familiar people and surroundings, the State of Alaska has particularly encouraged the development of home and commu-nity-based services as a preferred alternative to institutional care. This goal faces two related challenges in Alaska. First, it is difficult to support a broad range of services in rural Alaska, where small populations struggle to support a continuum of appropriate services. Second, it is economically difficult to sustain appropriately trained workers and adequate facilities when there is a small population to support them. While the State of Alaska supports the goal of helping seniors �age in place� in princi-ple, there are limited resources to assist communities in meeting this goal. To be suc-cessful, community members � service providers, seniors, their family members, lead-ers, and others � must cooperatively work together to design, fund, and implement a realistic program of senior services. In this endeavor, good information, collaboration, flexibility, and creativity are key. In contrast, it is interesting to note that Alaska�s seniors are one of the largest single sources of money flowing into the state. As described in a report entitled Issues Affecting the Economic Well-being of Alaska Seniors, prepared in 2000 by the McDow-ell Group for the Alaska Commission on Aging, this is due to retirement income and medical payments, which have a �significant beneficial effect on the state�s economy� (p.1). The report estimates that senior income and medical payments result in an overall impact of $2.4 billion per year. Despite this contribution to the state�s economy, the authors found that about half of Alaska�s senior households live below HUD-defined poverty levels.


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B. City of Wrangell, Alaska The City of Wrangell, with a population of 2308 per the 2000 U.S.Census, is located on the northern tip of Wrangell Island near the mouth of the Stikine River, along the Inside Passage of Southeast Alaska. The Stikine River is an historic trade route to the Canadian Interior. It is 155 miles south of Juneau, Alaska�s capital city, and 89 miles northwest of Ketchikan. Access is by air and by water. It is on the main route of the Alaska Marine Highway and there are twice daily Alaska Airlines flights. It is in a maritime climatic zone, with cool summers, mild winters, and year-round rainfall. According to the Alaska State Department of Community and Economic Development, Wrangell is one of the oldest predominantly non-Native settlements in Alaska, dating from the early 1800s. Its early history involved fur trading, and centered on a Russian-built fort, which was subsequently leased by the British Hudson�s Bay Company. A large Stikine Indian village, known as Kotzlitzna, was located thirteen miles south. In 1867, the purchase of Alaska by the United States resulted in establishment of a U.S. military post called Fort Wrangell. Over the years, the town outfitted and supported prospectors during a series of gold rushes. By the start of the twentieth century, fishing and forest products had become the primary industries. Decline of those industries has impacted Wrangell; nonethe-less, the community has a variety of opportunities to develop a more diversified eco-nomic base due to its location and abundant natural resources. The past decade has seen a decline in the town�s population, after a long period of increase (see Figure 1). Approximately 23% of current Wrangell residents are of Alaska Native heritage.

Figure 1

Population of the City of Wrangell, Alaska (Census Data)

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1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

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C. Health and Other Senior Services The community enjoys a wide array of health care services. These include the Wrangell Medical Center, a public health clinic, two private practice dental offices, emergency medical services, a chiropractor, and several massage therapists. A variety of itinerant specialists also visit Wrangell periodically. The Wrangell Medical Center houses a family clinic with three family practitioners, and a long-term care facility. It includes a physical therapy department, a laboratory, and a radiology department. Currently there are eight acute care beds, four of which are considered �swing beds,� and fourteen long-term care beds. One acute bed is desig-nated as an ICU (intensive care unit) bed. The long-term care unit is currently at 100% occupancy, a situation that has prevailed for the past six months, and has gen-erally been true for 2-3 years. The Medical Center�s swing beds have been used to supplement the unit. For about three months, these beds have also been filled with long term care patients. In the past this situation was unusual. Other organizations provide the following services: mental health counseling, counsel-ing for alcohol and other substance abuse problems, special services for the develop-mentally disabled, programs for youth including a teen center, home and community-based care services for the elderly and physically disabled, and a community loan closet that houses a collection of medical equipment. Wrangell facilities which specifically serve seniors include senior apartments, the long-term care facility within the Wrangell Medical Center, and a senior center that provides meals and transportation to seniors three days a week at a nominal charge. Meals are also delivered to seniors� homes by the senior center. A new assisted living facility is opening to provide housing and limited care for five seniors. Previously there was an assisted living facility that did have one senior resident, but a majority of its residents were younger disabled adults. Other available senior services found within Wrangell include a home health aide program, a home health program based at the Medical Center, an emergency Call Care system, and a grocery delivery service. For those seniors who qualify for Project Choice, a Medicaid program, services are available such as: remodeling homes, transportation, chore services, respite care, and ongoing visits by a care coordinator. Others may purchase these services. Wrangell�s services for seniors will be described more fully below. D. 2001 Senior Needs Assessment The City of Wrangell contracted with the Alaska Center for Rural Health (ACRH) to carry out a Senior Services Needs Assessment. ACRH is a private, non-profit organi-zation housed within the Institute for Circumpolar Health Studies, in the University of Alaska Anchorage. Created in 1987, the mission of ACRH is to improve access to a


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comprehensive, culturally relevant health care system for rural Alaska by providing information, coordination, technical assistance, and professional development to rural health providers and systems. ACRH and the University of Washington Community Health Services Development Program conducted a community needs assessment in Wrangell in 1991. Concurrent with this Senior Services Needs Assessment, the two organizations are also conduct-ing a new community-wide assessment for the Wrangell Medical Center that will utilize information gained in the prior assessment and expand upon it. This will provide use-ful supplementary information for the senior needs assessment. The Medical Center and its long-term care unit are key elements in the continuum of senior services. The goals of the Senior Services Needs Assessment include:

• Gather information and opinion from a broad variety of sources in the Wrangell community,

• Identify and prioritize the needs of Wrangell�s senior citizens, • Explore possibilities for collaboration and funding, and • Facilitate the work of a local Planning Group towards the creation of a realistic

program design and implementation strategy. E. 1991 Community Needs Assessment The overall purpose of the Community Needs Assessment conducted in 1991 by ACRH and the University of Washington was to strengthen health services in Wran-gell. The approach included a mail survey, key informant interviews, and a commu-nity-wide goal-setting meeting. Assessments were also conducted in 34 other northwestern United States communities, and comparisons between these communities were made in the report. Pertinent results included a high rate of satisfaction with the nursing home services provided by Wrangell Medical Center (80%). However, many of those interviewed commented that there was significant room for improvement of home health and homemaker services. One of the five top goals identified during the community-wide goal setting meeting was to �Expand the Continuum of Care for the Elderly.” F. 1998-99 Senior Citizens Needs Assessment Survey--Catholic Community Services Catholic Community Services is a non-profit organization located in Juneau, Alaska that receives state grants, along with funds from other sources, for provision of meals, transportation, and other senior services in the southeast region of Alaska. It provides several programs in Wrangell, including the senior center and its associated congre-gate and home-delivered meals, senior van, and errand services.


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In 1998-99, Catholic Community Services carried out a survey of Wrangell�s senior citizens. The 85 participants evinced interest in the development of activity programs for both healthy and frail seniors, as well as programs for persons with dementia, and help with household chores, meals, and van transportation. Those responding to the survey indicated that they would be willing to pay a small amount for these services. The respondents� average age was 75.8 years. About half were married, a few were single, and the remainder widowed. Fifty-three percent (53%) lived alone, 44% lived with a spouse, and 2% lived with adult children. There was concern expressed about isolation and safety, particularly for those seniors who were living alone.


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II. METHODOLOGY A. Introduction ACRH employed both quantitative and qualitative tools in this needs assessment. A written survey was used for the quantitative portion, with questions asking opinions about current health care services within the community, health care services received outside of the community, and long-term care and senior services. This survey pro-vided information for both the Senior Services Needs Assessment and the Wrangell Medical Center Health Care Needs Assessment. There was also a list compiled of existing senior health, social, and support services in Wrangell. In addition to the survey and list of services, more information was collected on senior services using qualitative methods. Three assessment methods were used: focus groups1, key informant interviews2, and a structured town meeting3. These methods were used to collect information and facilitate discussion on the community�s percep-tions about senior services in Wrangell. ACRH staff worked for a local Planning Group in this project. The Planning Group formed specifically to direct ACRH activities � instrument development, implementa-tion, interpretation of results � for the Senior Services Needs Assessment and Wrangell Medical Center Health Care Needs Assessment. Without this active group, ACRH would have been unable to conduct the assessment. A list of Planning Group members is found at the beginning of this report. B. Survey The ACRH team conducted an audioconference on June 22, 2001 with the Wrangell Community Planning Group. A draft survey instrument developed by ACRH staff was reviewed and suggestions for revisions were elicited. The Planning Group also

1 Focus groups are informal, small group discussions designed to obtain in-depth qualitative information on a defined area of interest. The overall goal of any focus group is to reveal the participants� perceptions about the topics for discussion. To better ensure a highly interactive flow of conversation, participants should be relatively homogenous and not be inhibited about talking in the group. Ranging in size from 5 � 10 people, each session lasts about 90 minutes. The conversation is usually restricted to 3-5 related topics, with the moderator facilitating and guiding the conversation. They are analyzed via a thematic content analysis, similar to the key informant interviews. 2 Key informant interviews are conducted by a trained interviewer in a one-on-one environment with a set of standardized questions. The objectivity of the interviewer and the ability to compare answers across different interviewees is key to the method�s success. The inherent subjectivity of the method makes it difficult to know the accuracy of the obtained data, but is useful in developing an understanding of attitudes around a particular problem or situation. 3 A structured town meeting is advertised to the community to maximize participation. A facilitator may use nominal group technique, a method that identifies and ranks the major problems or issues affecting the group, and is effective at gaining consensus with all types and levels of participants. The nominal group process includes the following activities: silent generation, round robin, group clarification, voting and ranking of ideas, and discussion of results.


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suggested piloting the instrument in the nearby community of Petersburg, which has a similar-sized hospital and population. They also requested that the survey be sent to select Prince of Wales Island communities that receive itinerant health care services from Wrangell Medical Center. These include the communities of Point Baker, Port Protection, and Coffman Cove. ACRH staff worked on revising the survey instrument based on these suggestions and coordinating a pilot study in Petersburg. Thirty pilot surveys were completed in Peters-burg with a variety of community members, including some seniors. Pilot study partici-pants were encouraged to write comments and suggestions about the survey design. Based on this feedback, ACRH staff substantially altered the survey instrument. The final instrument had three distinct sections. The first two addressed perceptions and utilization of healthcare services, and were specifically related to the Wrangell Medical Center Health Care Needs Assessment. The third section focused on senior services, including future demand and the range of needed services in the community. The survey instrument is included as Attachment 2 of the survey report found in Appendix A. Appendix A contains a detailed discussion of the survey methodology, including demographic information on survey participants; a thorough discussion of the results of the first two survey sections related to the Wrangell Medical Center needs assess-ment; frequency tables for all three sections of the survey; and a description of data limitations for all three sections. A detailed discussion of the results of section three is included in the Results section of this report. A second audioconference was convened on July 13, 2001 with the Wrangell Commu-nity Planning Group to discuss: 1) pilot survey results, 2) the latest survey instrument, 3) participant incentives to increase response rate, 4) effective means of publicizing the survey, and 5) which community member would be the most appropriate person to write a cover letter to be included with the survey instrument. The Planning Group decided to offer five cash prizes totaling $1750. Ideas for publicizing the survey included articles in the Wrangell Sentinel, the Island News (to access health care recipients on Prince of Wales Island), and public announcements on the radio, as well as an interview with a local Planning Group member. Revisions of the survey instrument were completed in mid-July, and a final version was approved by the Planning Group in an audioconference on July 18, 2001. A cover letter and flyer, both to be enclosed with the survey instrument, were also approved at this time. A total of 1299 survey packets were mailed to all household post office boxes on July 27, 2001. 1119 were delivered to Wrangell, 80 to Coffman Cove, 36 to Port Protection, and 65 to Point Baker. Surveys began arriving in boxes the first week of August. Survey participants were requested to postmark surveys no later than August 24, 2001 if they wished to be included in the raffle drawing.


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C. Focus Groups and Key Informant Interviews ACRH conducted a fourth audioconference on August 13, 2001 to discuss the next phase of the project. Goals and methods for conducting focus groups and key informant interviews were described. Potential focus groups and key informant interviewees were identified. Members of the Planning Group volunteered to put together focus groups. Prior to a subsequent audioconference, the ACRH team worked with two members of the Planning Group to schedule meeting times and locations for the focus groups. ACRH staff called interviewees to set up meeting times and locations. Questions for both focus groups and key informant interviews were discussed and finalized during an audioconference with the Planning Group on August 27, 2001. Specifically, focus group questions centered on definition of the following issues, services, and concerns:

• Health and social services used by seniors or family members in Wrangell, and what they like about them;

• Health and social services for seniors that residents would like to see changed, added, or expanded; and

• Major health and social issues of senior citizens in Wrangell and programs that could be offered to address these issues.

Key informant interview questions used a similar format, but also included additional questions asking respondents to identify agencies or individuals that should take the lead in adding or expanding services, to prioritize the top three senior issues to be addressed in the next five years, and to identify potential funding sources for establish-ing or maintaining identified senior services (see Appendix B for a complete list of focus group and key informant interview questions). The ACRH team traveled to Wrangell during the first week of September to conduct the focus groups. Five were planned, but only three were finally implemented. The three groups included: residents of the senior apartments; seniors who use the senior center; and members of the Salvation Army League, which included seniors, family members of seniors, and caregivers. The ACRH staff also conducted sixteen key informant interviews while on site. Interviewees included seniors and providers of health care and social services to seniors. D. Community-Wide Goal-Setting Meeting In October, staff from ACRH and the University of Washington traveled to Wrangell to conduct an evening town meeting prioritizing needed senior services. In preparation for the meeting, Planning Group members personally invited friends and other resi-dents with an interest in senior services. The Senior Center offered van service for elders in need of transportation to the meeting. Two Letters-to-the-Editor and an


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advertisement were placed in the Wrangell Sentinel. The event was also advertised on the Mini-Scan. On October 15, 2001, from 6:30PM-8:00PM, Peter House from the University of Washington, and ACRH staff facilitated the community-wide meeting in the Wrangell High School commons. Seventeen residents attended. Unlike structured town meet-ings that employ nominal group process techniques, this event expanded on data collected by means of the survey, focus groups, and key informant interviews. Partici-pants were given an opportunity to add to a list of top priority senior service needs, resulting in a total of 21. They then prioritized the top six issues from this list of needs, using a multivoting technique4. Breaking into two groups, each group was facilitated to discuss and do initial planning for three of the top needs. There were four questions asked regarding each of the six issues:

1. Who is responsible? 2. Where could funding be found to address the need? 3. Where should a program be located/who should implement it? 4. How should it be implemented (initial steps)?

The top six needs identified were the following:

1. Long-term care unit expansion, 2. Additional assisted living, 3. Additional senior housing, 4. Senior service coordinator position, 5. Increased respite care, and 6. Hospice care.

4 A multivoting technique is a structured process used to rank the major problems or issues affecting the group, and is usually facilitated by a third party. It is used for managing participation in planning processes. The method is effective at gaining consensus with all types and levels of participants in a wide range of settings. A list of issues has already been prepared by some means. Each participant is given a number of votes that can be used to identify the issues felt to be of highest priority. Votes are tallied and the top-ranked issues determined.


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III. RESULTS A. Local Senior Services A number of the services provided to seniors in the City of Wrangell have been mentioned above. This section describes existing senior services in more detail. 1. Wrangell Medical Center The Medical Center provides eight acute care beds, including one ICU bed. There is an average daily census of 2.3 patients. Four of the acute care beds are designated as �swing beds� that can also be used for long-term care. Several family physicians, usually four in number, are employed by the Medical Center/Stikine Family Clinic. They provide general preventive and palliative care, including uncomplicated obstet-rics, and are trained to perform a number of diagnostic and treatment procedures. They recently participated in a statewide initiative to improve diabetes care. Radiol-ogy, ultrasound, mammography, and laboratory services are available at the Medical Center. There is a recurring schedule of specialist visits to the community important to senior residents. These specialties include: internal medicine, gynecology, general surgery, orthopedics, pulmonology, urology, dermatology, podiatry, ophthalmology, optomet-rics, ear nose and throat, audiology, dietetics, anesthesia, and radiology. Patients needing other specialist services are referred to Juneau, Ketchikan, Anchorage, or Seattle. Alaska Natives are referred to the Mt. Edgecumbe Hospital in Sitka. There is one scheduled Alaska Airlines flight to the north in the morning, and one to the south in the afternoon. The Alaska Marine Highway system provides service to Ketchikan to the south and Petersburg, sometimes Sitka, and Juneau to the north. Ferries run 1-3 times per week, with an expanded schedule in the summer months. While most residents fly to a care destination outside of Wrangell, some non-acute patients use the ferry system. The community recently lost its retail pharmacy. The hospital is coordinating pharmacy deliveries for residents in the short term, and will possibly open a small pharmacy to serve the community�s needs. Of special importance for Wrangell's seniors is the fourteen-bed long-term care unit, which has been close to or at 100% occupancy for the past several years. This unit is highly regarded and is felt to be in need of expansion. Currently the rooms are all double occupancy, and private rooms have been requested. If four or more beds are added, the Medical Center will have to staff the unit with two licensed nurses around the clock. There is a severe nursing shortage in Wrangell, as elsewhere, and this may be a challenge.


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Another service used by seniors is the Call Care system that connects with the Medi-cal Center. Seniors have a button located either on their phone or on a neck cord that, once pushed, activates an individually developed telephone tree, and can trigger an emergency response if needed. The hospital auxiliary provides funds for this system. There is a limited home health program provided by Medical Center nurses. This program is Medicare-funded and few seniors are eligible for the specific services offered, such as dressing changes and treatment of bed sores. Occasionally, doctors, nurses, and the physical therapist from the Medical Center will make home visits to homebound patients outside of the home health program. The Medical Center physical therapist provides assessment, training for home exercises, and orthotics. The presence of the physical therapist in the community for the past 1½ years has made rehabilitation services possible for patients in the long-term care unit. The hospital has a limited van service to bring people to the facility for appointments or other services. It holds workshops and clinics targeting health issues such as diabe-tes. It also sponsors an annual health fair. During the health fair, low-cost complete blood screens are available, along with other screenings and immunizations. 2. Public Health Center The Public Health Center provides a variety of services. It has a staff of two (a public health nurse and an administrative assistant), and also receives visits from a nurse practitioner. Along with an array of services targeted at younger ages, the public health nurse does sometimes make home visits for chronic disease patients, including senior citizens. She also provides immunizations important for seniors. There are fees for adult services, many of them based on a sliding scale. 3. Emergency Medical Services Emergency services, as well as Search and Rescue, are provided by the City of Wrangell�s volunteer fire department. The Fire Department covers an area of about 2500 square miles, including Petersburg and other remote communities. This is a well-staffed department with an excellent response time and high quality services. 4. Center for Community The Center for Community is an organization that serves southeast Alaska, with headquarters in Sitka. It provides personal care (home health) services in Wrangell. Currently there are five employees in Wrangell who provide care for nine clients. Personal care services are provided by state-qualified personal care attendants, using care plans approved by a registered nurse. Services may be paid for through Medi-caid or private pay. Personal care services are designed for people who require


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assistance with needs such as bathing, dressing, medication assistance, blood pressure and blood sugar checks, and range of motion/exercise. For those who qualify for personal care services, chore services may also be offered. Staff may assist in meal preparation, light housekeeping, and laundry assistance. At this time the Center for Community is not providing chore services in Wrangell. It does provide some respite services in Wrangell, through an Alzheimer�s grant. 5. Community Connection Located in Ketchikan, Community Connection currently provides chore and respite services for one client in Wrangell. It could potentially provide personal care services as well, but presently has no Wrangell clients for this service. 6. Wrangell Community Services (WCS) Wrangell Community Services provides a wide array of programs and social services to the community. It was previously known as Wrangell Mental Health. In addition to several professional staff, there are 25 part-time community service providers. Of interest to seniors, counseling and mental health treatment services are provided, along with medical social work services. The latter are provided at Wrangell Medical Center and its long-term care unit. Home-based social work services are also available if needed. Through Project Choice, which provides Medicaid-funded �waivers� for eligible individuals, WCS provides a home care program for people who would otherwise qualify for long-term care but choose to stay at home. At the time of this report, Wrangell has sixteen Older Alaskan Waivers in effect, and four additional waivers. Workers help individuals with cooking, cleaning, shopping, and other chores. The organization also provides care coordination and respite care. WCS offers a number of services for children, parents, families, and the developmen-tally disabled, as well as vocational assessments for the state. 7. Catholic Community Services Catholic Community Services, headquartered in Juneau, is a non-profit entity that provides a number of primarily state-funded services on a regional basis to communi-ties in southeast Alaska. These include nutrition (congregate meals and Meals-on-Wheels), van transportation, assistance with errands, health promotion, and a senior information and help line. In Wrangell, this organization operates the senior center on a limited schedule (Monday, Wednesday, and Friday from 8:30AM-4:00PM), and bases its other services from that location. The van service also operates during limited daytime hours (10:00AM-4:00PM), three days a week.


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8. Loan Closet The community loan closet has a collection of medical equipment donated for use by residents of Wrangell. There is no charge for borrowing any of these items. Available equipment includes wheelchairs, hospital beds, walkers, bath benches, commode chairs, raised toilet seats, and other small items. 9. Dental Services There are two dental offices in Wrangell. One houses two full time dentists, with part time dental hygiene services. They offer preventive and restorative services, endo-dontics, and prosthodontics. Orthodontic work is generally referred to Juneau or Ketchikan. Some surgical extractions are done locally. A nurse anesthetist periodi-cally travels from Ketchikan, primarily to allow the dentists to serve children who need extensive work. The other office is used by a dentist from Petersburg who provides comprehensive dental services, including orthodontics, in Wrangell every three weeks for 2-3 days. 10. Wrangell Volunteer Hospice Hospice provides medical and social assistance for terminally ill patients who desire to remain in their homes rather than being hospitalized at the end of their lives. This service was recently established in Wrangell and will provide services free of charge. 11. Positive Approach to Community Health (PATCH) PATCH works with other organizations to produce Wrangell�s Senior Resource Directory, which lists contact information for many programs and organizations. 12. AVENUES AVENUES is a private, non-profit organization focused on helping people deal with issues of substance abuse and chemical dependency. There are assessment, outpa-tient, aftercare, referral, and other counseling services available, as well as programs for youth and drunk driving offenders. 13. Chiropractor There is currently one resident chiropractor in Wrangell. He practices conservative chiropractic care, primarily using manual manipulation and some nutritional advice.


14

14. Massage Therapy Massage therapy is provided on a part-time basis by three individuals living in Wran-gell. Available services include Swedish massage, pressure points, deep tissue massage, and acupressure. 15. Senior Apartments A 24-unit senior apartment complex was built about sixteen years ago. There are individual one-bedroom apartments, and a communal room for activities. No meals or other types of personal assistance are provided by the facility, though residents may be provided in-home services by community agencies if needed. 16. Assisted Living Homes There are two assisted living homes in Wrangell. The first primarily serves devel-opmentally disabled adults, though there is a senior family member also living there. The second home will provide five beds for seniors, and was awaiting state certifica-tion at the time this report was prepared. 17. Salvation Army The Salvation Army provides some services for seniors, including visitations and holiday meals. There is an active seniors group associated with this organization. 18. Churches and Other Organizations Other churches in Wrangell also provide similar services for their members, including meals, food baskets, pastoral visits, and transportation to church. Some of the service organizations occasionally provide meals and social activities for seniors. The grocery stores have discounts for seniors and will deliver their groceries at no charge. Checking at Wells Fargo and newspaper subscriptions are also offered gratis. Adjacent to the school is a City-managed swimming pool, which may be used without fee by seniors, along with an exercise room. There are special hours designated for seniors at the pool, and lap swims and water aerobics are available. The library provides diversion and has evening hours. There are benches and ramps provided around town, though there are only a few handicapped parking spots, and some of the ramps and their associated doors are hard to use and even dangerous. Sales and property tax exemptions have in the past been provided to Alaskan seniors. State subsidy for senior sales tax exemptions was lost in recent years, and the City of Wrangell has discontinued that benefit. The property tax exemption applies to the first $125,000 of the value of a senior�s home.


15

B. Survey – Senior Services 1. Respondent Demographics Demographics of survey respondents show that they are fairly similar to the general population, as recorded by the U.S. Census in 2000, although respondents skew slightly older than the general population in the 45-75 year old age categories (see Table 1). Survey respondents are almost evenly divided between men and women with 49% of respondents being male and 51% female.

Table 1. Survey Demographics Compared to 2000 Census Characteristics

Characteristic 2000 Census

2001 Survey

% Male 51.5% 49% % Female 48.5% 51% % Under 5 Years 6.1% 6% % 5-9 Years 7.5% 7% % 10-14 Years 10.2% 8% % 15-19 Years 7.2% 7% % 20-24 Years 3.6% 3% % 25-34 Years 9.7% 8% % 35-44 Years 17.5% 14% % 45-54 Years 16.1% 18% % 55-59 Years 5.6% 8% % 60-64 Years 4.7% 7% % 65-74 Years 6.4% 10% % 75-84 Years 3.8% 3% % 85 + Years 1.5% 1%

Respondents have lived in Wrangell for varying lengths of time, with the largest percentage (36%) residing in the community for less than ten years. Fourteen percent (14%) state that they have lived in Wrangell for more than forty years. Ninety-five percent (95%) of respondents are Wrangell residents, with 3% stating resi-dence in Coffman Cove, and 1% in Port Protection. The return rate from Point Baker is very slim, with only one respondent, or less than 1%. Survey respondents� household incomes are fairly similar to the 1990 Census, the most recent census survey for which data are available. Again, this suggests the survey is broadly representative of the general population. The largest percent (39%)


16

of survey respondents live in a household earning $25,000-49,999; 35% of the Wran-gell population had this household income in 1990. An additional 28% of survey respondents live in households earning less than $25,000. In the 1990 Census, 24% of the population lived in households earning less than $30,000. Concurrently, 4% of survey respondents reside in families earning more than $100,000, compared to 6% in the 1990 Census. The survey included several questions specifically addressing services for seniors. Questions were asked concerning services that respondents felt were needed in Wrangell, as well as their expected use of the services. Approximately 260 people responded to the questions regarding senior services, though this varied for each question. 2. Location Survey participants were asked if they were to choose a location for long-term care for themselves or a household member, would they plan to stay in Wrangell, leave Wran-gell but stay in Alaska, or leave Alaska. Figure 2 indicates that the majority, 77%, would stay in Wrangell, with an additional 9% staying elsewhere in Alaska, and 13% leaving the state. This compares with the overall finding for the state that 92% of seniors prefer to stay in Alaska (McDowell Group, Issues Affecting the Economic Wellbeing of Alaska Seniors, 2000).

Figure 2

Note: "other" category contains 2 respondents who selected multiple answers.

Location of Long Term Care Choice (N=261)

Leave Wrangell, but

stay in Alaska(n=24)

9%Leave Alaska(n=34)13%

Other(n=2)1%

Stay in Wrangell(n=201)

77%

Note: n=number of respondents


17

These results indicate a strong preference for remaining in Wrangell, for �aging in place.� The implication of this preference is increasing demand for senior services into the future. As is true in other parts of the United States, the population of Alaska is aging, with those 85 years and older the fastest-growing age group. Alaska is also experiencing two related phenomena: more Alaskans are staying in the state at retirement than ever before, and, in fact, are bringing elderly relatives to the state to better care for them. In Wrangell, these trends are also noticeable. The response to one survey question indicated that 45 respondents expect older relatives to come to live with them in the next ten years, and 46 more are not sure if that will be a choice made by their family members. According to census data, Wrangell is also demonstrating the general aging trend. As seen in Figure 3, there are several large age cohorts coming along. If their members tend to stay in Wrangell rather than move away, and if relatively consistent age-spe-cific mortality rates are anticipated, there will be significant demand on the full array of senior services for the next forty years. This is a fact to be considered when planning expansion of existing services. This demand could be mitigated if the community experiences a substantial out-migration. However, after experiencing a drop in popu-lation in the mid-1990s, the population stabilized in the later years of the decade.

Figure 3

Population by Age (2000 Census) City of Wrangell, Alaska

141

236

84

239

8835

224166172

147

371405

050

100150200250300350400450

4 andUnder

5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age in Years

Num

ber o

f Ind

ivid

uals


18

3. Types of Care One survey question asked respondents� opinions about the importance of several types of care, including the following: nursing home, assisted living, in-home care services, adult day services, senior housing, respite care, and hospice care. They were also invited to identify other services and rate their importance. They could choose whether the care was �Very Important,� �Somewhat Important,� or �Not Important,� and could also select �Don�t Know� if they were unsure about a particular type of care. The results are shown in Figure 4. Definitions were provided for each type of care as follows:

• Nursing Home � a facility with full medical and nursing care support • In-home Care Services � lives at home, with personal care, chore, and other

support services • Assisted Living � living space within a home, all meals, assistance with personal

care • Senior Housing � independent apartments with social activities, no care services • Respite Care � relief services for family caregivers • Hospice Care � care for the terminally ill • Adult Day Services � structured day care center program

Figure 4 [Table 20, Appendix A: Attachment 3]

Importance of Long-term Care Services in Wrangell

0% 20% 40% 60% 80% 100%

Other (n=17)

Adult day services (n=252)

Respite care (n=253)

Hospice Care (n=256)

Senior housing (n=266)

Assisted Living (n=263)

In-home care services (n=260)

Nursing Home (n=264)

Serv

ice

Percent of Respondents

Very ImportantSomew hat ImportantNot ImportantDon't Know



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Fully 91% of those who answered this question with regard to nursing homes rated them as �Very Important� or �Somewhat Important.� In-home services, assisted living, and senior housing were also of high importance, with three-fourths of respondents indicating they were very important. These four types of care encompass a continuum of housing-care needs, each critical to achieving the goal of assisting seniors to remain in their own homes safely and comfortably for as long as possible, gradually moving into more supportive care settings as needed. Each of the other types of care listed (respite, hospice, and adult day services) are supplementary services that improve the quality of life for seniors and caregivers. Eighty-seven percent (87%) of respondents felt respite care was either very important or important. When family members or other volunteers are providing care for seniors, this service allows them to take care of other responsibilities. Respite care can be short term (e.g. allowing a caregiver to go to the store or run errands for an hour or two) or long term (e.g. taking a two week vacation), and can involve simple or complex care. It is an important service to prevent caregiver burnout and is often a component of in-home care that allows a family to maintain the elder at home. Hospice care was also seen as important, with 64% indicating it was very important, and 23% somewhat important, for a total of 87%. Hospice care supports the individual and their family at the end of life, and is often staffed by a combination of health and social service professionals and volunteers. While it can be provided in any setting, it is often utilized to enable terminally ill individuals to live out their days at home. Adult day services were rated by 83% of respondents as very or somewhat important. Adult day care is a form of respite care that provides a structured program of activities in a safe environment outside the home. Depending on the extent of such services, caregivers are then able to hold jobs or take at least some time away from their care-giving responsibilities. Adult day care is particularly helpful if a senior is prone to falls or begins to develop dementia and is unable to safely remain at home alone. Other services identified by respondents as important include the following: Alzheimer�s care, house calls, information on senior issues, health issues, Salvation Army services, hospital care, transportation and meals, and someone to talk to. 4. Services Required in the Next Ten Years The survey asked which types of long-term care services respondents, or their current or potential household members, anticipate using in the next ten years, assuming all were available in Wrangell. Of the 279 people responding, 108 (39%) did not expect they or others in their house-hold would need long-term care in the next ten years. However, there were significant numbers of individuals expecting to use each of the types of care listed (see Figure 5, next page).


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Note: Respondents were allowed to check more than one response on this question.

Other category includes the following individual responses: hospice; how does one know?; long-term care; LTC unit at WMC; move closer to a family member; unknown.

Most seniors prefer to remain in their own homes as long as possible, and a strong system of progressive in-home services is essential if this is to occur. There were 92 respondents who anticipated that they or their household members would require in-home care in the next ten years. Senior housing provides a congregate living setting where building maintenance tasks and sometimes meals are taken care of by others. Seventy-nine (79) people stated that senior housing might be a choice for someone in their household in the next ten years. Assisted living is the next care level, with provision of meals and assistance with activities of daily living. While residents of assisted living facilities do not require the ongoing services of registered nurses, their care can be quite complex. Seventy-four (74) respondents felt their household would require assisted living services for a resident within ten years. A nursing home provides the highest level of residential care, with a variety of services including nursing care, and is appropriate for seniors so disabled, frail, or chronically ill that they can no longer live at home or in other facilities even with support. There

Types of Long-term Care Services Expected to Use in the Next 10 Yers (N=279)

n=6

n=39

n=41

n=64

n=74

n=79

n=92

n=108

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Other

Respite Care

Adult Day Services

Nursing Home

Assisted Living

Senior Housing

In-home Care

Don't expect to use in next 10 years

Long

-term

Car

e Se

rvic

es

Percent of RespondentsNote: n=number of respondents


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were 64 respondents who indicated that they or a household member expected to use nursing home services in the next decade. Adult day services were identified by 41 respondents, and respite care by 39. Six people identified other long-term care services they expected would be needed by their household in the next ten years. One anticipated need for hospice care, and one respondent commented that they plan to move closer to family. 5. Independent Living As has been discussed, in order for a senior to maintain an independent lifestyle as long as possible, and to remain at home safely, assistance may be required and must be tailored to the individual�s needs. Survey participants were asked to rate the various types of assistance for independent living as �Very Important,� �Somewhat Important,� �Not Important,� or �Don�t Know.� Figure 6 provides the results.


Importance of Types of Assistance to Live Independently

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Library house calls (n=265)

Recreation activities (n=268)

Expanded meal program (n=267)

Senior center (n=268)

Housekeeping and laundry (n=270)

Meals provided at senior center (n=269)

Dressing and bathing (n=269)

Meals delivered to home (n=271)

Care coordination (n=263)

Delivery services (n=270)

Chore services (n=272)

Home accessibility modif ications (n=266)

Handicap access for public places (n=267)

Assistance w ith paperw ork (n=271)

Home health care (n=269)

Emergency call system (n=270)

Transportation services (n=269)

Assistance w ith medications (n=275)

Type

s of

Ass

ista

nce





22

For all but one of these eighteen types of assistance, more than half of survey respon-dents indicated that they were of high importance. When including those who indi-cated the services were at least somewhat important, all but the last four were rated highly by at least 90% of respondents. While the services listed are presently avail-able to Wrangell residents on a limited basis, there are clear indications that these services are highly valued and that demand will grow in the future. There were a number of additional types of assistance mentioned by one or more respondents, including the following: access to swimming pool, church involvement, foot care, mail pickup, special meals for diabetics, and hospice care. Several respon-dents noted the need for seniors to interact with others and be involved in the commu-nity, mentioning the need for people to visit with, more time spent with seniors, a program to coordinate regular visitations, and trips to get them out into the community and beyond. 6. Nursing Home Services The nursing home at Wrangell Medical Center (the long-term care unit) is viewed favorably by community residents. While nursing homes have often been viewed as a terminal location for frail seniors, it is the mission of a nursing home to return each patient to as full functioning as possible to enable him/her to return to a lower level of care, either at home or in another supportive residential environment. To that end, as well as to provide stimulation for more permanent residents, nursing homes provide a variety of services, activities, and amenities. Survey participants were asked to rate these services as �Very Important,� �Somewhat Important,� �Not Important,� or �Don�t Know.� Figure 7 (next page) provides an overview of these results. The quality of meals provided in a nursing home setting is very important to residents for both nutrition and comfort. Respondents ranked this service highly, with 84% indicating it is very important, and an additional 13% feeling it is somewhat important, for a total of 97%. The provision of activities and presence of an activity room also had a high number of respondents (76% and 74%) who judged them to be very important. The inclusion of physical therapy/rehabilitation services, as well as a high staff-to-resident ratio, also received ratings of �Very Important� by more than 70% of respondents (72% and 71%, respectively). Somewhat lower in importance, but still rated as �Very Important� by more than half of the respondents, include: trips out of the community (67%), an outdoor recreation area (55%), and private rooms (55%). Massage therapy and mental health counseling each received a �Very Important� rating by 42% of respondents. There were a number of other suggestions about services that were important to nursing home residents. Several focused on improving quality of life, such as: having visitors, including visits from animals and children; keeping pets and live plants; being provided entertainment, music, car rides, native foods, and transportation for visits home; and interacting with community activities.


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7. Open-Ended Questions The survey provided an opportunity for respondents to make additional comments about the health and senior services provided in Wrangell. A thematic analysis was performed on these comments. In general, respondents were satisfied with both the scope and quality of services provided in Wrangell. The service most often identified as needing to be added was surgery. One respondent commented, “It would be much more convenient, less expensive and easier for seniors if there were some surgical ability in Wrangell, at least for relatively minor problems.” Respondents also expressed the desire for increased access to specialists. According to respondents, the nursing home at Wrangell Medical Center needs to be expanded, with one stating, the “Hospital is in desperate need of expansion for long term care,” and indicating that private rooms for most residents would be preferable. Several of those surveyed also said it would be better if more separation of different types of patients was possible. For instance, separating those who are mentally alert from those who are not, and postpartum mothers and babies from the ill and elderly. Respondents also used the open-ended comments section to describe several new or expanded programs they felt would be of benefit to Wrangell�s seniors. The first was a volunteer activity that would match homebound seniors and handicapped people with

Importance of the Following Nursing Home Services

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Massage therapy (n=271)

Mental health counseling (n=269)

Outdoor recreation area (n=269)

Private rooms (n=271)

Trips out of the community (n=272)

High staff to resident ratio (n=269)

Physical therapy/rehabilitation (n=272)

Activity room (n=269)

Activities (n=273)

Quality meals (n=273)

Nurs

ing

Hom

e Se

rvic

es





24

volunteer visitors, for both home visits and telephone conversations. This was seen as a program that should be organized and that training should be provided for volunteers. There were also requests for more planned recreational activities. One said, “I have too much time on my hands. I need to have more activities to keep busy. I don’t mix well without help.” One respondent felt the existing senior center could house “a real senior center program with planned activities to meet social needs.” One asked that funding for the senior center be increased. “Need to keep the senior center open more for meals and activities. Don’t cut funding in this area!” It was mentioned that, if a senior services coordinator position was established, this coordinator could be helpful to Wrangell seniors in a number of ways, including assisting them to access currently available services and programs, helping with necessary paperwork, and coordinating activities and services. Respondents were generally satisfied with services such as meals, transportation, and senior housing. However, they requested that more of these services be made avail-able, including longer hours of operation and increased quantity. They also requested more handicapped accessibility and more home-based services. A major concern for seniors was the high cost of services, especially medical services. Mentioned as problematic were travel costs, hospital charges, physician costs, and pharmaceuticals. There was the sense that these costs tended to be higher in Wran-gell than elsewhere, particularly for prescription medications. Suggestions were made for a program to help with unexpected medical travel costs, more frequent health fairs, and an attempt by local authorities to address the issue of the uninsured. C. Focus Groups and Key Informant Interviews There were three focus groups held during the assessment process. The first included members of the seniors group associated with the Salvation Army, the second was made up of residents of the senior apartments, and the third group was comprised of members of the �Lunch Bunch� who gather frequently for lunch at the Senior Center. In addition, sixteen formal interviews concerning senior services were conducted with key informants. Full thematic analyses of the focus groups and interviews are found in Appendix C and Appendix D. During the course of the focus group sessions and interviews, there was discussion about the array of services provided in Wrangell for seniors. Generally, the services were rated highly. One participant stated, “I think there is a very caring atmosphere for the elderly in Wrangell.” However, nearly all services and facilities were considered to be quantitatively inadequate. The growing senior population will put increasing pres-sure on these limited resources. A lack of coordination and organization of services was also cited as a general weakness.


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1. Wrangell Medical Center Services The Wrangell Medical Center generally received high ratings from the focus group and interview participants, and the services available there are much appreciated. The ad-ministration and the physician group are felt to be capable and forward-thinking. There is a desire to broaden the range of specialty services provided; eye and foot care were specifically mentioned, as was pain management. Participants also indicated there was a need for better access to surgery, as well as for medical equipment upgrades so diagnostic and treatment procedures could be done locally, especially when specialists are on site. There was recognition that “Wrangell can’t have the range of services that larger communities can offer.” Concern was expressed about the social support needs of residents who are sent out of the community for care. The long-term care unit is perceived as an excellent facility�“one of the best in the state,” with a caring and competent staff. It is experienced as friendly and informal, allowing visits from family members, children, and pets. Activities there are engaging, the food is good, and there are opportunities for outside activities including gardening and lunch outings. Participants felt that residents are well cared for, nourished, and “do not have bed sores.” There were frequent comments that this unit needs to be expanded. A suggestion was made to expand the common room or add another, and to add some private rooms. “Residents are in double rooms, but some people don’t make good roommates.” A consideration in adding a second common room would be that the facility and activities in one could be tailored for those patients with dementia. Having adequate room to be able to provide respite care was also considered impor-tant. It was mentioned that adult day care used to be provided in the long-term care unit, and a number of people felt there should be consideration given to re-starting this program at some location in Wrangell. Participants felt the Medical Center could get more involved in other aspects of senior services in the community, with one example being provision of meals. One individual stated that she felt the hospital should consider providing meals to school children as well as seniors. Expanding the use of the hospital van might also be considered, supplementing the van service provided by the senior center. 2. Community Health Services Home health services are felt to be too limited, particularly those nursing services provided by the Medical Center that are severely constrained by Medicare regulations. That health professionals in the community, including hospital-based staff and the public health nurse, provide occasional home visits to those homebound is appreciated. The quality of services provided by home health aides employed by the Center for Community is felt to be quite good. Besides delivering personal care, the aides are company for homebound seniors and reduce the workload of family caregivers. “They usually know the person who works as the aide. This gives them a sense of trust, a


26

sense of community.” There are a limited number of certified aides available in the community and there will likely be a growing need for these services. The Call Care system and Emergency Medical Services (EMS) are highly regarded by Wrangell�s seniors. One participant declared, “Call Care buttons are great!” Partici-pants praised the promptness and quality of EMS services. One stated, “Our EMTs are the best! They are immediately there.” The care coordination and other services provided by Wrangell Community Services for seniors also received a number of appreciative comments. Participants approved of the public health nurse and the services she provides. “The health nurse is wonderful here.” They especially noted that the PHN provides preven-tive flu shots, and that she will go to people�s homes to provide services if they are homebound. Volunteer hospice services were too new to assess. This is a service that many felt was needed in the community, so it should be welcomed. 3. Senior Center Services Funding limitations have curtailed the hours and days of operation of the senior center and its related services: congregate and home-delivered meals, van transportation, and social activities. The building itself is seen as a detriment, with cramped space and problematic access. It is under-utilized and participants were concerned about maintaining and strengthening it. There was a feeling that an increased sense of community ownership needed to be developed. The senior center program is critical to seniors� ability to remain independent in their own homes, as well as in decreasing the isolation that many experience. Participants felt there is a real need to enhance its functionality. Senior center staff are appreciated–“I like the generous nature of the staff.” It was noted that it would be beneficial if the staff participated in inter-agency meetings, and perhaps should seek training in organizing activities and motivating seniors to participate. Availability of the senior center van is very important to seniors� mobility and participa-tion in community activities, and there was agreement that expanding its operation would be of benefit, particularly into the evening and on weekends. “There are lots of people who can’t go anywhere at night or on the weekend because there is no van service and they don’t drive.” There are some difficulties experienced with the van itself in terms of access and egress. “Elders fall into your arms when they descend.” Suggestions were to obtain a vehicle that is lower to the ground, perhaps through donation of a used car, or implementing a cab voucher discount program. Meals options were also discussed, and it was felt that local restaurants might be approached to offer discounted meals for seniors – “blue plate specials.” As was mentioned above, some participants thought the Medical Center should consider providing senior meals. There were also suggestions made about how food harvested


27

from the local area could be distributed to seniors. People seemed to be quite dependent on the senior center meals, and would like them to be available on other days of the week. Attention to special diets would be helpful. There were differing opinions about the quality of the meals provided by the senior center � some found them tasty and others were less positive. Planned recreational and educational activities were felt to be lacking. The existing senior center does not appear to have the resources and/or space to host crafts, pot-lucks, computer classes, exercise classes, bingo, card and board games, parties, dances, and other social events that participants indicated would be beneficial. Infor-mational sessions on various topics, such as living wills, death and dying, and avail-able senior services and benefits, would be appreciated. “I think a lot of seniors don’t know.” Other venues and coordination for indoor activities are needed. A senior volunteer program could help engage seniors in community activities. An example would be �senior grandparents� for children. Some are involved in Welcome Wagon and other volunteer efforts now, but this could be expanded. Other sugges-tions included finding volunteers to take seniors fishing and on other outings; setting up a visitation/telephone contact program; scheduling indoor events and activities; and providing adult day care (perhaps in conjunction with an assisted living home). It was felt the Medical Center newsletter could include informational content about health issues, changes in Medicare and Medicaid, etc. Assistance with complex health insurance documents, taxes, wills, and other paperwork would also be helpful. Some felt that if some of these services were based at the senior center, it would potentially help keep the senior center open and better utilized. 4. Senior Housing Housing for seniors was also identified as in need of expansion at all care levels. There is a waiting list for the senior apartments, there have been few assisted living beds for seniors, and the long-term care unit is always full. There may be a need for a transitional type of residence between the senior apartments and assisted living. Im-proved maintenance for the senior apartments was another need identified. Increased facility-based respite care was also noted; the Medical Center will sometimes provide respite care but is usually too full. 5. Other Community-Based Services Inability of seniors to obtain needed chore services was another concern expressed. While there are three agencies that can potentially assist with household chores, it is felt that there are few workers willing and trained to provide chore services and, for those seniors that are not subsidized for such services, the costs are very high. Suggestions were made to pay young people, perhaps as a school project, or to coordinate volunteers who would help with seniors� chores.


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There are also regulatory difficulties noted with the state-subsidized chore services program. For instance, in order to get help with household chores such as cooking or cleaning, a person must receive personal care services (e.g., bathing and dressing). Some seniors are too modest to accept such help, and so do not receive the support they need with chores either. Also, if an aide assists one spouse, she/he is not allowed to have the other spouse as a client, even though the individual may be also eligible for and need services. Participants appreciated the placement of benches around the community, and those facilities that have ramps. However, there were a number of comments made about the difficulty of navigating ramps � particularly those made of grating which tend to trip people who cannot raise their feet high. If the grating is wide, walkers and canes may catch in the mesh. Participants also mentioned that the doors at the top of ramps often open outward and cannot be successfully manipulated by people using walkers or in wheelchairs. The Post Office building was an example given. Many buildings that seniors frequent, including churches, are not presently accessible. Only the school building has an elevator. Also, many commented that there were not enough handicapped parking spaces in town. 6. Coordination of Services A strongly expressed need was for organization and coordination of all senior services in the Wrangell community, though participants were not clear on which organization might be tapped to provide such coordination. Wrangell Community Services and the Wrangell Medical Center were mentioned most frequently in this regard. Other entities were identified to coordinate certain aspects � such as the City to coordinate mobility/ access issues. A task force or coalition was suggested to consider how to obtain such a position for the community, and where to house the coordinator. It was felt that a Senior Services Coordinator position would be of real benefit and could directly help seniors with paperwork, inform them about available services, and coordinate activities and events with the many organizations involved. 7. Concerns Summarizing the concerns of focus group and interview participants, and considering those already discussed above, key issues for seniors in Wrangell include the following:

• High costs and inadequate finances • Impaired mobility, accessibility, and transportation • Limited community- and home-based services • Insufficient residential units at every level of care • Lack of recreational opportunities • Isolation, pride, denial of need, safety issues


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• Diminished health, fitness, and nutrition One participant noted that, in some ways, the elderly in Wrangell remain independent longer than elsewhere, “but ultimately the loss of the ability to live alone and making the transition is difficult for them emotionally.” Pride gets in the way of seeking needed services � “they don’t want to appear frail.” This is a safety issue, as are the common problems of organizing multiple medications and obtaining and integrating an array of essential medical, social, and support services. The high costs associated with medi-cal care, particularly if a person needs or desires to go outside the community, is sometimes a deterrent for seeking health care, and may result in the need for higher cost care when it is finally sought. There was agreement that seniors would partici-pate in expanded activities. One individual stated that “more activities would enrich and possibly lengthen people’s lives.” Isolation was a real concern � “It is difficult to not get depressed if you never get out of the house.” D. Results of the Community-Wide Goal-Setting Meeting As mentioned above, there were many high priority senior service needs identified in the assessment and presented to the seventeen attendees at the community-wide goal-setting meeting. Seventeen needs were identified by staff as a result of the survey, focus groups, and key informant interviews. Community members added four more at the meeting. Needs listed were as follows: • Expanded van service • Expanded meal service • Expanded home health services • More senior activities • Senior service coordinator • More chore services • Upgrade senior center services • Expanded long term care unit • Paperwork assistance • More respite care • Adult day care • Handicapped access • Better location for senior center

• Pain clinic at hospital • Increased podiatrist services • More senior housing • Improve coordination between

senior service agencies • Hospice • Improve community awareness of

medical equipment loan service and improve the volume of equipment available

• Assisted living • More staff in the long term care unit

After attendees ranked these issues, the following six were selected to work on further during the meeting. 1. Long Term Care Unit Expansion Those responsible for addressing the expansion of the long-term care unit were thought to be the Medical Center board, Medicaid, private payers, Medicare, the City,


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and the Veterans Administration. Funding might be sought from Medicaid, grant funds, private trusts (such as the Nolan and Rasmussen Trusts), loans (e.g., Housing and Urban Development, HUD), the City of Wrangell, and state revenues. The loca-tion might be either an expansion of the current unit or a new facility in a different location. Initial implementation would include going through the certificate of need process, and putting the project on the City�s capital project list. 2. Assisted Living Those responsible for adding to the assisted living facilities in Wrangell could include private individuals and families, an agency in the community, Medicaid, and the State of Alaska. Funding might come through private pay, Medicaid, private developments, loans, creation of a new corporation, and the Medical Center. Additional assisted living could be housed in larger homes in the community, a new complex, expansion of the existing facilities, and perhaps on the Wrangell Institute property. The following initial implementation steps were listed: identify the extent of the need, sell the idea to seniors, get the City�s economic development director involved, and approach the Tlingit Native Housing authority to lend assistance. 3. Senior Housing Those responsible for addressing senior housing needs would be: seniors and their families, private corporations, HUD, the City of Wrangell, and Tlingit Native Housing. Funding could potentially come from private pay, USDA, HUD, and church sponsors. The location for additional senior housing might be on the existing site (perhaps adding two more buildings), or on the Institute property. Implementation steps identified include: identify the need, approach the board of Wrangell Senior Apartments, attract a developer, and consider development of a retirement community. 4. Senior Services Coordinator Parties responsible for addressing the need for a senior services coordinator position would be Wrangell Community Services, the City, the Medical Center, the senior center, and senior apartments. Seed money could come from grants, but there is a problem with sustainability. Local contributions could be sought. No particular location was identified. A senior service coordinator would potentially do the following: provide assistance with legal documents such as wills and powers of attorney, and information on state and local agency services; coordinate (or at least have access to) a network of volunteers; begin an adopt-a-grandchild program; and coordinate van transportation and meals.


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5. Respite Care Wrangell Medical Center and Wrangell Community Services are already providing respite care, and would be the logical organizations to address this issue. Funding could be from Medicaid, a state grant, or self-pay. Implementation ideas included: the coordinator could manage it, improve awareness of service availability, and ensure a diversity of skills are available. 6. Hospice Care When this need was prioritized, group members were not aware that a new hospice program, Wrangell Volunteer Hospice, had just been established. E. Wrangell Medical Center Community-Wide Goal-Setting Meeting The same week that the community-wide goal-setting meeting was held concerning senior services, there was a second town meeting held that focused on the Wrangell Medical Center and other health services. Several recommendations by attendees at that meeting were relevant to this Senior Services Needs Assessment. Pertinent to the long-term care unit were recommendations to expand the unit (perhaps incorporated into a new hospital facility) and provide private rooms. There was also a recommendation to double the size of senior housing, adding a dining room and moving the senior center there. There would be high value in making such an investment for Wrangell's seniors, community professionals, other residents, and the local economy. However, key community players would need to make a conscious choice to move and improve from the status quo.


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IV. DISCUSSION AND RECOMMENDATIONS For a small town, Wrangell has a good variety of health and social services available for its senior citizens, and most are widely praised. If anything, it is the quantity of services, including days and hours of operation, that is felt to be inadequate. Coordi-nation of services was also identified for improvement, and costs are of concern to seniors. Using several different assessment methodologies, ACRH staff found that there was substantial agreement in the community about service deficiencies, as well as preferences for new or expanded services. RECOMMENDATION 1: Collaboratively determine what level of senior services the community would like to establish, and how services should be configured. In a structured community strategic planning process, Wrangell residents would reach consensus on a direction, major tasks, responsible parties, and a timeline for enhance-ment of the community�s senior services. This planning process would include a re-view of existing services, consideration of residents� input as expressed in this report, an understanding of resource limitations and possibilities, and a vision of the future of senior services in Wrangell. As an example of the latter, the following are rather distinct senior service scenarios that exemplify directions that Wrangell might take. In reality, it is unlikely than any one of these specific examples would be chosen. Rather, there are many feasible alterna-tives that would combine features of two or three of the scenarios. Scenario 1: Wrangell could continue to have a variety of generally uncoordinated and limited services, with continued gaps and overlaps, and minimal collaboration between agencies. Scenario 2: The community could invest moderately in improving its infrastructure to enhance accessibility; increase support for independent living; offer more housing options and activities; and encourage coalition-building between organizations, becoming a more �senior-friendly� community for its residents. Scenario 3: Wrangell could make a conscious decision to become and to market itself as an attractive location for retirement, with a well-coordinated menu of services, activities, housing, and support for seniors at every stage of care needed. The first option is not entirely negative. Sometimes the familiar is most comfortable and workable. The current situation has arisen through history, probably mostly due to disparate funding streams and personalities, and it will take an investment of energy, a willingness to collaborate, time for planning and coordination, and a commitment of resources to move to either of the other options. While there would be high value in making such an investment for seniors, community professionals, other residents, and the local economy, the first step in deciding to improve from the status quo would have to be consciously accepted and agreed by key community players.


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The second option would be achievable mostly through creative collaboration, and improving the infrastructure by addressing and coordinating traditional funding streams. Wrangell already seems to be caring and attentive toward its seniors, and there are a variety of services in existence that can be built upon. With a goal of achieving coherence of services and enhancing the quality of life for seniors and others in the community, reducing isolation, and strengthening available services, this integral and growing segment of the population would be well-served. Seniors have a lot to offer any community, both in terms of their accumulated wisdom and skills, and the economic benefit they bring. Children especially benefit from expo-sure to their opposites on the age spectrum. Seniors often have the time to devote to children that working parents do not. The last scenario described above may appear to be a long-term goal, but it should be considered at this juncture to determine if it is a viable and philosophically acceptable future direction or not. The assumption here is that Wrangell would create a �retire-ment community� environment, develop an integrated, comprehensive continuum of care and array of activities, and market to people outside of its current population. While it might seem that retirement communities would be unbalanced toward older ages, in fact there are successful small town models that emphasize multigenerational interaction and contribution, and serve to revitalize the entire community. It would be of interest to discuss just what and where this market might be, what it would take to create such a community in southeast Alaska, and what special funding sources would be required to develop it. There are models in small towns elsewhere in the country that could be adapted by Wrangell. This would be a planned economic investment. It would be expected to provide additional, mostly service, jobs in the community. There are many questions that would need to be answered in considering this option: Is this appropriate considering the skills of the current working population? Where would potential residents be found? Would new and current seniors and townspeople be compatible? Would the newcomers be welcomed or resented? What would it take to accomplish and would the community really want to do this? As an alternative to the last scenario, it might be possible to instead develop attributes of Wrangell that would enhance it as a senior tourist destination, rather than a retirement community. This could improve the economy without as much investment in infrastructure. However, a broad base of services for the growing population of resident seniors would still be needed. RECOMMENDATION 2: Improve coordination of and expand senior services and activities.

a. Develop an ongoing Senior Services Coalition to meet regularly, share information and ideas, and coordinate services.

b. Establish and maintain a Senior Services Coordinator position in the community.


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If Wrangell is to improve its services to seniors, coordination is an essential element. Those on the current Planning Group representing senior services could form the core of a Senior Services Coalition. This could be an informal community-based organiza-tion, coming together regularly to share, plan, discuss, and coordinate service delivery. Or it could be formalized, perhaps as a standing committee of city government or the Medical Center�s board of directors. Even if formalized, it should ideally be an open, working forum, so all interested service providers, as well as consumers, could partici-pate actively in discussions and reach most decisions through consensus-building. To facilitate and support the Coalition, it would be helpful to have a Senior Services Coordinator position funded on a continuing basis in the community. There would be three main responsibilities for this position. The first would be to function as an informational resource for Wrangell�s seniors and their caregivers. The Coordinator would be able to reference and rally existing services on behalf of a senior. He/she would provide or find assistance for seniors in dealing with medical bills, insurance forms, and other complex paperwork. The second role would be to coordinate existing services, facilitating Coalition meetings, and working with organizations to establish a smooth continuum of care for seniors. This would include organizing and utilizing volunteers in a variety of ways. The final key element of the Coordinator�s role would be to work toward expanding services and activities for seniors. The individual would ideally have a strong passion and ability for mobilizing people and resources in support of seniors. It is apparent that home-based services in Wrangell are fairly limited. Chore services especially are needed but not available. There will be increased demand for afford-able personal care, chore, and respite services as the population continues to age. A system of visitations and contacts will be needed to decrease loneliness and increase activity and safety. Social work and financial services will be important for the mainte-nance of seniors� life and health. Transportation and meals are also essential. To some extent, the rules and organization of existing programs may not be flexible enough to meet an individual senior�s needs, and there will need to be work on a statewide or national level to change these rules and regulations. Creating a true home-based support network would be a challenging and satisfying part of the Coordinator�s role. Another arena for coordination and enhancement would be in health care services. The concurrent Wrangell Medical Center Needs Assessment will look at the feasibility of the community�s desires for additional medical services in general, including surgery. The Coordinator could advocate for particular needs seniors have identified, such as the training of podiatric aides, the expansion of home nursing services, and the development of a protocol for treating chronic pain. Seniors need assistance in organizing and scheduling multiple medications; this need should be addressed as pharmacy services are reconfigured.


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In planning for the Coordinator position there are many things to consider. For example, if the Coordinator is staff to the Senior Services Coalition, who would he/she report to? In which organization would the position reside? How would sustainability of the position be ensured? What authority would the Coordinator possess to organize and commit resources to services and activities? Indeed, is one Senior Services Coordinator for Wrangell organizationally feasible, or should specific areas needing coordination be identified and assigned to different organizations, each of which would delegate their coordination tasks to someone internally? RECOMMENDATION 3: Develop a master plan for facilities in Wrangell to meet the needs of seniors at all levels of care, now and in the future. It is very difficult to make accurate predictions about the number of seniors in a community in the future, particularly during a period of economic transition when the rate of in- and out-migration is unpredictable. However, we can make some broad assumptions and develop an estimate for planning purposes. As has been stated, the senior population in Wrangell per the 2000 Census was 270 people 65 years and over. In the last few years of the 1990s, the population downturn due to the closure of the mill seemed to stabilize. For purposes of this projection, we will make the assumption that the population will generally be stable for the next two decades. Considering 1990 age group mortality statistics for Alaska, we can estimate that after ten and twenty years, in 2010 and 2020, the following numbers might occur (Table 2):

Table 2. Projected Populations in Wrangell

Age Group 2000 2010 2020 45-54 years 371 NA NA 55-64 years 239 334 NA 65-74 years 147 203 284 75-84 years 88 118 163 85+ years 35 81 116 Total 65+ 270 402 563

This represents an increase in the senior population of 209%. While this may seem excessive, it should be remembered that the projection made by the Alaska Commis-sion on Aging is for a 249% increase statewide by 2025, so these numbers are in line with their expectations. If the Wrangell population remains stable at around 2300 residents, the senior population in 2020 would comprise 24% of the population. If instead, the overall


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Wrangell population grows at the state-expected rate of 30% by 2025, it would reach about 3,000 residents by 2020, and seniors would be 19% of that population. This growing percentage not only has implications for the quantity of senior services needed, but also means that there will be fewer working age individuals to support funding them through taxes and to staff them. This is reflected in the �dependency ratio� which indicates the percentage of children and seniors in relation to the number of working age people in a community. In Wrangell, the current dependency ratio is 74%, which means that each working person supports about ¾ of a child or senior. If we use the state estimates for 2025, by then Wrangell�s dependency ratio would be 93%, and each working person would support nearly one other person. If working age people leave the community and seniors stay, this ratio could go even higher. We can use the senior population projections to estimate a potential need for long term care beds in Wrangell. Table 3 displays the national criteria used.

Table 3. Criteria for Long-term Care Bed Needs in Wrangell Senior Populations

Age group # of beds per 1000 65-74 years 12.5 75-84 years 58 85+ years 220

This is based on actual utilization from the 1997 National Nursing Home Bed Survey. Utilization rates are likely to have shifted in the past four years, and these figures reflect a national emphasis on institutional care rather than the home-based emphasis in Alaska. However, we know that the aging population will certainly increase demand on the long-term care unit, so applying these criteria will at least give us a sense of the potential need for long-term care beds in Wrangell. Considering the age groups represented in Wrangell�s senior population today, this criteria would indicate that the Medical Center�s long-term care unit should currently be sized at 15 beds. That would imply that the current fourteen-bed unit with four swing beds should be adequate for the population. However, for several months there have consistently been eighteen nursing home patients. There are at least two aspects to consider here. The formula assumes that only seniors use the unit, which we know is not the case, though they are the predomi-nant users. Also, it may be true that some of the resident seniors could actually be cared for at a lower level of care, such as assisted living, if there were sufficient beds available. So perhaps the existing unit is about the right size for Wrangell�s current senior population, but it would be useful to further analyze its high utilization.


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Projecting into the future, we can see that this picture changes rather quickly. By 2010, applying the above criteria would suggest that 27 long-term care beds would be needed by the senior population. Of senior respondents to the survey, 75% indicated they would choose to remain in Wrangell for long term care services for themselves or a family member. If 75% of the seniors remain in Wrangell for care, the need would be for a minimum of 20 beds for the expected population of seniors in 2010. By 2020, the need for long-term care beds would increase again. Without considering migration, the projected need would be for 36 beds. If 75% of the anticipated senior population remains, the bed need would be for 27 beds in the long-term care unit. Even if a choice is made to focus immediate development on assisted living beds or other types of housing or services, demand on the long-term care unit can be expected to increase into the future. So, is there a similar projection that can be made for assisted living beds? This is a little harder to estimate. However, the Alaska Commission on Aging has encouraged the development of assisted living and home-based services in the state, rather than the addition of nursing home beds. In the Alaska State Plan on Aging 2001-2003, they report that the ratio of long term care to assisted living beds in Alaska is 1 LTC to 1.6 AL. This is in contrast to the United States as a whole, where nursing home beds have predominated. There, the ratio is 1 LTC to .4 AL bed. If we apply the Alaska ratio to Wrangell�s current configuration of fourteen long-term care beds, there should be 22 assisted living beds in Wrangell now. Wrangell has six assisted living beds available for seniors, giving a ratio of 1 LTC bed to .4 AL bed, which is the same as the U.S. ratio, and much less than ideal for Alaska. Using the Alaska ratio and assuming that 75% of seniors would remain in Wrangell for care, in 2010 the assisted living bed need is projected to be 32. In 2020, it would be 60 assisted living beds. Besides the need for additional long-term care and assisted living beds in the commu-nity, there are other facility needs that should be considered in the planning process. There is already a waiting list for the senior apartments. Assessing the present and future market for senior housing would yield important information for the plan. The inadequacy of the existing senior center building has been identified by many participants in this needs assessment. Perhaps in planning for expansion of housing at various levels, a new senior activity center could be developed in conjunction with one of the new or expanded facilities. Some have commented that the Medical Center already provides meals to its residents and limited van service. Perhaps a partnership could be developed between the senior center program and the Medical Center. Another facility-dependent program is adult day care. The Alaska Commission on Aging projects that 13% of those 65 and over are at risk for Alzheimer�s disease and


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other dementias. That would mean that the Wrangell population at risk for dementia would increase from 35 today to 52 in 2010, and to 73 in 2020. The need will increase accordingly for adult day care, facility-based respite for caregivers, long-term care and assisted living beds for dementia patients, and related services. Existing community facilities also need attention to increase their accessibility. Be-sides complying with Americans with Disabilities Act requirements, it seems to be important to assess the practicality of measures implemented to increase accessibility. This assessment could include testing of ramps and associated doors, mapping of handicapped parking places, and addressing accessibility and safety issues in seniors� homes. RECOMMENDATION 4: Inventory existing funding sources for senior services, activities, and facilities; identify unfunded need; develop a financial plan; and seek additional funds. In order to afford to implement a plan for expansion of existing services, activities, and facilities � or the development of new ones � both traditional and new funding streams must be maximized. As part of the strategic planning process, and its follow-up, an advisory committee on financial issues related to senior services could be formed to inventory current resources and needs, and to develop a budget and financial plan to support strategic expansion of senior services for the community. Committee mem-bers might include current financial managers of seniors programs, the City of Wrangell, the Medical Center, and other advisors. These four recommendations comprise the foundation of a collaborative and ongoing strategic planning process for senior services in the community of Wrangell. In the face of significantly increasing demand, and limited services and resources, it is recommended that the community commit the time and energy needed to establish this comprehensive process.

Appendix A

Wrangell Community Health Care Needs Assessment Survey Report

Wrangell Senior Services Needs Assessment “Survey Report” Appendix A

A1

Wrangell Community Health Care Needs Assessment Survey Results

I. BACKGROUND AND METHODOLOGY A. Introduction The Wrangell Community Health Care Needs Assessment Survey was designed to contribute information to two separate projects: the Wrangell Medical Center Needs Assessment and the City of Wrangell Senior Services Needs Assessment. The Alaska Center for Rural Health (ACRH) contracted with both the City of Wrangell and with the Medical Center to carry out these needs assessments. To maximize efficien-cies and avoid confusion within the community, one survey instrument was developed to meet the data requirements for both. The results discussed in the following report cover Sections 1 and 2 of the survey, aimed at looking at satisfaction with local health services and community health priorities. Results for Section 3 of the survey, which focused on senior services needs, are reported separately in the report titled �City of Wrangell Senior Services Needs Assessment.� B. Background After detailed discussions with the Wrangell Medical Center�s administrator, it was concluded that a mail survey was the best methodology to obtain data that would meet the hospital and community�s needs. There was interest in receiving broad community input on what services residents used, which services they did not use, and a priori-tization of services available in the community. Such information would help the community and the hospital engage in long-term strategic planning to determine how to deliver services in the future. A survey was agreed upon as the best method for obtaining a wide number of perspectives from a high volume of residents. A benefit to the survey methodology was that it would allow for some comparisons to a similar survey implemented in Wrangell by the University of Washington in 1991. Some basic findings from the 1991 assessment are included within this report, with more detailed comparisons in Attachment 1. During the first audio conference with the Community Planning Group, conducted on June 22, 2001, a draft survey instrument developed by ACRH staff was reviewed and suggestions for revisions, additions, and deletions were elicited from the Community Planning Group. In addition, the Community Planning Group requested ACRH staff field test the draft survey instrument with a group of Petersburg residents. The community of Petersburg is similar in size and geographic location and also has a similar sized medical center.


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ACRH conducted a second audio conference with the Community Planning Group on July 13, 2001 to discuss feedback from the Petersburg pilot survey, and to review the improved survey instrument developed by ACRH staff. Suggestions were made by Planning Group members for improving the clarity of the instrument. A request was also made by the Planning Group to send surveys to select Prince of Wales Island communities that receive itinerant health care services from WMC, in addition to Wrangell households. These communities included Point Baker, Port Protection, and Coffman Cove. In order to provide an increased incentive to filling out surveys, ACRH staff suggested offering participants a raffle prize. Community Planning Group members elected to offer participants five individual cash prizes totaling $1750. The drawing would be completed during a Community Goal Setting Meeting in the fall. Suggestions for survey publicity were also discussed and included: a) articles/advertisements in local papers; b) radio announcements and interviews; c) an advertisement on the GCI scanner; and d) flyers posted around town. Revisions of the survey instrument were completed in mid July 2001, and the Commu-nity Planning Group approved a final version of the survey during a third audio confer-ence on July 18th. A cover letter and flyer, both to be enclosed with the survey instru-ment, were also reviewed and approved at this time. The survey instrument is included in Attachment 2. C. Design and Field Test The survey design includes three sections. The first section is similar to the survey used by the University of Washington in 1991. In addition to basic demographic information, it includes questions regarding patient satisfaction with a wide array of community health services, including the aspects of those services generating satis-faction or dissatisfaction. Section two is an expansion of the 1991 instrument. It col-lects data on the utilization of health services both within the community and outside of Wrangell for the respondent and the respondent�s household. Household data were not collected in the 1991 instrument. This section also includes information on insur-ance coverage and household income. The third section was written specifically for a project ACRH is completing for the City of Wrangell regarding senior services. It was included with this survey to minimize the number of surveys sent to Wrangell resi-dents, thereby reducing confusion and hopefully retaining a fair response rate. Further, parts of section three provide broader insight into aspects of Wrangell�s health care system that most affect seniors, such as the long-term care unit at Wrangell Medical Center. Although results of the senior services portion are not described in this report, graphical representation of those findings are included in Attachment 3, Section 3. A field test of the draft survey instrument was conducted during the first week of July 2001. Thirty pilot surveys were completed in Petersburg, with respondents ranging in age from 30 to 83. Pilot study participants were encouraged to provide feedback about the clarity of questions and to make suggestions for improvement. The instrument was revised and improved based on comments received through the field test. The final 10-page survey instrument was not field tested due to time constraints.


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D. Implementation Through an agreement with the Wrangell postmistress, surveys were distributed to all community residents with a local Post Office box.1 Surveys were dispersed only to boxes that were manually identified by postal service staff as households rather than businesses. A similar agreement was made with postal employees for survey distribu-tion in Coffman Cove, Port Protection, and Point Baker. At the time of mailing, there were reportedly 1119 household post office boxes in Wrangell, 70 in Coffman Cove, 36 in Port Protection, and 65 in Point Baker. To advertise the upcoming survey, an article was published in local newspapers, in-cluding the Wrangell Sentinel and Island News, describing the purpose of the assess-ment and the importance of residents voicing their opinions. A display advertisement was also published in the local newspapers one week prior to the survey arrival in mailboxes. Public announcements ran on the local GCI scanner and the radio station in Wrangell just prior to and during the arrival of surveys in the mailboxes. Flyers were also posted on bulletin boards around Wrangell to remind residents of the survey. Surveys were mailed on July 27, 2001 in a 9� x 12� white University of Alaska Anchor-age envelope, along with a cover letter from a well-respected, long-term community member. Respondents were eligible to be included in a raffle drawing, and a raffle ticket and flyer describing the prizes were also included. Surveys began arriving in boxes the first week of August 2001. Participants were requested to complete and mail back surveys with a postmark no later than August 24th if they wished to be included in the raffle drawing. Unfortunately, by coincidence, a similar sized UA envelope containing course catalogs also arrived on the same day. To allay fears voiced by the Community Planning Group that the envelopes were inadvertently being tossed due to confusion created by this factor, additional radio announcements were made. Arrangements were made for surveys to be available to those community members who had �accidentally� tossed their survey. This unfortu-nate coincidence may have affected the overall response rate. One week prior to the August 24th postmark deadline, an additional advertising cam-paign was conducted. An announcement was submitted to the Wrangell Sentinel and flyers were posted on Wrangell bulletin boards urging residents to complete and mail in their surveys.

1 It should be noted that ACRH staff attempted to obtain a list of household addresses in Wrangell. Unfortunately, no complete list was found to be available in an electronically readable format. Specifically ACRH attempted to use utility company files, information from the Permanent Fund Dividend (PFD), and the Booster Club at the High School. The agreement with the Postmistress provided an alternate method for survey distribution.


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E. Response Rate Due to the complications of the survey distribution described above, it is not possible to report a completely accurate overall response rate. Specifically, it is unclear how many surveys the postmistress actually distributed to households. A total of 1340 surveys were made available to all communities: 1150 to Wrangell, 80 to Coffman Cove, 40 to Port Protection, and 70 to Point Baker. This number included over and above the number of active post office boxes at the time of mailing which were: Wrangell-1119; Coffman Cove-70; Port Protection-36; and Point Baker-65 at the time. A total of 279 surveys were returned. However, despite these complications, a relatively small range can be given for response rates. If the number of surveys actually mailed is used, the response rate was 20.8%. If the response rate is based on the number of active post office boxes, the return was 21.6%. Table 1 (next page) shows the number of surveys returned by each community.

Table 1. Surveys Returned by Community

Community Number Wrangell 264 Coffman Cove 8 Port Protection 2 Point Baker 1 Surveys with no zip codes 4 Total surveys received 279

F. Data Limitations The University of Washington implemented a similar survey in 1991, and ACRH at-tempted to incorporate those findings and results for comparative purposes into this report. However, quantitative comparisons between the 1991 and 2001 data cannot be stated due to qualitative differences in the surveys. To quantitatively measure trends over time, certain methodological requirements must be met in order to conclude that there are statistically significant differences. Whether sampling household units or individual respondents, it is necessary to ensure that the population of interest is essentially the same in both instances of the survey. Here there are limitations in assuring that the samples for both surveys are representative of the populations being examined, leading to the inability to compare quantitatively between surveys. It is often possible to make the inference that the sample and population are similar if either the response rates are quite high or a non-response analysis shows that those


A5

who did respond to the survey are really no different than those who did not. If ade-quately high response rates existed, it can usually be shown that the majority of the variability in the population was captured in the responding sample. Here, however, the response rates from both the 1991 and 2001 surveys were relatively small, and do not allow for this kind of assessment. As a result of the limitations stated above, all comparisons between 1991 and 2001 survey data are provided for subjective pur-poses only. See Attachment 4 for a discussion of data limitations by survey question. G. Comparisons Between 1991-2001 Surveys In order to show a more accurate comparison of the 1991 and 2001 data, �don�t know� or �never used� answers were excluded in the calculation of 2001 percentages used for these purposes, as they were in 1991. In much of the rest of the narrative, and in the charts and graphs, the �don�t know� or �never used� were included, as we believe it is useful to know which services are not used as heavily. Because of these differences in calculating percentages, it is suggested that the comparative information provided in the accompanying text boxes and in Attachment 1 be reviewed as a corollary to the rest of the report, but somewhat in isolation from the rest of the report to avoid confusion.


A6

II. SURVEY FINDINGS

A. Respondent Demographics Demographics of survey respondents show that they are fairly similar to the general population, as recorded by the U.S. Census in 2000, although respondents skew slightly older than the general population in the 45-75 year old age categories. Survey respondents are almost evenly divided between men and women, with 49% of respon-dents being male and 51% female. For more in-depth tables on gender and age, please see Attachment 3.

Table 2. Survey Demographics Compared to 2000 Census Characteristics

Characteristic 2000 Census

2001 Survey

% Male 51.5% 49% % Female 48.5% 51% % Under 5 Years 6.1% 6% % 5-9 Years 7.5% 7% % 10-14 Years 10.2% 8% % 15-19 Years 7.2% 7% % 20-24 Years 3.6% 3% % 25-34 Years 9.7% 8% % 35-44 Years 17.5% 14% % 45-54 Years 16.1% 18% % 55-59 Years 5.6% 8% % 60-64 Years 4.7% 7% % 65-74 Years 6.4% 10% % 75-84 Years 3.8% 3% % 85 + Years 1.5% 1%

Ninety-five percent (95%) of respondents are Wrangell residents, with 3% stating residence in Coffman Cove, and 1% in Port Protection. The return rate from Point Baker is very slim, with only 1 respondent, or less than 1%. In fact, the majority (58%) of respondents live within 1 mile of the Wrangell Medical Center (WMC), and an addi-tional 24% live within 5 miles of the hospital. The vast majority of respondents (85%) use an automobile to travel to the medical center. Only 6% use planes or boats as their main source of transportation for medical services. A full 9% use other means, with many stating that they generally walk to WMC for services. This is likely possible because of the high percentage of respondents who live within less than a mile from the facility. For tables of this information, please see Attachment 3.


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Respondents have lived in Wrangell for varying lengths of time. Figure 1 shows that the largest percentage (36%) have resided in the community for less than 10 years. Fourteen percent (14%) stated that they have lived in Wrangell for more than 40 years.

Figure 1 [Table 4, Attachment 3]

Survey respondents� household incomes are fairly similar to the 1990 Census, the most recent census survey data available. Again, this suggests the survey is broadly representative of the general population. The largest percent (39%) of survey respon-dents live in a household earning $25,000-49,999; 35% of the Wrangell population had this household income in 1990. An additional 28% of survey respondents live in households earning less than $25,000, with 24% of the population living in households earning less than $30,000 in the 1990 Census. Additionally, 4%of survey respondents reside in families earning more than $100,000, compared to 6% in the 1990 Census.


Total Yearly Household Income (N=267)

n=12n=19

n=58

n=104

n=74

0%5%

10%15%20%25%30%35%40%45%

Less than$24,999

$25,000 -$49,999

$50,000 -$74,999

$75,000 -$99,999

$100,000and up

Income

Perc

ent o

f Res

pond

ents

Note: n= number of respondents

Length of Residence in Community (N=279)

n=100

n=54n=46 n=40

n=15 n=14 n=10

0%5%

10%15%20%25%30%35%40%

0-10 11-20 21-30 31-40 41-50 51-60 61+

Years

Perc

ent o

f Res

pond

ents

Note: n= number of respondents


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Fifty-five percent (55%) of respondents stated that they would expect private insurance to pay the majority of their medical bills if they were hospitalized tomorrow. However, a large percent said most of the costs would be borne by themselves and their family, with 15% stating they would pay for such services themselves. Fourteen percent (14%) have Medicare coverage for this, while 9% rely solely on Medicaid. Seven per-cent (7%) count on IHS/SEARHC in such circumstances. It is important to note that a number of respondents have coverage from several sources; the purpose of this ques-tion was to basically determine which payer would be the primary source of coverage. B. Satisfaction with Services

1. Local Health Services Respondents are generally satisfied with the health services they receive within Wrangell. Seventy-two percent (72%) are either satisfied or very satisfied with services provided by Wrangell Medical Center (WMC). Similarly, respondents are either satisfied or very satisfied with the Public Health Nurse (69%), the Stikine Family Clinic (72%), and EMS services (74%). Ratings for EMS services are particularly noteworthy. Only 2% of those who had used EMS were neutral, and less than 1% were very dissatisfied with these services. Likewise, among those who have used the Public Health Nurse, only 10% were neutral or somewhat dissatisfied, and nobody expressed extreme dissatisfaction with these services. In addition, a number of services are popular among those who use them, but are less widely accessed within the community. Chiropractic services had not been used by 41% of respondents. However, among those who had used local chiropractic services, 73% were either satisfied or very satisfied. Only 6% of those who had used these services expressed dissatisfaction. Long-term care services have similar results, with nearly half (46%) of respondents never having used these services. However, among those who had accessed LTC, 75% were satisfied or very satisfied, and only 9% were somewhat or very dissatisfied. Dissatisfaction was greatest for pharmacy services, and this is a service widely utilized by community respondents, with only 5% saying they have never used local pharmacies. Only 7% of respondents said they are very satisfied with pharmacy services, and over a third (38%) said they are either somewhat or very dissatisfied.

Percent of Respondents Reporting They are Satisfied or Very Satisfied

with Wrangell Medical Center

1991 Survey 2001 Survey 89% 75%

*Methodology notes included in page footer

Services with Greatest Change In Satisfaction Between 1991 and 2001 Surveys

(% Rating Service Excellent/Good)

Service 1991 Survey 2001 Survey Pharmacy 78% 40% Alcohol Treatment 67% 40%


*Note: Percentages for 2001 data listed in text boxes are calculated differently than for the rest of the report and graphs. They exclude "never used" or "don't know" answers from calculations, as was done in 1991, to make more accurate comparisons be-tween the two surveys. Also, quantitative differences between the two surveys cannot be stated. Comparisons are for subjective purposes only.


A9

Other services received mixed reviews, and these differences are not easily explained by race or age, although some differences based on income do exist. Approximately half (53%) of respondents are satisfied or very satisfied with dental care, but large numbers of respondents also expressed dissatisfaction (19%) or neutrality (13%). These discrepancies in views are not due to gender or age considerations. Men and women were equally likely to be satisfied with dental services. Further, there were no major differences in perceptions between different age categories. There did appear to be some differences based on income, with satisfaction with dental services increasing with income. Respondent households earning less than $25,000 were less likely to report satisfaction than respondent households over $75,000 (Figure 3).

Figure 3 [Table 5b, Attachment 3]

Satisfaction with mental health care within the community is also mixed (see Figure 4, next page). While half of the respondents have never accessed these services (50%), the remainder is divided. Twenty-one percent (21%) are pleased with these services, while 15% are neutral, and 13% are displeased. As with other services which have mixed reviews, these differences in perception could not be linked to differences in gender, income, or age.

Satisfaction with Dental Services by Income (N=266)

0%

5%

10%15%

20%

25%

30%35%

40%

45%

Very satisf ied Satisfied Neutral Somew hatdissatisf ied

Verydissatisf ied

Never used

Income

Perc

ent o

f Res

pond

ents Less than $24,999

$25,000 - $49,999$50,000 - $74,999$75,000 - $99,999$100,000 and up



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Figure 4 [Table 5a, Attachment 3]

2. Visiting Health Services With the exception of the visiting eye clinic, the majority of respondents have never utilized visiting specialists in Wrangell. Seventy-one percent (71%) have used the visiting ophthalmologist/optometrist, but it is the only visiting specialist that has been accessed by over 50% of those surveyed. The next highest utilized specialists include the visiting internist, with a 41% utilization rate, and the visiting dermatologist, who has been seen by 36% of respondents. Likewise, 38% of total respondents, and 44% of all female respondents, have utilized the visiting OB/GYN. While most respondents have not used the visiting specialists, those who have are generally satisfied with their services (see Figure 5, next page). Dissatisfaction with most of the visiting specialists hovers around 4-5% of respondents. The visiting ophthalmologist/ optometrist received the distinction of having both the highest satisfaction and dissatisfaction ratings among visiting specialists. Nine percent (9%) stated they are somewhat or very dissatisfied with these services, while 51% are

Satisfaction of Health Care Services in Wrangell

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Massage Therapy (N=269)

Pharmacy Services (n=274)

Mental health services (n=270)

Avenues/Wrangell Council on Alcohol (n=269)

Physical Therapy (n=273)

Dentists (n=276)

Long-term care facility (n=274)

Chiropractor (n=273)

Stikine Family Clinic (n=276)

Wrangell Medical Center (n=274)

Public Health Nurse (n=275)

EMS (EMTs, ambulance) (n=274)

Heal

th C

are

Serv

ices


Very Satisfied Satisfied Neutral Somew hat Dissatisf ied Very Dissatisf ied Never Used



A11

satisfied/very satisfied. Also receiving high marks for satisfaction are the visiting internist (26% satisfied/very satisfied) and visiting OB/GYN (23% satisfied/very satisfied).

Figure 5 [Table 5c, Attachment 3]

Together, these results paint a picture of residents who are generally happy with the quality of health services received in the community through both local providers and itinerant physicians. Pharmacy services appear to be the largest outlier to this generalization, with over one-third (36%) expressing dissatisfaction with services.

Satisfaction of Visiting Physicians/Specialists in Wrangell

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Visiting Psychiatrist (n=273)

Visiting ENT Specialist (n=272)

Visiting Podiatrist (n=268)

Visiting Audiologist (n=273)

Visiting Dermatologist (n=272)

Visiting Pediatrician (n=272)

Visiting Orthopedist (n=274)

Visiting OB/GYN (n=271)

Visiting Surgeon (n=269)

Visiting Internal Medicine Physician (n=271)

Visiting Ophthalmologist/Optometrist (n=272)

Visi

ting

Phys

icia

ns/S

peci

alis

ts


Very SatisfiedSatisfiedNeutralSomew hat Dissatisf iedVery Dissatisf iedNever Used



A12

3. Reasons for Satisfaction – WMC/Stikine Family Clinic Respondents are pleased with a number of aspects of the care provided by the Wrangell Medical Center/Stikine Family Clinic. Highest marks are reserved for aspects surrounding the perceived quality of care and patient environment. Patients identify the cleanliness of facilities as exceptional, with 89% of respondents marking them as either good or excellent, although this was a slightly lower percentage than in the 1991 survey. A number of other clinical factors are also given high marks, with nearly three-fourths of respondents rating them as either good or excellent. These include: nursing care (79%), overall quality of care (78%), laboratory services (77%), physician services (76%), staff concern and compassion (74%), emergency room care (72%), and radiology services (72%). In addition, very few respondents rated these clinical areas as poor. None of the aspects mentioned above had more than 5% �poor� ratings, and most had poor ratings of less than 1-2%.

While patients showed great satisfaction with most of the clinical aspects of care, results for the financial facets of care were mixed. Nearly one-third of respondents believed that the cost of care is unreasonable, with 31% rating the cost of care as poor. However, nearly equal numbers rated the reasonableness of charges as good/excellent (31%) or fair (29%). Interestingly, there were only minor differences in the perception of the reasonableness of charges between households with different income levels (see Figure 6, next page. Respondents with household incomes less than $25,000 were just as likely to state that the cost of care is excellent or good as respondents with household incomes over $100,000. However, lower income houses were more likely to categorize the cost of care at WMC as poor. Nearly 33% of respondents with household incomes below $25,000 called charges poor. Households with incomes over $100,000 categorized charges as poor 17% of the time.

Highest Rated Aspects of Care at WMC (% Excellent/Good)

Aspect 1991 Survey 2001 Survey Building Cleanliness 95% 93% Emergency Room Care 86% 84% Overall Quality of Care 85% 84% Nursing Care 83% 89%


Lowest Rated Aspects of Care at WMC (% Poor)

Aspect 1991 Survey 2001 Survey Reasonableness of Charges 37% 34%




A13


Similar results are found for billing and financial services. Although they have the second highest �poor� ratings (13%), results are varied, with 58% rating them as excellent/good and 20% rating them as fair. In summary, patients are most satisfied with clinical aspects of care received at WMC/Stikine Family Clinic, and less satisfied with the financial element (see Figure 7, next page).

Satisfaction with Reasonableness of Charges of Wrangell Medical Center by Income (N=266)

0%

5%

10%

15%

20%

25%

30%

35%

Less than$24,999

$25,000 -$49,999

$50,000 -$74,999

$75,000 -$99,999

$100,000 and up

Income

Perc

ent o

f Res

pond

ents

Excellent Good Fair Poor Don't Know Note: n=number of respondents


A14


4. Reasons for Satisfaction – Wrangell Physicians Ratings are similar for Wrangell�s physi-cians. High marks were received for clinical aspects of care, including 80% who stated that physician compassion is �good� or �excellent.� Similarly good reviews are given for the competence of support staff (74%) and the overall quality of medical treatment (72%).

Top Three Aspects of Physician Care in Wrangell in 1991 Survey

(Percent marking each as “excellent” or “good”)

1. Competence of Support Staff (83%) 2. Quality of Medical Treatment (77%) 3. Ability to Get Appointment Quickly (77%)


Rating of Wrangell Medical Center/Stikine Family Clinic Services

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Reasonableness of charges (n=277)

Billing and financial services (n=273)

Food services (n=271)

Overall quality of care (n=276)

Laboratory services (n=275)

Staff concern/compassion (n=274)

Nursing care (n=272)

Physician care (n=275)

Radiology services (n=273)

Emergency room care (n=276)

Building cleanliness/condition (n=276)

Heal

th C

are

Serv

ices


ExcellentGoodFairPoorDon't Know




A15

However, over one-quarter (29%) of respondents felt the charge for seeing local physicians is unreasonable, and only 7% stated that the cost of physician care is excellent. As was the case with the cost for care at WMC, household income only partially explains differences in perception of the cost of care (see Figure 8 for a breakdown of level of satisfaction by income). Lower income houses were twice as likely to categorize the cost of physician care as poor; thirty-five percent (35%) of respondents with household incomes under $25,000 marked the cost as �poor,� while

only 17% of respondents with household incomes over $100,000 found them �poor.� It should be noted, however, that income level does not fully explain differences in perception of cost. Respondents with household incomes between $75,000-$99,000 have the third highest �poor� markings for this question, with 32% stating charges are �poor.�


Results surrounding physician access are mixed and wide-ranging. Fifty-seven percent (57%) graded physician access as excellent/good, while 16% gave poor ratings. Similarly, respondents were varied with their viewpoints on the ability to see the physician promptly at the scheduled time. Over half (51%) found this good or

Top Three Aspects of Physician Care in Wrangell in 2001 Survey

(Percent marking each as “excellent” or “good”)

1. Concern/compassion for patient (84%) 2. Competence of Support Staff (79%) 3. Quality of Medical Treatment (76%)


Rating for Reasonableness of Charges of Wrangell Physicians by Income Level (N=264)

0%5%

10%15%20%25%30%35%40%45%

Less than$24,999

$25,000 -$49,999

$50,000 -$74,999

$75,000 -$99,999

$100,000 andup

Income

Perc

ent o

f Res

pond

ents

Excellent Good Fair Poor Don't Know Note: n=number of respondents



A16

excellent, while 29% categorized it as fair, and 14% considered it poor. On one measure of physician access, Wrangell providers score high. A majority (54%) of respondents rated weekend/night time access to physicians as good or excellent, while only 8% were displeased with this service. On a positive note, the majority of those surveyed felt confident that Wrangell physi-cians and their staff are maintaining patient confidentiality (Figure 9). Sixty-seven percent (67%) rated confidentiality as good or excellent, while only 8% marked this area as poor.


Rating of Wrangell Physicians

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Reasonableness ofcharges (n=274)

Ability to see MD promptlyat scheduled time (n=275)

Ability to get appointmentquickly (n=275)

Competence of supportstaff (n=272)

Night/w eekend careavailability (n=273)

Quality of medicaltreatment (n=274)

Confidentiality (n=271)

Concern/compassion forpatient (n=275)

Phys

icia

n Q

ualit

y


ExcellentGoodFairPoorDon't Know



A17

C. Geographical Preferences for Health Service Delivery

1. Market Share Wrangell maintains a healthy market share for both inpatient and outpatient services, similar to the results of the 1991 survey. Of the 215 individuals who reported being hospitalized within the past two years, 137 individuals (64%) reported being hospital-ized at least once at the Wrangell Medical Center. In addition, almost half (47%) of the total number of reported hospitalizations over the past two years occurred locally in Wrangell, with an additional 23% occurring in Ketchikan (see Figure 10).

Figure 10 Figure 11 [Table 12, Attachment 3] [Table 14, Attachment 3]

Outpatient services maintain an even larger market share. Ninety-five percent (95%) of all individuals who reported being seen in an outpatient medical office over the past two years reported being seen at least once in the local Wrangell medical office. In addition, Figure 11 shows that a full 84% of all office visits were reported to take place locally, with 5% occurring in Ketchikan. Three percent (3%) of office visits were reported in �other� communities, which appear to be mostly communities within the Pacific Northwest region and are likely emergency services accessed while the patient was away from home. It is difficult to compare results on outpatient services to the 1991 survey due to differences in the way the questions were asked.

Percent of Total Hospitalizations Occurring at WMC During Past Two Years

1991 Survey 2001 Survey 51% 47%


Total Number of Hospitalizations Reported in the Past Two Years

(N=445)

Wrangell Medical Center(n=210)

47%

Other(n=27)

6%

Seattle(n=45)10%

Juneau(n=15)

3%

Sitka(n=23)

5%

Anchorage(n=21)

5%

Ketchikan(n=104)

23%

N ote: n=number of respondents

Number of Medical Office Visits Reported in the Past Two Years

(N=4966)

Other(n=157)

3%

Anchorage(n=43)

1%

Wrangell Medical Center

(n=4196)84%

Ketchikan(n=260)

5% Sitka(n=25)

1%

Seattle(n=186)

4%

Juneau(n=99)

2%

Note: n=number of medical office visits (605 individuals reported a total of 4966 medical office visits)


A18

2. Reasons for Accessing Care in Different Geographic Locales Patients who had accessed care outside of Wrangell during the past two years were asked to expound on their reasons for leaving the community for these services. Respondents were asked to check all reasons that applied, not just the primary reason, so percentages will add up to more than100%. For hospital care, the most prevalent rea-son for receiving care outside of Wrangell is that the services needed were not avail-able locally (69%). Sixty percent (60%) also stated that they used the non-local providers at least in part because they were referred by their physicians else-where. One-quarter (25%) of respondents receiving hospital services outside of Wrangell stated that one of the reasons they went elsewhere was for better quality of care. This is displayed in Figure 12.


Note: Respondents were allowed to check more than one response on this question. A total of 150 respondents checked 314 responses.

Percent Citing Quality Concerns as a Reason for Receiving Services Outside

Wrangell

Type of Service 1991 Survey 2001 Survey Hospital 40% 25% Physicians 54% 22%



Reasons for Being Hospitalized Outside of Wrangell Medical Center

n=10

n=11

n=12

n=15

n=16

n=20

n=37

n=90

n=103

0% 10% 20% 30% 40% 50% 60% 70% 80%

Other

Family Support

More privacy at non-local hospital

Services cheaper elsew here

Indian Health Service perference/requirement

Travel

Quality of services better elsew here

Referred by physician

Services not provided locally

Reas

ons

for H

ospi

taliz

atio

n



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Reasons for obtaining outpatient physician care outside of Wrangell closely mirrored reasons for hospital care (see Figure 13). The most often cited reasons for leaving Wrangell for medical office visits is because the services are not provided locally (66%) or the patient is referred by a physician (48%). As was the case with hospital services, nearly one quarter (22%) of respondents who had gone out of the community for physician services did so in part because they believed they would receive better quality of services elsewhere. One major difference with hospitalization services, though, is the number of respondents who received physician services outside of Wrangell at least in part due to the cost of services locally. Nearly one-fifth (17%) felt services would be cheaper elsewhere, and this fact played at least a partial impact in their decision to receive services outside of Wrangell. This corresponds with findings described elsewhere in this report, which showed fairly high levels of dissatisfaction with the cost of care locally, particularly for physician services.


Note: Multiple responses allowed (262 individuals checked 522 responses).

Reasons for Visiting Medical Offices Outside of the Wrangell Medical Center

n=173

n=127

n=58

n=44

n=36

n=22

n=20

n=13

n=29

0% 10% 20% 30% 40% 50% 60% 70%

Other

More privacy w ith non-local physician

Family support

Indian Health Service preference/requirement

Travel

Services cheaper elsew here

Quality of services better elsew here


Services/specialty not provided locally

Med

ical

Rea

son



A20

3. Types of Services Accessed in Different Geographic Locales General satisfaction with local health services is exemplified again in questions aimed at determining where patients would first seek treatment for different types of health needs. Respondents overwhelmingly selected Wrangell as their primary point of contact with the health system. Marks for Wrangell are high for preventive services, as well as more urgent conditions. Figure 14 shows where respondents would initially seek care for a variety of services. Eighty-seven percent (87%) of respondents would select to stay in Wrangell for general physical exams, with only 3% choosing Ketchikan, and 3% choosing Seattle. Other communities received even smaller numbers. Retaining such a high market share for these types of preventive services is a nice accomplishment for the local health system since patients could easily choose to coordinate such non-urgent exams during scheduled trips to other communities. Respondents also prefer to receive services locally for a wide range of urgent and emergent care. Seventy-seven percent (77%) would choose to receive services within the community for minor fractures, and 79% would choose to be hospitalized at WMC in the case of pneumonia. Ketchikan is the second largest winner for these services, with 13% of respondents choosing to go to Ketchikan for treatment of a fracture, and 7% going there for hospitalization associated with pneumonia.

Figure 14

[Table 9a, Attachment 3]

Location Where Respondent Would Initially Seek Care

n=238

n=212

n=210

n=164

n=67

n=108

n=119

n=36

n=56

n=63

n=63

n=133

n=201

n=157

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Cancer Treatment (n=268)

Outpatient Surgery(n=265)

Mental Health Counseling(n=252)

Pregnancy/delivery(n=227)

Minor Fracture (n=273)

Pneumonia hospitalization(n=268)

General Physical Exam(n=274)

Perc

ent o

f Res

pond

ents

Type of Care

WrangellOut of Wrangell



A21

Even without anesthesia available, most women also prefer to deliver their children locally. Seventy-two percent (72%) selected Wrangell as their initial choice for labor and delivery services, while 16% would prefer to deliver in Ketchikan. Eighty-eight percent (88%) of 1991 respondents stated they would choose local labor and delivery. Forty-one percent (41%) of respondents would choose to utilize visiting physicians and have outpatient surgery locally. Large numbers selecting Ketchikan (25%) and Seattle (17%) may have been related to whether the types of surgery required were available locally, and how much time they would need to wait to schedule the surgery until the itinerant physician visited. Mental health counseling is one of the only services available locally which less than half of respondents choose to access locally. Only 47% would first initially seek mental health counseling locally. Other responses were distributed over a number of choices, including 15% for Seattle, 6% for Ketchikan, 5% for Juneau, and 4% for Anchorage. Interestingly, a fairly large percentage of respondents (21%) stated they would seek mental health counseling at a different, unspecified location. They were not asked to specify what this location might be. It is also unclear why local mental health services did not retain as large of a market share as other local services. Plausible explanations may include confidentiality concerns, or a perceived stigma associated with mental health counseling. For services not available locally, such as cancer treatment, respondents would most often choose to go to Ketchikan or Seattle. Seattle is the primary choice for cancer treatment, with 59% choosing this as their initial point of contact. Twenty-five percent (25%) would attempt to receive initial services locally in Wrangell, an increase from the 1991 survey. Since cancer treatment is not available locally this may signal that patients would initially seek care from their local physicians and then continue their care with a physician they are referred to by their local primary care provider.

Biggest Changes In Geographic Choice for Initial Treatment Between 1991 and 2001 Surveys

(Percent choosing to receive care in Wrangell)

Service 1991 Survey 2001 Survey Cancer Treatment 15% 25% Pregnancy/Delivery 88% 72% Mental Health Counseling 62% 47%




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4. Specialties Accessed Outside of Wrangell The vast majority of respondents have not accessed physician specialists outside of Wrangell in the past two years. For patients who did, surgeons were the specialty most likely to be used (Figure 15). Thirty-two percent (32%) of respondents acknowledged using surgical services outside of Wrangell during the past two years. It is unclear the type of surgeons employed in all cases. Those identified by at least one respondent included orthopedic surgeons and neurosurgeons. Cardiologists (13%) and eye care specialists (13%) were the next most popular specialties, although it is unclear whether any of these included cardiac or ophthalmalic surgery.


Patients were least likely to leave Wrangell to access behavioral health specialists (1%), obtain radiological screenings (1%), acquire alternative medicine therapies (1%), or see an oncologist (2%).

Physician Specialties Seen Outside of Wrangell in the Past Two Years (N=411*)

n=133

n=54

n=52

n=39

n=38n=22

n=21

n=7

n=6

n=5n=3

n=31

0% 5% 10% 15% 20% 25% 30% 35% 40%

Other

Behavioral Health

Radiology

Adjunct Therapy

Oncologist

ENT specialist

Dental w ork/orthodontist

Medical Specialties

OB/GYN

Cardiologist

Ophthalmologist/Optometrist

Surgeon/surgical specialties

Phys

icia

n Sp

ecia

lty

Percent of RespondentsNote: Multiple responses allowed.n=number of respondents


A23

5. Place of Service for Primary Care Respondents are overwhelmingly staying close to home for basic primary care services. Figure 16 shows that eighty-nine percent (89%) stated that they and their household members see their primary care provider in Wrangell. Only 7% maintained that they had a primary care provider located elsewhere. Of those who access primary care outside of Wrangell, the majority asserted that their primary care provider was located in the �lower 48� in a place other than Seattle. These may be people who split their residency with another community and obtain most of their primary care in their other home community, although no data exist to support this theory. Very few respondents (7) access primary care services in Ketchikan.

D. Community Health Priorities 1. Importance of Local Health Services There is widespread agreement that the Wrangell Medical Center and Stikine Family Clinic are important and valuable community resources. Respondents unequivocally stated that it is very important that these facilities remain open within the community (see Figure 17, next page). Ninety-three percent (93%) affirmed that it is very important that they remain open, and an additional 5% believed they are somewhat important. Only 4 respondents (1%) maintained that these resources are of no consequence within the community.

*Note: Five of these respondents listed Wrangell in conjunction with other communities

Importance of WMC Remaining Open in the Community

(Percent rating “very important”)

1991 Survey 2001 Survey 96% 93%




Location of Primary Care Provider (N=682)

No primary provider(n=27)

4%

Outside of Wrangell/

Other(n=46)

7%

Wrangell*(n=609)

89%



A24


2. Health Service Priorities Wrangell residents rated access to health providers, including physicians, emergency medical personnel, dentists, eye care specialists, and pharmacists as their most important health service priority. Access to a wide variety of health education, counseling, and mental health services were regarded as lower concerns. The highest priority for residents is access to physician providers within the commu-nity. Eighty-four percent (84%) ranked local physician access as a high priority, and an additional 14% thought this is a moderate priority. Few disagree, with only 2% pronouncing that it is not a priority at all. Access to emergency medical personnel is also of value to respondents. Ninety-four percent (94%) rated access to the EMS system, including ambulances and emergency medical personnel, as a moderate or high priority. Likewise, 91% rated medical evacuation services as a high or moderate priority. Access to other types of health providers also merited high response. Almost 90% of respondents rated access to a number of health providers as high or moderate priorities. Health providers mentioned the following specific priorities: dentists (91%), pharmacists (89%), eye care specialists (89%), and public health nurses (85%). Several areas of prevention and screening were also ranked as high community health priorities. Respondents affirmed the importance of access to early cancer screening and prevention tools, with 89% ranking this as a moderate or high priority. First aid and lifesaving skills were also rated high (79% moderate/high), as were the importance of immunizations (78% moderate/high). Surprisingly, while many prevention services were viewed as high priority services, one area of prevention was not rated highly, and in fact received the lowest priority ranking of all � family planning. Eighty-one percent (81%) of respondents found family planning to be of low priority or not a priority at all. In this statistic, there were no major

Importance of Wrangell Medical Center/Stikine Family Clinic

Remaining Open (N=272)Somew hat important(n=13)

No opinion(n=1)

Not important

(n=4)

Very important(n=254)



A25

differences between men and women, or with women in childbearing years. The Stikine Family Clinic and the local Public Health Center do provide prescriptions for birth control, pregnancy, and prenatal care. A wide array of counseling, mental health, and behavior modification services were viewed as lower priority items within the community. In fact, nearly three-fourths of respondents rated smoking cessation (76%), HIV/Aids testing and counseling (75%), and alcohol/drug treatment (73%) as low priority or not a priority. Also rated as low priorities were family counseling (71% low priority/not priority), mental health counseling (68%), and psychiatric services (66%). (See Figure 18, next page.)


A26


Household Priorities for Health Care Services

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Family planning (n=270)

Family counseling (n=270)

Aids/HIV testing and counseling (n=270)

Alcohol/drug treatment and counseling (n=271)

Psychiatric services (n=270)

Classes/counseling to help stop smoking (n=268)

Mental health counseling (n=272)

Developmental disabilities assistance (n=269)

Nutrition counseling (n=269)

Suicide prevention counseling (n=267)

Home health aide (n=273)

Care during pregnancy (n=267)

Sexually transmitted disease testing/counseling (n=269)

Injury prevention information (n=271)

Health education (n=268)

Hearing services/audiology (n=270)

Traditional/alternative medicine (n=271)

Long-term care facilities/services (n=273)

Specialty clinics (n=270)

School dietary programs/lunches (n=269)

School physical exams (n=269)

Women's health services (n=272)

Life saving skills/f irst aid training (n=271)

Hospital inpatient care (n=272)

Public Health Nurse (n=272)

Eye care (n=274)

Pharmacy services (n=270)

Immunizations (n=271)

Dental services (n=271)

Early cancer detection & screening (n=273)

Medivac services (air ambulance) (n=272)

EMS (EMTs, ambulance) (n=271)

Physician services in the community (n=274)

Perc

ent o

f Res

pond

ents

Health Care Service

high prioritymoderate prioritylow prioritynot a priority



A27

E. Findings from Open-Ended Questions At the end of the survey, respondents were given an opportunity to communicate other things they felt had not been adequately addressed in other areas of the question-naire. While many took the occasion to further emphasize issues discussed elsewhere in the survey, others conveyed priorities and opinions on subjects that might have otherwise been missed. The major themes discussed and telling comments include: 1. Overall praise for local health services, including WMC and local physician staff.

• “I think Wrangell is very lucky to have the high level of hospital services and senior-related services. Not many towns of our size have these services.”

• “For the most part, the services provided in Wrangell are very good considering the size and remoteness of the town.”

• “We are so fortunate to have the medical facilities presently in Wrangell and the excellent staff.”

2. The most popular expansion of health services mentioned was the desire for more

local surgery, increased access to sub-specialists, improvements to WMC, and more alternative medicine therapy options are also favorite ideas.

• “It would be much more convenient, less expensive, and easier for seniors if

there were some surgical ability in Wrangell, at least for relatively minor problems.”

• “It would be nice to have specialist doctors visit Wrangell more often.” • “The hospital, I feel, needs to be up-to- date…I would like to see us utilize

unused space for a more up to date feel.” • “For our size town, services are excellent. I wish there were a way to include,

acknowledge, and validate Native approaches to healing.” 3. Increased support group and health education opportunities were new social

services requested. Respondents also wanted new programs for alcohol treatment.

• “We need more organized groups for the community such as co-dependents’ groups, children of alcoholics, single parent groups, parenting groups, walking groups, divorce groups…domestic violence information groups, foster parent groups, etc.”

• “We need community health education and a consistent hospital newsletter sent at specific intervals 3-4 times yearly.”

• “Alcoholism is a major problem in the Pt. Baker/Port Protection area. If there could be some kind of an awareness program to possibly help some of these folks it would be great. I don’t know what would help – maybe you have some ideas.”


A28

4. Respondents commented that community health services could be improved through a variety of means. Regarding physician services, patients noted a desire for improved appointment access, greater continuity of care, and more preferred providers. Others questioned the competency of some local physicians. Also mentioned was the need for improved billing systems and assured patient confidentiality.

• “The wait to see a doctor is too long. If you have an appointment at 9 am you

will be lucky to see the doctor by 10 am, and that was when we had four doctors on staff. What is it going to be like with only two?”

• “The physicians that are now here are very nice but it is a bit frustrating having to see four different doctors. One never knows who will be the doctor at your appointment. It would be nicer to only have one doctor to yourself.”

• “I believe the doctors should look into a patient’s medical history a bit deeper before they try and come up with an off-the-wall diagnosis, and they should ask the other doctors if they don’t really know.”

• “My husband is employed by the federal government and we have insurance through them. From what I’ve heard others say, it is very difficult to get reimbursed because we have no doctors in Wrangell who are providers of the plan (Blue Cross/Blue Shield). Is there a remedy for this?”

• “My main complaint with Wrangell Medical Center is the billing statements. They are hard to match up with insurance payments. I wouldn’t know how much to pay! It’s certainly not efficient.”

5. An overarching theme was the concern seniors expressed regarding the high cost

for services, especially medical services. They cited apprehension regarding the cost for a wide range of services, including travel costs, hospital charges, physician costs, and pharmaceuticals.

• “Something has to be done about cost. I know many people, myself included, who don’t see doctors when really should because of the extreme cost. It is shameful that we have the facility and the ability to treat, but uninsured people can’t afford to use the services.”

• “Prescriptions are too high in Wrangell. For example, thirty pain pills in Seattle cost a little over $8 and in Wrangell the same pills cost $40. This is outrageous.”

For a more complete analysis of open-ended question themes and comments, please see Attachment 5.

Wrangell Senior Services Needs Assessment �Survey Report� Appendix A: Attachment 1 A29

Attachment 1:

COMMUNITY SURVEYS 1991 – 2001 Comparison Study

A. Background Due to differences in methodology used between the 1991 and 2001 surveys, it is not possible to do a quantitative analysis1 of the data, but we can do a subjective assess-ment of the changing attitudes with regards to health care in Wrangell over time. Below is a summary of some side-by-side comparisons of people�s perception of the health services available and where people are going for services in 1991 and 2001. Please note that in order to show a more accurate comparison of the 1991 and 2001 data, �don�t know� or �never used� answers were excluded in the calculation of the 2001 percentages, as they were by the University of Washington in 1991. In much of the rest of the survey report and in the charts and graphs, �don�t know� or �never used� were included, because ACRH believes inclusion can provide useful information. Therefore, percentages used for comparison here are calculated slightly differently than those used in the Survey Report found in Appendix A, and the tables found in Attachment 3. B. Satisfaction with Local Health Care Services Respondents were asked about the importance of the Wrangell Medical Center (formerly Wrangell General Hospital) remaining open in their community. Ninety-six percent (96%) of the respondents in 1991 responded it was �very important� for the hospital to remain open, and 93% reported the same in 2001. When asked to rate the satisfaction level of the Wrangell Medical Center, 89% reported �very satisfied� or �somewhat satisfied� in 1991; 75% reported �very satisfied� or �satisfied� in 2001. Respondents from both the 1991 and 2001 surveys seemed satisfied with many aspects of the Wrangell Medical Center. The most highly rated aspects in both 1991 1 To measure trends over time, certain methodological requirements need to be met in order to implement quantitative analysis of the data to conclude statistically significant differences. Whether sampling household units or individual respondents it is necessary to ensure that the population of interest is essentially the same in both instances of the survey. This does not require that exactly the same individuals be surveyed, but it does require that the specification of population (e.g., households or individuals), geographic distribution, and composition of the responding sample be similar. Here there are limitations in assuring that the samples for both surveys are representative of the populations being examined, which therefore leads to the inability to compare quantitatively between both surveys.

It is often possible to make the inference that the sample and population are similar if either the response rates are quite high or a non-response analysis shows that those who did respond to the survey are really no different than those who did not. If adequately high response rates existed, it can usually be shown that the majority of the variability in the population was captured in the responding sample. Here, however, the response rate from both the 1991 and 2001 surveys was relatively small and does not allow for this assessment.


and 2001 that respondents felt were either �excellent� or �good� were: building cleanliness/condition (95% in 1991; 93% in 2001); emergency room care (86% in 1991; 84% in 2001); overall quality of care (85% in 1991; 84% in 2001), and nursing care (83% in 1991; 89% in 2001). The lowest rated aspect in both years was reasonableness of charges: 37% in 1991 and 34% in 2001. Respondents were also asked to rate the quality of care provided by Wrangell physicians in both 1991 and 2001. The top three aspects rated in 1991as either �excellent� or �good� were: competence of support staff (83%), quality of medical treatment (77%), and ability to get appointment quickly (77%). In 2001, respondents were asked the same question. The top aspects were concern/compassion for patient (84%), competence of support staff (79%), and quality of medical treatment (76%). It should be noted that only 37% of respondents rated reasonableness of charges as �excellent� or �good.� This is a drop from the 56% reported in 1991. Lastly, respondents were asked to rate other local health care services in both 1991 and 2001. EMS services were identified in both surveys as having the highest rating: 98% of the respondents rated the ambulance service as �excellent� or �good� in 1991, and 97% reported the same for EMS service in 2001. Two health care services that have a noticeable difference in the ratings between 1991 and 2001 include pharmacy services and alcohol treatment. In 1991, 78% respondents rated pharmacy services as �excellent� or �good�, while 40% of the 2001 respondents did. Sixty seven percent (67%) of the 1991 respondents felt alcohol treatment was �excellent� or �good,� while only 40% of the 2001 respondents did. C. Where Respondents Would Choose to Seek Care In both 1991 and 2001, respondents were asked to identify where they would initially seek treatment for certain health care needs such as a minor fracture or cancer treatment. Choices given were Wrangell, Juneau, Sitka, Ketchikan, Anchorage (2001 survey only), Seattle, and Other. When looking at those respondents who chose Wrangell as their first choice for health care it should be noted that a higher percentage of respondents chose Wrangell for cancer treatment in 2001: 15% in 1991 and 25% in 2001. Two areas to note that had less respondents reporting they would seek care in Wrangell from 1991 include: pregnancy/delivery (88% in 1991; 72% in 2001) and mental health counseling (62% in 1991; 47% in 2001). D. Location of Hospitalizations in the Past Two Years In 1991, 51% of the total reported hospitalizations in the past two years for household members occurred at the Wrangell Medical Center. This is similar to the 47% of total hospitalizations reported in 2001 for the Wrangell Medical Center. When asked why household members were hospitalized outside of Wrangell, the top reasons were the same in 1991 as in 2001: services not provided locally (77% in 1991; 69% in 2001) and referred by a local MD (69% in 1991; 60% in 2001). It should be


noted that fewer respondents chose quality better elsewhere as a reason in 2001 than in 1991: 25% in 2001 and 40% in 1991. E. Location of Past Medical Office Visits It is a little more difficult to compare 1991 and 2001 survey results regarding medical office visits because of the way the questions were asked. In the 1991 survey, visits to physicians were separated out from visits to practitioners, which included nurse practi-tioners, public health nurses, midwives, and physician assistants. In addition, respon-dents were only asked to report the number of visits for the past year. The 2001 survey took a different approach when looking at physician market share. Respon-dents were asked to report the number and location of medical office visits for them-selves and household members during the past two years. Survey results from 1991 showed that 82% of the medical care visits to physicians and 79% of visits to non-physician offices occurred in Wrangell. In the 2001 survey, 95% of individuals reported at least one medical office visit in Wrangell during the past two years. Of all medical office visits, 84% reportedly occurred in Wrangell in 2001. Respondents were asked to list reasons household members visited non-local physicians in 1991. Reasons for using medical offices outside of Wrangell in 2001 were also asked. The two most cited reasons for both years were services/specialty not provided locally (91% in 1991; 66% in 2001) and referred by a local MD (66% in 1991; 48% in 2001). It should be noted that 54% of the 1991 respondents chose quality better elsewhere as a reason, while only 22% of the 2001 respondents did. F. Primary Care Provider In 1991, respondents were asked if they had a personal physician who cared for most of their medical needs. Eighty-seven percent (87%) reported they did, and 89% of these respondents reported that their personal physician was located in Wrangell. In the 2001 survey, 96% of the respondents reported having a �primary care provider.� Of these, 93% reported that provider was located in Wrangell. G. Non-Local Specialists Seen Outside of Wrangell In 1991, respondents were asked to list any �non-physician health care providers� seen outside of their local community in the past year. Many of the 1991 responses included physician specialties as well and were noted in the report. In the 2001 survey, respondents were asked to include physician specialties seen outside of Wrangell in the past two years. These factors make it a little more difficult to compare the two. When looking at all specialties listed in the 1991 report, the top non-local specialists reportedly seen in the past year were dentists (49%), dental specialties (14%), and OB/GYNs (17%).


In 2001, the top three physician specialties reportedly seen outside of Wrangell in the past 2 years included: surgeons (29%), ophthalmologist/optometrist (13%), and cardiologist (13%).

Complete Comparison Charts

1991-2001 Survey Data

Table 1

Rating of Wrangell Medical Center* 1991 2001 Building cleanliness/condition 95% 93% Emergency Room Care 86% 84% Overall quality of care 85% 84% Nursing Care 83% 89% Staff concern/compassion 78% 79% Outpatient Services** 77% ▬ Physician Care 77% 80% Billing and financial services 74% 63% Food Services 68% 79% Reasonableness of charges 37% 34%

*“Don’t know” answers not included. Percentages calculated for those respondents reporting “Excellent” or “Good.”

**Outpatient services listed separately in 2001: radiology (88%) and laboratory (87%)

Table 2

Rating of Wrangell Physicians* 1991 2001 Competence of support staff 83% 79% Ability to get appointment quickly 77% 61% Quality of medical treatment 77% 76% Night/weekend care availability 73% 70% Concern/compassion for patient 72% 84% Reasonableness of charges 56% 37% Ability to see MD promptly 53% 53%

*“Don’t know” answers not included. Percentages calculated for those respondents reporting “Excellent” or “Good.”


Table 3

Satisfaction with Health Care Services in Wrangell*

1991 2001

Ambulance service** 98% 97% Wrangell Medical Center 89% 75% Public health nursing 88% 86% Nursing home care 83% 74% Visiting ophthalmologist/Optometrist 83% 71% Pharmacy services 78% 40% Visiting orthopedic 70% 60% Visiting dermatologist 69% 54% Dentists 68% 61% Alcohol treatment 67% 40% Visiting internal medicine physician 66% 62% Chiropractor 65% 73% Mental health care 52% 42%

*“Don’t know” and “Never Used” answers not included. Percentages calculated for those respondents reporting “Very Satisfied” or “Somewhat Satisfied” in 1991 and “Very Satisfied or Satisfied” in 2001. The Likert scale used in 2001 had slightly different headings than 1991.

**Listed as EMS on 2001 survey

Table 4

Percentage of Respondents who Would Seek Treatment* in Wrangell for the Following Health Care Needs:

1991 2001

General Physical Exam 91% 87% Pregnancy/Delivery 88% 72% Pneumonia hospitalization 83% 79% Broken arm* 81% ▬ Minor Fracture ▬ 77% Mental Health Counseling 62% 47% Appendix surgery 57% Cancer Treatment** 15% 25% Knee surgery 8% Outpatient Surgery 41%

*In 2001 survey, respondents asked where would see initial treatment

**In 1991 survey “(long term follow-up care)” was listed after cancer treatment


Table 5

Note: Percentages are calculated from total number of hospitalizations reported.

*Two hospitals in Sitka not differentiated in 2001 survey

Table 6

Reasons for Non-local Use of Hospital* 1991 2001 Services not provided locally 77% 69% Referred by local MD** 69% 60% Referred by non-local MD 16% ▬ Quality better elsewhere 40% 25% Services cheaper elsewhere 21% 10% Indian Health Service Requirement*** 13% 11% Indian Health Service Preference 8% ▬ Privacy 5% 8%

*Respondents could check multiple answers for both 1991 and 2001 surveys so percentages will not add to 100%

**2001 survey did not differentiate local or non-local MD, but stated “referred by physician”

***2001 survey lumped Indian Service preference and requirement

Location of Hospitalizations in Past Two Years

1991 2001

Wrangell General Hospital (Medical Center) 51% 47% Seattle 16% 10% Ketchikan 15% 23% Mt. Edgecumbe (SEARHC) 7% ▬ Sitka Community Hospital 2% ▬ Sitka* ▬ 5% Other 5% 6% Juneau 4% 3% Anchorage 5%


Comparison of Physician Market Share Between 1991 and 2001

Table 7

Physician Market Share 1991 Wrangell 82% Ketchikan 4% Seattle 7% Other (includes Sitka, Juneau, Anchorage) 6% Practitioner Market Share 1991 Wrangell 79% Seattle 17% Other (including Ketch, Sitka, Juneau, Anchorage) 4%

Table 8

Medical Office Visits Reported by Location During Past Two Years, 2001 Survey (N=4966)

# of Medical Office Visits

% of Total

Wrangell Med Center 4196 84% Ketchikan 260 5% Anchorage 43 1% Sitka 25 1% Juneau 99 2% Seattle 186 4% Other* 157 3%

*See Table 14c, Attachment 3 for a complete list of “other” choices.

Table 9

Reasons for Non-Local Use of Physicians* 1991 2001 Services/specialty not provided locally 91% 66% Referred by local physician** 66% 48% Referred by non-local physician 16% ▬ Quality of services better elsewhere 54% 22% Services cheaper elsewhere 28% 16% More privacy with non-local providers 13% 5% Non-local providers easier to get to 6% ▬ Takes too long to get appointment with local physician 3% ▬ Wait in office to see local physician too long 2% ▬ Other ▬ 11% Indian Health Service preference/requirement ▬ 8% Travel ▬ 14% Family Support ▬ 8%

*Respondents could check multiple answers for both 1991 and 2001 surveys so percentages will not add to 100%

**2001 survey did not differentiate local or non-local MD, stated “referred by physician”


Non-local Specialists Seen During the Past Two Years It should be noted that the information collected in 1991 differs from 2001. In 1991 respondents were asked to list non-physician health care providers and physician specialties seen outside of Wrangell in two separate questions. In the 2001 survey, respondents were given a list of specialists to choose, but were also given the opportunity to note other specialists seen that were not on the list. In the 2001 survey, respondents were asked for physician specialists, but several respondents noted other specialists seen as well.

Table 10

Non-Local Specialists Seen 1991 OBGYN 17% Orthopedic 12% Internal Medicine 12% Chiropractor 12% Surgery 11% Cardiology 10% General Practice 7% Other 7% Non-Local Practitioner Specialists Seen

1991

Dentist 49% Dental Specialty 14% Optometrist 12% Chiropractor 12% Physical Therapy 5% Nurse Practitioner 3% Other 4%

Table 11

Non-Local Specialists Seen* 2001 Surgeon/surgical specialties 32% Ophthalmologist/Optometrist 13% Cardiologist 13% OB/GYN 9% Medical Specialties 9% Other 8% Dental work/orthodontist 5% ENT specialist 5% Oncologist 2% Adjunct Therapy 1% Radiology 1% Behavioral Health 1%

*See Table 16, Attachment 3 for a comprehensive list.

WrangellWrangellWrangellWrangellCommunity Health CareCommunity Health CareCommunity Health CareCommunity Health Care

Needs AssessmentNeeds AssessmentNeeds AssessmentNeeds Assessment

Alaska Center for Rural Health Wrangell Medical Center City of Wrangell

Who should fill out this questionnaire?The adult in the household who makes the primary health care decisions for household members.

For optimum accuracy, please print carefully and avoid contact with the edges of the box. The following willserve as an example:

PLEASE USE A BLACK OR BLUE PEN TO FILL OUT THIS FORM

Mark choice boxes like:

0486649872 Attachment 2: 048664987204866498720486649872

2. Approximately how far do you live from Wrangell Medical Center? miles

4. How long have you lived in this community? years

1. Zip code:

5. How satisfied are you with each of the following aspects of health care served by Wrangell? check one choice for each item Very

Satisfied Satisfied NeutralSomewhatDissatisfied

VeryDissatisfied

Wrangell Medical CenteraPublic Health NursebStikine Family ClinicDentistsPharmacy servicesEMS (EMTs, ambulance)Mental health servicesAvenues/Wrangell Council on AlcoholLong-term care facilityChiropractor

Visiting Ophthalmologist/OptometristVisiting OrthopedistVisiting Internal Medicine PhysicianVisiting Dermatologist

Physical therapyMassage therapy

cdefghijklmnopqr

NeverUsed

st

Visiting PediatricianVisiting Psychiatrist

u

Visiting OB/GYN

vw

Visiting ENT SpecialistVisiting PodiatristVisiting AudiologistVisiting Surgeon

The following 3 pages ask for your opinion on health care services which:*Are provided by the Wrangell Medical Center and Stikine Family Clinic*You consider important to your household

Automobile Boat Airplane Other

Section 1

3. What form of transportation do you usually use to get to Wrangell Medical Center?

please specify

6396649878 A38 Appendix A: Attachment 2639664987863966498786396649878

6. How would you rate Wrangell Medical Center/Stikine Family Clinic in each of the following categories?

Excellent Good Fair Poor Don't Know

Overall quality of carePhysician care

Nursing careBuilding cleanliness/condition

Emergency room careFood services

Billing and financial services

Laboratory services

Radiology servicesReasonableness of chargesStaff concern/compassion

Excellent Good Fair Poor Don't Know

Quality of medical treatmentConcern/compassion for patientCompetence of support staffReasonableness of chargesNight/weekend care availabilityAbility to get appointment quicklyAbility to see MD promptly at scheduled time

7. How would you rate the following aspects of Wrangell physicians?

Confidentiality

8. How important do you feel it is that Wrangell Medical Center/Stikine Family Clinic remain open within your community?

Very important Somewhat important Not important No opinion

Wrangell KetchikanSitkaJuneau Seattle

9. Where would you initially seek care for each of the following health care needs?

Cancer treatmentMinor fracturePregnancy/deliveryPneumonia hospitalizationOutpatient surgeryMental health counselingGeneral physical exam

Anchorage Other


10. Please rate how important you consider the following to be to your household.Low

PriorityModeratePriority

HighPriority

Physician services in the community

Early cancer detection & screening

Psychiatric services

Hospital inpatient care

Specialty clinics

EMS (EMTs, ambulance)

Medivac services (air ambulance)

Immunizations

Women's health services

Family planning

Care during pregnancy

Traditional/alternative medicine

Pharmacy services

Eye care

Dental services

School physical exams

abcdefghijklmnopq

Health education

Injury prevention informationLife saving skills/first aid training

Developmental disabilities assistance

Family counseling

AIDS/HIV testing and counselingAlcohol/drug treatment and counseling

Public Health Nurse

Long-term care facilities/services

Classes/counseling to help stop smoking

Nutrition counseling/WIC

Mental health counseling

Sexually transmitted disease testing and counseling

Suicide prevention counseling

Home Health Aide

School dietary programs/lunches

rstuvwxyzaabbccddeeffgg

Not aPriority

Hearing services/Audiology


years of age

MaleFemale

MaleFemale

MaleFemale

MaleFemale

MaleFemale

11. Enter the sex and age of the members of your household including yourself.

sex

12. How many times have you and the household members above been HOSPITALIZED during the past 2 years ineach of the following places? If none, skip to question 14.List a number, or put a zero when none.


Ketchikan

Anchorage

Sitka

Juneau

Seattle

Other (e.g. Petersburg, Portland)

13. If you or household members were hospitalized outside Wrangell Medical Center during the past 2 years, whywere other hospitals used? Please check all that apply.

Services not provided locally

Quality of services better elsewhere

Services cheaper elsewhere


More privacy at non-local hospital


Other

If other, please specify where

yourselfhouseholdmember #1

householdmember #2

householdmember #3

householdmember #4

yourself #1 #2 #3 #4


The following 3 pages ask about hospitalizations and medical office visits made by household members duringthe past 2 years.

*DO NOT include hospitalizations or office visits made before living in this community*If you have more than 4 household members, besides yourself, answer for those 4 members who use health care services the most

Travel

Family support

If other, please specify why

Section 2

(If less than 1 year of age, mark with a 1.)


15. Why were medical offices outside of Wrangell used in the past 2 years? Please check all that apply.

16. Please list the physician specialties seen outside Wrangell in the past 2 years. Please check all that apply.

14. Please estimate how many MEDICAL OFFICE VISITS you or household members have made in the past 2years in each of the following places?


Ketchikan

Anchorage

Sitka

Juneau

Seattle


Cardiologist

ENT specialist

OB/GYN

Ophthalmologist/optometrist

Orthodontist

Surgeon

Oncologist

Other


householdmember #2

householdmember #3

householdmember #4


If none, skip to question 17.


Services/specialty not provided locally

Quality of services better elsewhere

Services cheaper elsewhere


More privacy with non-local physician


Other


Travel

Family support

If other, please specify why

If other, please specify


17. Where do you and household members see your primary health care provider?Check only one for each household member.

Wrangell

Ketchikan

Sitka

Juneau

Anchorage

Seattle

No primary health care provider


18. If you or household members were hospitalized tomorrow, who do you think would pay the majority of the bill?Check only one for each household member.

Out of pocket/Self-pay

Medicaid

Medicare

Indian Health Service

SEARHC

Private Insurance

Other (e.g. VA)

19. Which of the following categories best describes your yearly total household income? Check oneless than $24,999$25,000 - $49,999$50,000 - $74,999

$75,000 - $99,999$100,000 and up


householdmember #2

householdmember #3

householdmember #4


If other, please specify



20. What types of long-term care services do you think are needed in the community of Wrangell?

Nursing homeAssisted livingIn-home care servicesAdult day services

Respite care

VeryImportant

SomewhatImportant

NotImportant

Don'tKnow

Other specifyHospice care

Senior housing

Terms associated with long-term careNursing home: Full medical and care supportAssisted living: Living space within a home, all meals, assistance with personal careIn-home care: Live at home with personal care and chore servicesAdult day services: Structured day center programSenior housing: Independent apartments with social activities, no care servicesRespite care: Relief services for family caregiversHospice: Care for the terminally ill

21. If choosing long-term care for yourself or a household member, would you plan to: choose one Stay in Wrangell

Leave Wrangell, but stay in Alaska

Leave Alaska

22. Do you or any household members expect to use long-term care services in the next 10 years? Yes No

Not sure

(if known, list town here )

(if known, list location here )

f

abcde

gh

23. Do you have older relatives who may come to live with you in the next 10 years? Yes No

Not sure

The following 2 pages ask about long-term care and senior services in Wrangell. Please provide: *Your household's expected use of these services*Your opinion on services needed in Wrangell

24. Which type of long-term care services do you or household members (including older family members who maynot currently live with you) anticipate using in the next 10 years if it were available in Wrangell?

Please check all that apply.

please specify

Nursing Home

Assisted living

In-home care

Adult day services

Senior housing

Respite care

Don't expect to use in next 10 years

Other

Section 3


26. In a nursing home or long-term care facility, which of the following services do you consider important?

Private rooms

Activity room

Physical therapy/rehabilitation

Massage therapy

VeryImportant

SomewhatImportant

NotImportant

Don'tKnow

Activities

Trips out into community

Outdoor recreation area

Quality of meals

25. Which of the following types of assistance do you consider important for seniors to live independently?

Meals delivered to home (Meals on Wheels)

Chore services (shoveling snow, mowing lawn)

Housekeeping/laundry

Recreation and activities

VeryImportant

SomewhatImportant

NotImportant

Don'tKnow

Dressing and bathing

Assistance with medications

Expanded meal program

Senior center (expanded for activities)

Home health care

Handicap access for public places

Other specify

Other specify

Emergency call system

Mental health counseling

High staff to resident ratio

Home accessibility modifications

Meals provided at senior center

Care coordination

Library house calls

Delivery services

Assistance with paperwork

(list any otherservices here)

Transportation services (doctor's appt., shopping)


29. Please provide us with any other comments you may have about this questionnaire, Wrangell community healthcare services, or other senior related services in general.

27. Please list any additional health care services you think should be provided by the Wrangell Medical Centerthat have not been mentioned in this questionnaire.

Instructions:*Place completed questionnaire in the enclosed postage paid return envelope*Tear off half the raffle ticket and put it in the enclosed en velope, keep the other half*Seal and mail the envelope

Envelope mus t be postmarked by August 24th, to be included in the raff le drawing .

46

28. Please list any additional health or social senior services needed in your community that have not beenmentioned in this questionnaire.

4827649875482764987548276498754827649875

Wrangell Senior Services Needs Assessment �Survey Report� Appendix A: Attachment 3

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Attachment 3:

Wrangell Community Health Care Needs Assessment Survey Results Tables

The following tables contain data reported by respondents who completed the Wrangell Community Health Care Needs Assessment survey. Tables are arranged by survey question. Note: n=the number of respondents answering each question.

SECTION 1 1. Zip code 2. Approximately how far do you live from the Wrangell Medical Center?

Table 2

Household Distance from Wrangell Medical Center Distance in Miles Number Percent 0-1 163 58% 1-5 66 24% 5-10 23 8% 10-15 13 5% 15-20 1 0% 20+ 13 5% Total 279 100%

3. What form of transportation do you usually use to get to Wrangell Medical Center?

Table 3

Transportation Used to get to WMC Form of Transport Number Percent Automobile 229 85% Boat 10 4% Airplane 5 2% Other 25 9% Total 269 100%

Note: 8% (22 respondents) also mentioned walking as a type of transport. Other individual responses included the following: taxi, friend, the doc comes to Coffman Cove, boat & bicycle and boat or airplane


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4. How long have you lived in this community?

Table 4

Length of Residence in Community # of Years in Community Number Percent 0-10 100 36% 11-20 54 19% 21-30 46 16% 31-40 40 14% 41-50 15 5% 51-60 14 5% 61+ 10 4% Total 279 100%


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5. How satisfied are you with each of the following aspects of health care served by Wrangell?

Table 5a

Satisfaction of Health Care Services in Wrangell Very Satisfied Satisfied Neutral Somewhat Dissat. Very Dissatisfied Never Used Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent

EMS (EMTs, ambulance) (n=274) 162 59% 42 15% 5 2% 0 0% 1 <1% 64 23% Public Health Nurse (n=275) 97 35% 92 33% 23 8% 5 2% 1 <1% 57 21% Wrangell Medical Center (n=274) 70 26% 126 46% 25 9% 26 9% 14 5% 13 5% Stikine Family Clinic (n=276) 68 25% 132 48% 23 8% 24 9% 7 3% 22 8% Chiropractor (n=273) 59 22% 58 21% 34 12% 6 2% 3 1% 113 41% Long-term care facility (n=274) 52 19% 58 21% 24 9% 11 4% 2 1% 127 46% Dentists (n=276) 43 16% 102 37% 37 13% 34 12% 19 7% 41 15% Physical Therapy (n=273) 31 11% 61 22% 44 16% 12 4% 3 1% 122 45% Pharmacy Services (n=274) 20 7% 84 31% 57 21% 61 22% 37 14% 15 5% Mental health services (n=270) 19 7% 39 14% 41 15% 13 5% 23 9% 135 50% Avenues/Wrangell Council on Alcohol (n=269) 19 7% 29 11% 48 18% 9 3% 14 5% 150 56% Massage Therapy (N=269) 7 3% 13 5% 33 12% 2 1% 5 2% 209 78%

Table 5b (crosstab)

Satisfaction With Dental Services by Income (N=266) Very Satisfied Satisfied Neutral Somewhat Dissat. Very Dissatisfied Never Used Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent

Less than $24,999 7 9% 21 28% 14 19% 9 12% 7 9% 16 22% $25,000 - $49,999 13 13% 42 41% 14 14% 13 13% 10 10% 11 11% $50,000 - $74,999 10 17% 22 38% 7 12% 9 16% 1 2% 9 16% $75,000 - $99,999 6 32% 8 42% 1 5% 3 16% 0 0% 1 5% $100,000 and up 3 25% 5 42% 1 8% 0 0% 0 0% 3 25%


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Table 5c

Satisfaction of Visiting Physicians/Specialists in Wrangell Very Satisfied Satisfied Neutral Somewhat Dissat. Very Dissatisfied Never Used Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent

Visiting Ophthalmologist/ Optometrist (n=272) 48 18% 91 33% 30 11% 20 7% 5 2% 78 29% Visiting Internal Medicine Physician (n=271) 29 11% 41 15% 31 11% 5 2% 6 2% 159 59% Visiting Surgeon (n=269) 21 8% 28 10% 27 10% 4 1% 5 2% 184 68% Visiting Orthopedist (n=274) 20 7% 34 12% 31 11% 3 1% 2 1% 184 67% Visiting OB/GYN (n=271) 19 7% 44 16% 26 10% 8 3% 6 2% 168 62% Visiting Dermatologist (n=272) 14 5% 39 14% 29 11% 10 4% 6 2% 174 64% Visiting Pediatrician (n=272) 14 5% 30 11% 27 10% 3 1% 2 1% 196 72% Visiting ENT Specialist (n=272) 10 4% 31 11% 24 9% 2 1% 3 1% 202 74% Visiting Podiatrist (n=268) 10 4% 20 7% 19 7% 1 <1% 4 1% 214 80% Visiting Audiologist (n=273) 11 4% 31 11% 25 9% 3 1% 3 1% 200 73% Visiting Psychiatrist (n=273) 6 2% 10 4% 27 10% 3 1% 8 3% 219 80%


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6. How would you rate Wrangell Medical Center /Stikine Family Clinic in each of the following categories?

Table 6a

Rating of Wrangell Medical Center/Stikine Family Clinic Services Excellent Good Fair Poor Don't Know Number Percent Number Percent Number Percent Number Percent Number Percent

Building cleanliness/condition (n=276) 108 39% 138 50% 18 7% 1 <1% 11 4% Emergency room care (n=276) 98 36% 100 36% 33 12% 5 2% 40 14% Nursing care (n=272) 89 33% 125 46% 24 9% 3 1% 31 11% Physician care (n=275) 91 33% 117 43% 38 14% 14 5% 15 5% Radiology services (n=273) 91 33% 106 39% 24 9% 3 1% 49 18% Staff concern/compassion (n=274) 88 32% 115 42% 43 16% 12 4% 16 6% Laboratory services (n=275) 79 29% 131 48% 25 9% 7 3% 33 12% Overall quality of care (n=276) 75 27% 140 51% 35 13% 7 3% 19 7% Food services (n=271) 47 17% 86 32% 28 10% 7 3% 103 38% Billing and financial services (n=273) 45 16% 113 41% 55 20% 36 13% 24 9% Reasonableness of charges (n=277) 16 6% 69 25% 80 29% 87 31% 25 9%

6b (crosstab)

Satisfaction with Reasonableness of Charges of Wrangell Medical Center by Income (N=266) Excellent Good Fair Poor Don't Know

Number Percent Number Percent Number Percent Number Percent Number Percent Less than $24,999 5 7% 19 26% 20 27% 24 33% 5 7% $25,000 - $49,999 3 3% 22 21% 33 32% 35 34% 11 11% $50,000 - $74,999 3 5% 18 31% 17 29% 16 28% 4 7% $75,000 - $99,999 2 11% 5 26% 5 26% 6 32% 1 5% $100,000 and up 1 8% 3 25% 4 33% 2 17% 2 17%


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7. How would you rate the following aspects of Wrangell Physicians?

Table 7a

Rating of Wrangell Physicians Excellent Good Fair Poor Don't Know Number Percent Number Percent Number Percent Number Percent Number Percent

Concern/compassion for patient (n=275) 105 38% 116 42% 29 11% 12 4% 13 5% Confidentiality (n=271) 84 31% 98 36% 29 11% 22 8% 38 14% Quality of medical treatment (n=274) 79 29% 118 43% 45 16% 18 7% 14 5% Night/weekend care availability (n=273) 68 25% 80 29% 42 15% 21 8% 62 23% Competence of support staff (n=272) 59 22% 142 52% 45 17% 7 3% 19 7% Ability to get appointment quickly (n=275) 59 21% 99 36% 59 21% 43 16% 15 5% Ability to see MD promptly at scheduled time (n=275) 51 19% 88 32% 80 29% 39 14% 17 6% Reasonableness of charges (n=274) 20 7% 71 26% 76 28% 80 29% 27 10%

Table 7b (crosstab)

Rating for Reasonableness of Charges of Wrangell Physicians by Income Level (N=264) Excellent Good Fair Poor Don't Know

Number Percent Number Percent Number Percent Number Percent Number Percent Less than $24,999 6 8% 21 29% 16 22% 25 35% 4 6% $25,000 - $49,999 7 7% 20 19% 32 31% 31 30% 14 14% $50,000 - $74,999 6 11% 17 30% 17 30% 12 21% 5 9% $75,000 - $99,999 1 5% 8 42% 3 16% 6 32% 1 5% $100,000 and up 0 0% 4 33% 4 33% 2 17% 2 17%


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8. How important do you feel it is that Wrangell Medical Center/Stikine Family Clinic remain open within your community?

Table 8

Importance of Wrangell Medical Center/ Stikine Family Clinic Remaining Open (N=272)

Number Percent Very important 254 93% Somewhat important 13 5% Not important 4 1% No opinion 1 <1%

9. Where would you initially seek care for each of the following health care needs?

Table 9a

Location Where Respondent Would Initially Seek Care Stay in Wrangell Leave Wrangell

Number Percent Number Percent General Physical Exam (n=274) 238 87% 36 13% Pneumonia hospitalization (n=268) 212 79% 56 21% Minor Fracture (n=273) 210 77% 63 23% Pregnancy/delivery (n=227) 164 72% 63 28% Mental Health Counseling (n=252) 119 47% 133 53% Outpatient Surgery (n=265) 108 41% 157 59% Cancer Treatment (n=268) 67 25% 201 75%

Table 9b

Location Where Respondent Would Initially Seek Care For Cancer Treatment

Number Percent Seattle 159 59% Wrangell 67 25% Ketchikan 9 3% Anchorage 9 3% Sitka 4 1% Juneau 2 1% Other 18 7% Total 268 100%


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Table 9c

Location Where Respondent Would Initially Seek Care For Minor Fracture

Number Percent Wrangell 210 77% Ketchikan 36 13% Seattle 8 3% Juneau 5 2% Sitka 5 2% Anchorage 4 1% Other 5 2% Total 273 100%

Table 9d

Location Where Respondent Would Initially Seek Care For Pregnancy or Delivery


Table 9e

Location Where Respondent Would Initially Seek Care For Pneumonia Hospitalization



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Table 9f

Location Where Respondent Would Initially Seek Care For Mental Health Counseling

Number Percent Wrangell 119 47% Seattle 37 15% Ketchikan 14 6% Juneau 13 5% Anchorage 11 4% Sitka 5 2% Other 53 21% Total 252 100%

Table 9g

Location Where Respondent Would Initially Seek Care For Outpatient Surgery

Number Percent Wrangell 108 41% Ketchikan 65 25% Seattle 44 17% Juneau 19 7% Anchorage 9 3% Sitka 6 2% Other 14 5% Total 265 100%

Table 9h

Location Where Respondent Would Initially Seek Care For General Physical Exam

Number Percent Wrangell 238 87% Ketchikan 9 3% Seattle 8 3% Juneau 4 1% Anchorage 4 1% Sitka 2 1% Other 9 3% Total 274 100%


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10. Please rate how important you consider the following to be to your household.

Table 10

Household Priorities for Health Care Services High Priority Moderate Priority Low Priority Not a Priority Number Percent Number Percent Number Percent Number Percent

Physician services in the community (n=274) 231 84% 37 14% 1 <1% 5 2% EMS (EMTs, ambulance) (n=271) 216 80% 39 14% 8 3% 8 3% Medivac services (air ambulance) (n=272) 203 75% 45 17% 9 3% 15 6% Early cancer detection & screening (n=273) 198 73% 46 17% 13 5% 16 6% Dental services (n=271) 167 62% 79 29% 11 4% 14 5% Immunizations (n=271) 166 61% 45 17% 20 7% 40 15% Pharmacy services (n=270) 165 61% 75 28% 11 4% 19 7% Eye care (n=274) 160 58% 84 31% 21 8% 9 3% Public Health Nurse (n=272) 152 56% 80 29% 16 6% 24 9% Hospital inpatient care (n=272) 145 53% 63 23% 20 7% 44 16% Life saving skills/first aid training (n=271) 134 49% 80 30% 30 11% 27 10% Women's health services (n=272) 131 48% 84 31% 22 8% 35 13% School physical exams (n=269) 116 43% 56 21% 15 6% 82 30% School dietary programs/lunches (n=269) 113 42% 40 15% 23 9% 93 35% Specialty clinics (n=270) 100 37% 86 32% 29 11% 55 20% Long-term care facilities/services (n=273) 100 37% 64 23% 45 16% 64 23% Traditional/alternative medicine (n=271) 89 33% 76 28% 48 18% 58 21% Hearing services/audiology (n=270) 83 31% 89 33% 52 19% 46 17% Health education (n=268) 75 28% 84 31% 35 13% 74 28% Injury prevention information (n=271) 71 26% 80 30% 57 21% 63 23% Sexually transmitted disease testing/counseling (n=269) 69 26% 51 19% 39 14% 110 41% Care during pregnancy (n=267) 57 21% 24 9% 17 6% 169 63% Home health aide (n=273) 57 21% 50 18% 44 16% 122 45% Suicide prevention counseling (n=267) 47 18% 47 18% 44 16% 129 48% Nutrition counseling (n=269) 47 17% 82 30% 41 15% 99 37% Developmental disabilities assistance (n=269) 44 16% 40 15% 37 14% 148 55% Mental health counseling (n=272) 37 14% 49 18% 68 25% 117 43% Classes/counseling to help stop smoking (n=268) 35 13% 30 11% 37 14% 166 62% Psychiatric services (n=270) 34 13% 59 22% 62 23% 115 43% Alcohol/drug treatment and counseling (n=271) 33 12% 41 15% 54 20% 143 53% Aids/HIV testing and counseling (n=270) 30 11% 38 14% 49 18% 153 57% Family counseling (n=270) 23 9% 54 20% 61 23% 132 49% Family planning (n=270) 18 7% 34 13% 38 14% 180 67%


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SECTION 2 11. Enter the sex and age of the members of your household including yourself.

Table 11a

Gender Distribution of Respondents Gender Number Percent Male 347 49% Female 361 51% Total 708 100%

Note: There were a total of 718 respondents reported for Section 2 of the survey. 10 respondents did not report gender.

Table 11b

Age Distribution of Respondents Age Distribution Number Percent Under 5 39 6% 5 to 9 49 7% 10 to 14 55 8% 15 to 19 52 7% 20 to 24 22 3% 25 to 34 54 8% 35 to 44 96 14% 45 to 54 127 18% 55 to 59 56 8% 60 to 64 47 7% 65 to 74 71 10% 75 to 84 23 3% 85 years and up 7 1% Total 698 100%

Note: There were a total of 718 respondents reported for section 2 of the survey. 20 respondents did not report an age.


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12. How many times have you and the household members above been HOSPITALIZED during the past 2 years in each of the following places?

Table 12a

Number of Hospitalizations in Each Location Reported During the Past Two Years (N=445)

Location Number Percent Wrangell Medical Center 210 47% Ketchikan 104 23% Seattle 45 10% Anchorage 21 5% Sitka 23 5% Juneau 15 3% Other* 27 6%

*Note: for “other” responses, see Table 12c

Table 12b

Number of Respondents Reporting Hospitalizations in Each Location During the Past Two Years(N=215*)

Location** Number Percent Wrangell Medical Center 137 64% Ketchikan 70 33% Seattle 37 17% Sitka 17 8% Anchorage 13 6% Juneau 13 6% Other*** 20 9%

*A total of 215 Individuals reported being hospitalized in at least one location.

**Individuals may have been hospitalized in more than one location.

*** Note: for “other” responses, see Table 12c.

Table 12c

"Other" Categories Listed for Hospitalizations Number

Lower 48 2 Arizona 1 Good Sam-Puyallys, WA 1 Idaho 1 Iowa 1 Las Vegas 1 Mexico 1 Michigan 1 San Juan Gen. Hospital Stockt 1 South 1 Vamc, Tuscon, AZ 1 Yakima, WA 1


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13. If you or household members were hospitalized outside of Wrangell Medical Center during the past 2 years, why were other hospitals used?

Table 13

Reasons for Being Hospitalized Outside of Wrangell Medical Center Reason Number Percent

Services not provided locally 103 69% Referred by physician 90 60% Quality of services better elsewhere 37 25% Travel 20 13% Indian Health Service perference/requirement 16 11% Services cheaper elsewhere 15 10% More privacy at non-local hospital 12 8% Family Support 11 7% Other* 10 7% Total Responses 314

Note: Respondents were allowed to check more than response on this question. A total of 150 respondents checked 314 responses.

*Other includes the following responses: choice, VA disability-free medical, was in AZ when needed, lived there, Blue Cross preferred provider, vacation, medivaced out (2), were out state at the time

14. Please estimate how many MEDICAL OFFICE VISITS you or household members made in the past 2 years in each of the following places.

Table 14a

Number of RESPONDENTS Reporting Medical Office Visits in Each Location During the Past Two Years

(N=605*)

Location** # Visiting Medical Offices

Percent of Total

Wrangell Medical Center 574 95% Ketchikan 111 18% Anchorage 19 3% Sitka 14 2% Juneau 43 7% Seattle 75 12% Other*** 60 10%

*A total of 605 Individuals reported visiting a medical office in the past two years in at least one location.

**Individuals may have visited medical offices in more than one location.

** Note: for “other” responses, see Table 14c.


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Table 14b

Number of MEDICAL OFFICE VISITS in Each Location Reported During the Past Two Years (N=4966)

Location # of Medical Office Visits Reported % of Total

Wrangell Medical Center 4196 84% Ketchikan 260 5% Anchorage 43 1% Sitka 25 1% Juneau 99 2% Seattle 186 4% Other* 157 3% 4966 100%

* Note: For “other” responses, see Table 14c.

Table 14c

"Other" Categories Listed for Medical Office Visits

Location Number Petersburg 5 Anchorage 2 Arizona 2 Bellingham 2 Boise 2 Iowa 2 Portland 2 Spokane, WA 2 Cheney, WA 1 Corvallis, OR 1 Eugene, OR 1 Idaho 1 Ketchikan 1 Klawock 1 Mexico 1 Michigan 1 Minnesota 1 Oregon 1 Out of State 1 PSG 1 Pullman, WA 1 Puyallys, WA 1 San Diego, CA 1 South 1 Tacoma 1 VA 1 Vamc-Tuscon, AZ 1 Yakima, WA; Ellenburg, WA 1


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15. Why were medical offices outside of Wrangell used in the past 2 years?

Table 15a

Reasons for Visiting Medical Offices Outside of the Wrangell Medical Center

Number Percent Services/specialty not provided locally 173 66% Referred by physician 127 48% Quality of services better elsewhere 58 22% Services cheaper elsewhere 44 17% Travel 36 14% Indian Health Service preference/requirement 22 8% Family support 20 8% More privacy with non-local physician 13 5% Other* 29 11%

Note: Respondents were allowed to check more than response on this question. A total of 262 respondents checked 522 responses.

*For "other" responses, see Table 15b.

Table 15b

Other Reasons Given for Visiting Medical Offices Outside of Wrangell Medical Center

Number Away at School 2 In AZ When Needed 2 More Convenient 2 Second Opinion 1 Alternative Medical Care 1 Bad Hopp. 1 Choice 1 Dentist 1 Family Help 1 Free Medical 1 Insurance Recovery 1 Live There 1 More Comfortable, Convenient 1 My Dr is Visiting Physician, Easier to Get Apnt in Ketchikan 1 Not Available in Wrangell 1 On Vacation 1 Out of State 1 Puyallys, WA 1 Selling Fish When Injury Occurred 1 Spouse Retired Army-Health 1 Virginia 1 Was in Ketchikan Because of Work When Illness Appeared 1 Working in Juneau 1


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16. Please list the physician specialties seen outside Wrangell in the past 2 years.

Table 16

Physician Specialties Seen Outside of Wrangell in the Past Two Years

Number Percent Ophthalmologist/Optometrist 54 13% Cardiologist 52 13% OB/GYN 39 9% ENT Specialist 21 5% Dental Work Orthodontist 17 4% Dentists 4 1% Endodontist 1 <1% Surgeons 115 28% Other Surgical Specialties named Orthopedics 14 3% Foot Surgeon 1 <1% Fractured Hand 1 <1% Neurosurgeon 2 <1% Oncologist 7 2% Medical Specialties Neurologist 10 2% Internal Medicine 6 1% Gastroenterologist 4 1% Allergies 3 1% Urologist 3 1% Arthritus Specialist 2 <1% Dermatologist 2 <1% Nephrologist 1 <1% Rheumatologist 2 <1% Pain Control 1 <1% Pneumonologist 1 <1% Pulmonary 2 <1% Vascular Specialist 1 <1% Adjunct Therapy Alternative Medicine 1 <1% Chiropractor 1 <1% Physical Therapist 2 <1% Podiatrist 2 <1% Radiology Bone scan 1 <1% MRI for back pain 1 <1% Radiologist 2 <1% Mammogram 1 <1%


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(Table 16 cont.)

Behavioral Health Counseling 1 <1% Psychiatrist 1 <1% Mental Health 1 <1% Other General physician 1 <1% Nurse 1 <1% School Clinic 2 <1% V.A. 1 <1% Sports Medicine 1 <1% Blood Work 1 <1% Pediatrician 1 <1% Infertility Specialist 2 <1% Marked but not identified 21 5%

17. Where do you and household members see your primary care health provider?

Table 17

Location of Primary Care Provider Location Number Wrangell 604 No primary health care provider 27 Out-of-State (except Seattle) 11 Seattle 9 Ketchikan 7 Juneau 3 Klawock 2 Ketchikan/Seattle 2 Anchorage 2 Wrangell/Sitka 1 Wrangell/Ketchikan 1 Wrangell/Juneau/Seattle 1 Wrangell/Seattle 1 Wrangell/Other 1 Coffman Cove 1 Craig 1 Sitka 1 Juneau/Anchorage/Seattle 1 Juneau/Other 1 Ketchikan/Other 1 VA services 1 Other 3 Total 682


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18. If you or household members were hospitalized tomorrow, who do you think would pay the majority of the bill?

Table 18

Anticipated Source for Majority Payment* of Hospitalizations (N=684)

Number Percent Out of pocket/Self-pay 101 14.8% Medicaid 61 8.9% Medicare 93 13.6% Indian Health Service/SEARHC 45 6.6% Private insurance 379 55.4% Other 5 0.7% Total 684 100.0%

*Note: 75 respondents marked multiple responses to this question, although the question requested only one response.

Multiple responses were grouped into above categories based on which payer would be primary.

19. Which of the following categories best describes your yearly total household income?

Table 19

Total Yearly Income (N=267) Household Income Number Percent Less than $24,999 74 28% $25,000 - $49,999 104 39% $50,000 - $74,999 58 22% $75,000 - $99,999 19 7% $100,000 and up 12 4% Total 267 100%


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SECTION 3 20. What types of long-term care services to you think are needed in the community of Wrangell?

Table 20

Importance of Long-term Care Services in Wrangell Very Important Somewhat Important Not Important Don't Know Number Percent Number Percent Number Percent Number Percent Nursing Home (n=264) 210 80% 30 11% 4 2% 20 8% In-home care services (n=260) 198 76% 45 17% 4 2% 13 5% Assisted Living (n=263) 197 75% 43 16% 6 2% 17 6% Senior housing (n=266) 200 75% 40 15% 8 3% 18 7% Respite care (n=253) 163 64% 58 23% 8 3% 24 9% Hospice Care (n=256) 164 64% 58 23% 10 4% 24 9% Other (n=17) 9 53% 1 6% 0 0% 7 41% Adult day services (n=252) 132 52% 78 31% 13 5% 29 12%

21. If choosing long-term care for yourself, or a household member, would you plan to: 1) stay in Wrangell, 2) leave Wrangell, but stay in Alaska (if known, list town), or 3) leave Alaska (if known, list location).

Table 21a

Location of Long-term Care Choice (N=261) Number Percent Stay in Wrangell 201 77% Leave Wrangell, but stay in Alaska 24 9% Leave Alaska 34 13% Other 2 1% Total 261 100%

Note: "other" category contains 2 respondents who selected 2 answers.


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Table 21b

Locations listed for Long-term Care Choice Outside of Wrangell

Number Anchorage 3 Ketchikan 2 Anywhere else 1 Anywhere on price of Whales Island 1 Petersburg 1 Petersburg or Wrangell 1 Sitka 1 Arizona 1 Arizona, all children are there 1 Bellingham, WA 1 California or Arizona 1 California, New Mexico 1 Dallas/Houston 1 Florida 1 Idaho or Utah 1 Lower 48 1 North Carolina 1 Seattle 1 Seattle, prior & part-time home 1 Sumner, WA 1 Texas or Arizona 1 Washington 1

22. Do you or any household members expect to use long-term care services in the next 10 years?

Table 22

Expected Use of Long-term Care Services in the Next 10 Years (N=271)

Number Percent Yes 23 8% No 172 63% Not sure 76 28% Total 271 100%

Note: see Data Limitations for this question, Appendix A, Attachment 4.


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23. Do you have older relatives who may come to live with you in the next 10 years?

Table 23

Older Relatives Expected to Come Live with Respondents in the Next Ten Years (N=271)

Number Percent Yes 45 17% No 181 67% Not sure 46 17% Total 272 100%

24. Which type of long-term care services do you or household members (including older family members who may not currently live with you) anticipate using in the next 10 years if it were available in Wrangell?

Table 24

Types of Long Term Care Services Expected to Use in the Next 10 Years (N=279)

Number Percent Don't expect to use in next 10 years 108 39% In-home Care 92 33% Senior Housing 79 28% Assisted Living 74 27% Nursing Home 64 23% Adult Day Services 41 15% Respite Care 39 14% Other 6 2%

Note: Respondents were allowed to check more than one response on this question

“Other” category includes the following individual responses: hospice; how does one know?; long-term care; LTC unit at WMC; move closer to a family member; unknown


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25. Which of the following types of assistance do you consider important for seniors to live independently?

Table 25

Importance of Types of Assistance to Live Independently Very Important Somewhat Import. Not Important Don't Know Number Percent Number Percent Number Percent Number Percent Assistance with medications (n=275) 225 82% 40 15% 3 1% 7 3% Transportation services (n=269) 218 81% 42 16% 2 1% 7 3% Emergency call system (n=270) 216 80% 45 17% 1 0% 8 3% Home health care (n=269) 199 74% 63 23% 1 0% 6 2% Assistance with paperwork (n=271) 197 73% 63 23% 4 1% 7 3% Handicap access for public places (n=267) 191 72% 55 21% 14 5% 7 3% Home accessibility modifications (n=266) 178 67% 68 26% 10 4% 10 4% Care coordination (n=263) 160 61% 83 32% 6 2% 14 5% Delivery services (n=270) 166 61% 84 31% 9 3% 11 4% Chore services (n=272) 165 61% 82 30% 17 6% 8 3% Meals delivered to home (n=271) 163 60% 83 31% 14 5% 11 4% Meals provided at senior center (n=269) 160 59% 91 34% 11 4% 7 3% Dressing and Bathing (n=269) 159 59% 85 32% 13 5% 12 4% Housekeeping and laundry (n=270) 147 54% 109 40% 7 3% 7 3% Senior center (n=268) 143 53% 92 34% 15 6% 18 7% Expanded meal program (n=267) 135 51% 77 29% 22 8% 33 12% Recreation activities (n=268) 135 50% 103 38% 13 5% 17 6% Library house calls (n=265) 68 26% 113 43% 63 24% 21 8%


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26. In a nursing home or long-term care facility, which of the following services do you consider important?

Table 26

Importance of the Following Nursing Home Services Very Important Somewhat Import. Not Important Don't Know Number Percent Number Percent Number Percent Number Percent Quality meals (n=273) 230 84% 35 13% 0 0% 8 3% Activities (n=273) 207 76% 52 19% 4 1% 10 4% Activity room (n=269) 200 74% 56 21% 4 1% 9 3% Physical therapy/rehabilitation (n=272) 195 72% 57 21% 4 1% 16 6% High staff to resident ratio (n=269) 190 71% 54 20% 5 2% 20 7% Trips out of the community (n=272) 182 67% 73 27% 5 2% 12 4% Outdoor recreation area (n=269) 149 55% 89 33% 13 5% 18 7% Private rooms (n=271) 149 55% 87 32% 19 7% 16 6% Massage therapy (n=271) 115 42% 105 39% 18 7% 33 12% Mental health counseling (n=269) 114 42% 99 37% 16 6% 40 15%


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Attachment 4:

WRANGELL HEALTH and SOCIAL SERVICES Survey Data Limitations

Survey Question 18: If you or household members were hospitalized tomorrow, who do you think would pay the majority of the bill?

The language in this question caused some confusion, as a number of respondents marked several payers in their answers rather than the one payer who would cover the majority. The question also assumes that patients understand which of their coverages would pay as primary (i.e. Medicare, Medicaid, private, IHS/SEARHC, etc.). In addition, we are assuming respondents would know the total dollar amount of care they would receive should they be hospitalized and whether it would fall into their deductible limits, including determination of where they currently stand in relation to their deductibles. Survey Question 21: If choosing long-term care for yourself or a household member, would you plan to (choose one): a) stay in Wrangell b) leave Wrangell, but stay in Alaska and c) leave Alaska ?

In one instance, we had a respondent who chose more than one answer on this question. We suspect it may have been because the respondent may have had a different response from their household member. If this question were to be used in the future, it is suggested that either the question be phrased so that either the respondent is only answering for him or herself or it is written in a way that it would be possible to mark different answers for different household members. Survey Question 22: Do you or household members expect to use long-term care services in the next 10 years?

Despite efforts to define long-term care in a broader context in Section 3, based on respondent answers it appears that many respondents interpreted long-term care in question 22 as meaning a �nursing home.� The intention of this question was to use the broader context of the term long term care that would include many services such as nursing home, assisted living, in-home care, adult day services, senior housing, respite care, and hospice. This inconsistency with interpretation was noted because several respondents marked No on question 22, but proceeded to mark several boxes in question 24 where respondents were asked which types of long term services they or household members expected to use in the next 10 years. So the results of question 22 should be reviewed with caution. In retrospect, question 22 could have been deleted since the same information can be found in question 24. Survey Question 23: do you have older relatives who may come to live with you in the next 10 years?

The intent of this question was to determine the number of seniors that may be coming from outside of Wrangell that could potentially use long-term care services in the commu-nity. Unfortunately we didn�t specify this, so it is difficult to know how the question was interpreted. It is suggested that in the future the question be phrased: Do you expect any older relatives from outside of Wrangell to come live with you and/or use long-term care services within in Wrangell in the next 10 years?


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Attachment 5:

WRANGELL HEALTH and SOCIAL SERVICES SURVEY RESPONSES – OPEN ENDED QUESTIONS

Thematic Analysis Overall, respondents praised the health services available within Wrangell. Satisfaction with specific doctors and the Wrangell Medical Center facilities and staff were noted. Satisfaction with scope and quality Most respondents were content with both the scope and quality of health services available within Wrangell. Most appeared to have realistic expectations regarding available health services. “I think Wrangell is very lucky to have the high level of hospital services and senior-related services. Not many towns of our size have these services.” Another noted, “For the most part, the services provided in Wrangell are very good considering the size and remoteness of the town.” Satisfaction with staff and facilities Community members also took the opportunity to praise specific doctors. Dr. Prysunka was mentioned several times. “If Wrangell could continue with the support it receives from Dr. Lynn Prysunka and pass on her dedication – they would be alright.” Others commended Wrangell Medical Center (WMC), stating, “We are so fortunate to have the medical facilities presently in Wrangell and the excellent staff.” Local surgery is overwhelmingly the most popular expansion of health services respondents would like to see at Wrangell Medical Center. Increased access to sub-specialists, improvements to the Wrangell Medical Facility, and more options for alternative medicine therapies are also favorite ideas. Access to local surgery When asked about additional health services they would like to see provided at Wran-gell Medical Center (WMC), the overwhelmingly popular response was that people would like to have surgery available locally. One respondent said he would like, “Facili-ties and staff so visiting physicians can perform the less invasive types of surgery rather than leaving town for this service.” Respondents were mixed regarding whether the surgery should be provided by local staff surgeons, visiting surgeons, or a combi-nation. One suggested, “Two doctors are leaving. They should use the combined salaries of the doctors to hire a surgeon to have on staff.” The reasons for desiring local surgery were varied. The cost and convenience were both mentioned often. “It would be much more convenient, less expensive and easier for seniors if there were some surgical ability in Wrangell, at least for relatively minor problems.” Others cited that access to local surgery would improve the quality of care and decrease adverse medical outcomes. “I believe we need surgery reinstated at the Center. Too many people have died on the way to Ketchikan and Sitka.”


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Additional sub-specialists Wrangell citizens also expressed the desire for increased access to sub-specialists, both by itinerant physicians and through more specialists practicing full-time in Wran-gell. “It would be nice to have specialist doctors visit Wrangell more often.” Types of sub-specialty care that respondents would like to see provided more often by visiting physicians include; diabetic care, arthritis care, dentists, eye care, foot care, ENT, and bone density specialists. Others voiced the desire for female OB/GYN physicians. Types of care that respondents would like to see provided by local sub-specialists include eye care, anesthesiology, and caesarean sections. “It would be nice to have a full-time eye doctor. I have been waiting three months for an appointment… I’m blind in one eye and it is hard when you have to wait so long between visits.” Facility improvements Those surveyed suggested that WMC enhance its services through some facility improvements. “The hospital, I feel, needs to be up-to- date…I would like to see us utilize unused space for a more up to date feel.” Specifically mentioned was the need for more privacy for patients, larger waiting room areas, and greater separation between different types of patients. Regarding the need for more patient privacy, one respondent stated, the “Hospital is in desperate need of expansion for long term care. Residents should all have private rooms. Need a few double rooms for married residents.” Another mentioned the need for “More activities areas, as well as more area for such things as visiting doctors, physical therapy, and other specialty treatment area.” Several of those surveyed also wanted to be able to separate different parts of the patient population for greater comfort. “[There should be a] separate area for those who are mentally alert versus the ones who are not.” Also suggested was the creation of “a maternity ward where women can be separated (from) those who are sick and elderly who may need quiet or have illness.” More options for alternative medicine therapies A number of participants suggested that services at WMC could be improved by making alternative medicine therapies more readily available. This includes traditional Native healing techniques. “For our size town, services are excellent. I wish there were a way to include, acknowledge, and validate Native approaches to healing.” Several people wanted access to a homeopathic physician. �We definitely need a naturopathic doctor or an MD/Naturopathic doctor combined in one person.” Other specific therapies suggested include massage therapy and acupuncture. Increased support group and health education opportunities were new social services requested. Respondents also desired new programs for alcohol treatment and a program that would coordinate visits to homebound seniors. In addition, respondents would like to see more planned recreational activities provided by a senior coordinator. Increased number and variety of support groups Several of those surveyed suggested that Wrangell would benefit from greater access to support groups. There was great variety in the types of groups requested, including groups focused on health issues, social issues, gender issues, and more. “We need


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more organized groups for the community such as co-dependents’ groups, children of alcoholics, single parent groups, parenting groups, walking groups, divorce groups… domestic violence information groups, foster parent groups, etc.” Also specifically mentioned were cancer support groups, AL-ANON, and support groups for homosexual teens. More community education Respondents showed interest in having access to more community education programs. They suggested programs aimed at health and disease education as well as programs aimed at other social issues, such as parenting. One cited the need for “cancer, Alzheimer, diabetes, and nutrition education.” Another stated that the hospital newsletter was a good source of health education, but criticized its lack of consistency. One person stated the need for, “Community health education. A consistent hospital newsletter sent at specific intervals 3-4 times yearly.” More programs aimed at alcoholism treatment Those surveyed recognize alcoholism as a major health and social issue within the community and wanted more programs aimed at diagnosis and treatment. “Alcoholism is a major problem in the Pt. Baker/Port Protection area. If there could be some kind of an awareness program to possibly help some of these folks it would be great. I don’t know what would help – maybe you have some ideas.” One respondent suggested that Wrangell would benefit from the creation of a halfway house for recovering alcoholics. Creation of a senior visitation program Wrangell citizens see value in creating a program that would match homebound seniors and handicapped people with volunteer visitors. “I perceive the need to outreach the community for assistance to visit folks in long term care or who are otherwise limited in their activities to make sure they have someone who ‘cares,’ who thinks of them – a friend.” Several respondents echoed the idea. Some suggested that visits take place at least every few weeks, while others proposed daily telephone contact. All agreed that a standardized program, including training for volunteers, would help. “Enlisting volunteers for the helping and making friends of the elderly who don’t get out. [We need] programs as such, and training for the volunteers.” Planned recreational activities “I have too much time on my hands. I need to have more activities to keep busy. I don’t mix well without help.” Many seniors who responded felt they would benefit from increased numbers of planned recreational activities. Some felt that the senior center was the place best suited to do so. “A real senior center program with planned activi-ties to meet social needs.” One asked that funding remain with the senior center to provide such activities. “Need to keep the senior center open more for meals and activities. Don’t cut funding in this area!”


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Availability of a senior coordinator Seniors showed concern over the difficulty of finding out about and accessing the social services currently available within the community. Many felt having a senior coordinator would help services be utilized better. “More public awareness as to what is available for seniors or handicapped. I have talked to many persons who didn’t know what was available or where.” It was noted that such a coordinator could help in two ways � helping seniors become aware of services and programs, and helping with any necessary paperwork required for accessing such programs, such as Medicaid applications. Respondents commented that community health services could be improved through a variety of means. Regarding physician services, patients noted a desire for improved appointment access, greater continuity of care, and more preferred providers. Others questioned the competency of some local physicians. Also mentioned was the need for improved billing systems and assured patient confidentiality. Improved appointment access Respondents suggested several ways community medical services could be improved, and many were related to local physicians. Several complained that wait times were too long. “If you have an appointment at 9 am you will be lucky to see the doctor by 10 am, and that was when we had four doctors on staff. What is it going to be like with only two?” This fear about access to doctors due to departing physicians was voiced several times. “Currently we have four MDs. Will be down to two in September. We need at least three full-time MDs.” Greater continuity of care Several of those surveyed felt community medical services could be improved by improving the continuity of care provided by local physicians. Respondents criticized the fact that it is often difficult to see the same physician twice. “The physicians that are now here are very nice but it is a bit frustrating having see four different doctors. One never knows who will be the doctor at your appointment. It would be nicer to only have one doctor to yourself.” Others agreed, stating, it�s “Very difficult to see the same doctor twice.” The desire for improved continuity of care also translated into the desire for greater follow-up. One respondent wanted, “Appointment follow-thru! I have been on the ‘waiting list’ to see visiting physicians and told that would be informed when the physician is in town. So far, I have never been called back or been able to make an appointment.” Verified physician competency A number of respondents were uncertain about the competency of local physicians. One suggested, “Get a doctor as qualified as Dr. Bangman was 45 years ago. We had better surgery capability then, by a long shot.” One respondent proposed that doctors spend more time learning about the patient�s medical history. “I believe the doctors should look into a patient’s medical history a bit deeper before they try and come up with an off-the-wall diagnosis, and they should ask the other doctors if they don’t really


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know.” Others wanted a more caring approach to medicine. “Doctors need to know how to care for the individual, not send them somewhere else, not tell the patient ‘we have done all we can – don’t come back to us for medical care.’” More preferred providers It was requested that local providers consider signing up with insurance companies as preferred providers to reduce the out-of-pocket expenses incurred by patients. “My husband is employed by the federal government and we have insurance through them. From what I’ve heard others say, it is very difficult to get reimbursed because we have no doctors in Wrangell who are providers of the plan (Blue Cross/Blue Shield). Is there a remedy for this?” Others noted that the problem was not isolated to physicians, but to other Wrangell medical providers. “It would be beneficial to have preferred providers available for facility, physician, and pharmacy!” Easier billing systems Respondents noted that it was very difficult to understand billing claims received from Wrangell Medical Center and pleaded, “Please change the billing system!” Complaints centered on the format of the bills received and the difficulty in deciphering the amount due. “My main complaint with Wrangell Medical Center is the billing statements. They are hard to match up with insurance payments. I wouldn’t know how much to pay! It’s certainly not efficient.” Assured patient confidentiality Some of those surveyed did not feel confident that their patient information would remain confidential. A general request was made to assure, “More confidentiality within the hospital.” One respondent stated, “I feel overall hospital and doctor services have taken a turn for the worse in the past 10 years…Confidential information becomes street knowledge in a matter of moments, whether it is EMT knowledge, story sharing, etc.” The desire for greater patient confidentiality was noted across the spectrum of medical care, including physician services, hospital services, emergency medical services, and mental health services. Respondents were generally satisfied with senior services, including meal services, senior transportation, senior housing. However, they requested that there be more of these services available, including longer hours of operation and greater numbers. They also requested more handicapped accessibility and more home-based services. Transportation services Transportation services received generally high marks; however, a number of respon-dents requested that they be available more frequently. “Need expanded time for the senior van at the senior center to include evening and weekend hours.” Others sug-gested that these services be available at least five days a week, while others wanted the service seven days a week. One respondent suggested having transportation options other than the van for those with limited mobility. There should be, “Another


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type of transportation for person who are unable to climb into the van, have no car and can’t afford taxis. A car would be good. A person could request the car or van.” Meal services Survey respondents generally approved of meal services, though some felt the service should be available more often. A common sentiment was, “More days of meals on wheels.” Respondents suggested meals be available at least five days per week and up to seven days per week. Although most appeared happy with the quality of avail-able meals, one respondent suggested meals be prepared better. “I think health and senior services are excellent for a community of this size. Some things could be improved, such as the quality of the meals at both the senior center and the hospital. They are not desperately bad, just not inviting, or imaginative, or enough.” Senior housing “Wrangell could use another senior housing or apartments with assisted living. There just isn’t enough.” A number of respondents echoed this reaction. One person sug-gested that means testing associated with assisted living should be expanded. “There needs to be some type of assisted living for people who don’t qualify on a needs basis but are not wealthy enough to hire help on a long term basis.” In addition to the need for larger housing complexes, one respondent wanted more variety in the types of housing available. “What we need are two bedroom apartments for senior housing. There are a lot of older couples that want their own bedroom at this age. What’s the hold-up on building two-bedroom units?” Home health Several respondents requested more home health services be made available in order to enable seniors to remain independent longer. “I would like to use more assisted living or home visits to enable seniors to stay home as long as possible.” It was also mentioned that services rendered in the home were more convenient for patients than traveling to a physician�s office. The perceived quality of home services was mixed. A few respondents suggested that home health care workers receive more education and check on patients more often. “I have asked a home health nurse to check on a patient (e.g., a bedsore check). They do not always come in a timely manner.” Handicapped accessibility Respondents generally agreed that Wrangell does not currently have adequate wheel-chair accessibility to accommodate those with limited mobility. “Wrangell needs to wake up and get some handicap access. The Post Office is a good example. It has a wheelchair ramp but nothing for other handicaps, including the doors.” There was also concern regarding whether the handicapped facilities currently available were safe and practical. “Make wheelchair access safer and more usable.”


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An overarching theme was the concern seniors expressed regarding the high cost for services, especially medical services. They cited apprehension regarding the cost for a wide range of services, including travel costs, hospital charges, physician costs, and pharmaceuticals. Concern for high cost Respondents were concerned about the high cost of medical services. “For what services are here the care is overall very good. It would be nice to have the services be cheaper, but that is probably not possible.” Others noted that the burden was especially heavy for those with poor insurance or no insurance. “Something has to be done about cost. I know many people, myself included, who don’t see doctors when really should because of the extreme cost. It is shameful that we have the facility and the ability to treat, but uninsured people can’t afford to use the services.” There was a feeling that patients were charged a much higher rate for services in Wrangell than they would be for the same services elsewhere. “Prescriptions are too high in Wran-gell. For example, thirty pain pills in Seattle cost a little over $8 and in Wrangell the same pills cost $40. This is outrageous.” Some respondents suggested setting up more programs to help ease the cost for services. One suggested setting up a program to help the poor with unexpected medical travel costs. Others suggested programs, such as the health fair, be made available more often. A few respondents suggested that local authorities look at the issue of the uninsured. “I think that the problem of the uninsured needs to be addressed, not ignored, and addressed at the local level.” Residents were generally pleased with the questionnaire, and with having an opportunity to provide input into community planning efforts. Redesigning the mailing envelope and providing a return address within Wrangell could improve the process. Input on questionnaire generally positive Respondents showed enthusiasm with having an opportunity to comment on services and have their opinions heard and considered. “I am glad to see this questionnaire. It’s a chance to voice an opinion and be heard!” Others praised the way questions were asked. “This is an excellent, sensitive questionnaire. Congratulations! It makes me proud to be part of a community that sincerely cares about the people and actually elicits their opinions.” However, several respondents suggested redesigning the mailing envelope. “Very poor format to present to the community from the envelope received. Redo the outside mailer. It looks like junk mail.” Others stated that including a local Wrangell return address would have helped to get their attention. “This ques-tionnaire is a very good thing. Next time a Wrangell return address would be useful, as I had thrown this one out until I heard on the radio station that many had made that mistake. I then retrieved it and opened it!” Other specific improvements include redesigning question 12, which one respondent found confusing. “Question 12 is confusing. I’m not sure if ‘hospitalized’ referred to ER visits or not.”

Appendix B

Focus Group and Key Informant Interview Questions

Wrangell Senior Services Needs Assessment �Focus Group Questions� Appendix B

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Wrangell Senior Services Focus Group Questions Ice-Breaker: What brought you to Wrangell and how long have you lived here? 1. What current senior services do you or family members use in Wrangell? (Please

include long-term home and community-based services, social services, facilities, etc.)

2. What do you like about these services? 3. As you think about senior services currently offered in Wrangell, what are some

aspects of the services that you would like to see changed, added or expanded? 4. What do you currently see as the major health and social issues of senior citizens

in Wrangell? 5. As you think about these major health and social issues of senior citizens what

additional programs do you think should be offered to address these issues? How should they be delivered?

Wrangell Senior Services Needs Assessment “Key Informant Interview Questions” Appendix B

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Wrangell Senior Services Key Informant Interview Questions A. Current Home and Community Based Services in Wrangell 1. What types of home and community-based services for seniors and disabled

persons are available in Wrangell? (Include long-term care services for seniors, the chronically ill and disabled adults.)

2. What additional social senior services are available in the community? 3. What do you like about the home and community-based services in Wrangell? 4. What do you like about the additional social senior services available in the

community? B. Additional Home and Community-Based Service Needs in Wrangell 1. As you think about home and community-based services currently offered in

Wrangell, what are some aspects of the services that you would like to see changed, added or expanded?

2. As you think about the other social senior services available in the community,

what are aspects of the services you would like to see changed, added or expanded?

3. What agency or individual should take the lead in adding or expanding these

services? C. Wrangell’s Major Health and Non-Health Issues for Seniors 1. What do you currently see as the major health and social issues of senior citizens

in Wrangell? 2. a) As you think about these major health and social issues of senior citizens, what

additional programs do you think should be offered to address these issues? b) How should they be delivered?

3. Thinking on these health and social issues, please prioritize the top three senior

issues or programs to address in the next 5 years in Wrangell.

D. Resources 1. What are some potential funding sources for establishing and maintaining these

identified senior services?

Appendix C

Thematic Analysis: Focus Groups

Wrangell Senior Services Needs Assessment �Thematic Analysis: Focus Groups� Appendix C

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WRANGELL SENIOR SERVICES FOCUS GROUPS

Thematic Analysis Wrangell’s seniors currently access a large and diverse array of community services. Meal services, senior living, transportation services, “call-care” services, and the public health nurse are all popular among seniors. In addition, recreational and Emergency Medical Services are accessed by a number of seniors. Meal services Seniors mentioned that either they or somebody they knew had utilized meal services. The meals programs delivered by the senior center were by far the top choice of residents requiring meals, and it is a vital service to those who utilize it. “I didn‘t think I was going to make it without those meals.” Others mentioned the meal services at the Senior Center dining room. “They have a dining room too at the senior center, and encourage people to come for meals if they can. Otherwise, they deliver the meals.” Though meal services are an essential service to some, respondents voiced some reservations regarding the viability of the program based on total numbers using the service. “Up till a few years ago, they had trouble using the Meals program even 3 days per week.” Transportation services Transportation services, especially the community van, were extremely popular among participants. “I use the senior van. It takes me downtown shopping or wherever I have to go -- anywhere.” It was noted that for those who no longer drive, the senior van provides an important link to independent living. “I use the senior van for everything. I wish it would run the whole week.” Senior apartments A number of respondents reported living in senior apartments and enjoying this service. One respondent noted, “Yes, I live there. They are very nice, very accommo-dating.” In particular, respondents liked the totality of services available through senior apartments. “At senior housing: we have a laundry, they keep the grounds, there is always something going on in the day room. I keep my own apartment.” Call-Care �Call-care� is a well-liked service among Wrangell seniors interviewed. “I have a little button I can push and they will be there right away-it’s called “call care”. We have good communication with them.” The service provides seniors with a feeling of comfort and safety. “I have “call care”. I wear it when I go out to empty the garbage because I have to go down some stairs or if I don’t feel good. Or if I’m afraid I might get hurt, I wear it”: When pushed call care buttons set off an alarm at the hospital. Each button has associated response telephone numbers.


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Public Health Nurse Participants showed approval of the public health nurse and her services. “The health nurse is wonderful here.” In particular, they noted the utilization of preventive flu shots provided by the PHN. Recreation services Seniors noted the availability of recreation services including the senior center, and special hours and activities at the local pool and weight room aimed at seniors. “We have a pool here with a special time/activities for seniors. MWF from 10:30-12 at the high school.” It was noted, however, that participation at the senior center is on the decline. �We try to use the Senior Center once a month to keep it open. It has dwin-dled so there are so few who use it, and M-W there is only 2-3 people there. I feel bad that we don’t go more often.� Most recreational activities appear to be uncoordinated events. “For seniors, we don’t have much outside of Church. There are card games, but they aren’t organized.” Emergency Medical Services Many of the participants had received emergency medical services through the local EMTs. Noting the quickness with which services were delivered, one senior stated, “I used the EMTs once and they were there right away.” Respondents were generally enthusiastic about the quality and accessibility of these services. “We have a great bunch of boys who go out for the EMT training here.” Hospital care Although medical services did not generate a great deal of discussion, most participants acknowledged that they utilized the local hospital. “I use the hospital services.” In addition, one participant was pleased with the free, preventive services offered by the hospital. ”The hospital gives you blood pressure checks for free.” Other Also mentioned were Wrangell Community Services and visiting nurse services. Some participants were aware of chore services available. Several participants also men-tioned the informal networks of �neighbors helping neighbors� which aids many seniors with needed services. Factors influencing seniors’ satisfaction with currently available senior services include cost, the ease of accessing services, the quickness with which services are provided, and, in the case of meal services, the taste. Ease of access The ease of accessing services is a top factor influencing seniors� satisfaction with services. In particular, they applaud services where the provider comes to their home. “The Public health nurse comes to the house if you are handicapped and can’t get out. There are times when I can’t get my husband into the car – and she comes to us. It’s easier.” Ron, the Physical Therapist, was also mentioned for his willingness to make


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�house calls.� Even the grocery store seeks to improve the ease of shopping for seniors who have difficulty leaving home. “The grocery store does the shopping for you, and delivers the groceries.” Several participants expressed the desire to have pharmaceuticals delivered to the house. “It would be great if they could deliver medicines from the pharmacy. I had that service in California and it was great.” Promptness of service There was wide agreement among participants that the quickness with which services are provided, is important. The issue prompted a wide discussion surrounding the promptness of care received from Wrangell�s emergency medical personnel. “Our EMTs are the best! They are immediately there. When my husband had a stroke they were there within 3 minutes.” Similarly, the call-care service was commended for the quickness of service. “I have a little button I can push and they will be there right away-it’s called “call care”. We have good communication with them.” Cost Many of Wrangell�s seniors are cost-conscious, so economical services are popular. The Senior Center meal program was praised by one participant for its low cost. “It is $3 per meal. You can’t eat anywhere else in town at those prices.” Another member mentioned that they believed that choremaker services were cost efficient. �I know a couple people who use Chore/homemaker services. They wash clothes, housekeep-ing, etc. It doesn’t cost much.” Services that are more expensive are a major concern for seniors interviewed. Taste of meals One aspect of the popularity of the senior meals program is the taste of the food. Not only do the meals provide nourishment for those who have difficulty cooking, but they also are tasty according to several participants. “The meal was really good yesterday. My wife ate half of hers for lunch, and the other half for dinner. I ate it all for lunch.” Another stated, �Yesterday’s dinner was delicious.” Other In addition, Wrangell�s seniors are appreciative of the excellent service they receive from service providers. Specifically mentioned was the follow-up care received from emergency medical workers. “When they take you to the emergency room, the EMTs hang around to make sure everything is okay with you.” They are also grateful for the medical specialists who travel to Wrangell for clinics, allowing patients to receive needed services within the community. “We are thankful we have specialists here. The ophthalmologist comes every 2-3 months. And the hearing people come too.” Seniors believe that community services could be improved or enhanced through a variety of methods. They would appreciate longer hours of operation for many services. They also worry about the cost of some services and whether service providers have adequate capacity and staffing to meet the community’s need. Other suggestions included improving equipment and maintenance and increasing handicapped accessibility throughout the community.


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Extend Hours for meal and transportation services Some services were so popular that participants voiced the desire that they were available more often. This sentiment was most widely held by users of the senior van service. “Yes, we could use more hours for the van. It’s just 10 to 4 three days a week. You can’t always schedule all your appointments within that time. Sometimes they want you to come in earlier.” Another participant stated, “I would like to see the van work more frequently. Airport runs, Sunday services – we could use it 7 days per week.” Seniors perceived the current hours of operation to be linked to finances. “I think they reduced the van service because it was going in the hole – they couldn’t afford it.” Users of the �Meals on Wheels� program also shared that they wished the service was available more frequently. “My husband and I use Meals on Wheels. They bring the meals to the home - the van driver brings it. I wish it were 5 times per week.” Lower Costs for pharmaceuticals and medical transport While seniors were happy with the low cost of some services, they expressed concern about the high cost of others. The high cost of pharmaceuticals and the lack of Medi-care coverage for this item was a common discussion item among participants. “If you buy an antibiotic here, it is more expensive than other places. They won’t take your insurances, etc. But you need to be fast with an infection – it can’t wait.” The high cost of travel was also widely discussed. Participants noted the high cost of both emer-gency medical transportation, as well as travel associated with going to communities outside Wrangell for non-urgent care. “I see no problems if people can afford to travel for care. But for those who can’t, it is very expensive.” Another noted, “The cost is astronomical [when someone needs emergency care not provided in this town] and there are people who die or suffer because they can’t afford to be medically trans-ported.” Seniors also specified the high cost associated to see medical doctors, access housekeeping and handyman services, and receive foot care. Need for more senior apartments and bed space at WMC Participants mentioned that while many senior services are available in the commu-nity, there isn�t necessarily an adequate capacity of those services to meet the com-munity�s needs. Several seniors stated that there was a shortage of senior housing. “There is definitely more of a need for senior housing. The housing here is full. There’s always a waiting list for the senior apartments.” Others voiced a desire for more options for senior living. “We need more independent living like a small house or even some trailers. And then someone could come in and do all the yard work, wash the windows and so on. But if we could get 1 or 2 bedroom homes, that would be good.” In addition, there was concern about capacity at Wrangell Medical Center. “We do not have enough beds in the long term care unit; they go into swing beds.” Need for greater accessibility Another common sentiment among many participants was the notion that there is a scarcity of handicapped parking spaces available. “Handicapped parking is rare here, and not near anything. We need more. There’s one at the grocery store and another at the post office. My heart isn’t working well, and it is hard for me to get up the ramp.” While many participants lamented the lack of handicapped parking spaces available in


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Wrangell, they also noted a related issue � the feeling that many of the current handicapped ramps are not sufficient for the job. Some stated that the current ramps are difficult to use for ambulatory seniors with limited mobility. “If they fixed the ramp so one side is smooth, people could walk on it. Lots of people have had strokes where they drag their foot and they catch them in those grates.” Others noted the difficulty for those with limited movement or those who are bound to wheelchairs to access buildings throughout town. “The school has elevators, but other buildings don’t. They often have a ramp, but they aren’t really convenient.” Participants also discussed the obstacle of making their homes handicapped accessible, both because of perceived lack of workmanship by contractors hired to build ramps, and the waiting required to get government-funded contractors to Wrangell. Need for adequate staffing for LTC and home health Seniors expressed concern about the availability of nurses, and felt that increasing nurse staffing could improve services. This was particularly true for the local long-term care unit. “Another need - a bit larger staff in the hospital’s long-term care. Sometimes there is only one person working there – especially with 15-18 residents.” Another noted, “Home health nurses are cut back a lot now. Hospital administration told her that she has to work in the hospital or out – there is a nursing shortage at the hospital.” Update equipment and improve maintenance: Participants observed that some of the capital resources currently used to provide services need updating � both to continue current services and improve them. “We could use a new van -- it’s very old. It’s still running, but it does have a lot of dents in it. But this is another thing; we have to park out here on the hill. The lift is in the back of the van. We had an awful time trying to get Alice out so she wouldn’t roll down the hill.” Another mentioned that the senior apartments would benefit from improved upkeep and ongoing maintenance. “If funding were available, they should fix the back stairs to the senior apartments. I fell from the top to the bottom; it was horrible. I got to the top step, then fell backwards all the way to the cement.” Three of the largest issues facing Wrangell seniors include: 1) Managing finances on a limited budget; 2) assuring services are available which help seniors continue living independently; and 3) assuring that buildings are acces-sible to those with limited mobility. Cost of living and managing resources Seniors were very conscious of the cost of living and of the difficulties with managing finances on a limited budget. Participants showed concern for the high cost of medical services and the insufficiency of insurance coverage, as well as the general cost of living. Several participants discussed issues relating to Medicare coverage. Partici-pants were clearly grateful for the program. “Medicare is wonderful. What would we do without it?” However, many seniors maintained reservations about whether the coverage was enough to meet the entirety of their health needs. “Medicare doesn’t cover everything. Medicare doesn’t pay any travel expenses.” Others mentioned that


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Medicare alone is not sufficient to meet the full cost of medical services. “Some people might not have supplemental insurance.� It was noted that the cost for some services is often prohibitive. “I’d like to see the dentists give discounts. They only look at you for half an hour and charge you $85.” Another stated, “ Ron the PT is qualified to do it [foot care and nail cutting], but he is expensive. $65 to have your nails cut seems very high.” As mentioned earlier, discussion was also vigorous surrounding issues of the cost of travel for medical services � both for emergency medical transport and scheduled commercial travel for services unavailable within the community. In addition to the cost of medical services, seniors also showed concern about the generally high cost of living in Wrangell. “The cost of living here is very high.” Specifically mentioned were the cost of fuel and the cost for renting apartments. “I mean like the fuel. People here have their own homes and they don’t want to leave them. I asked the fuel company to give a senior discount. I was told it would be too much bother.” Referring to the high housing costs, one participant stated, �Yes, that’s a big thing. The new power system came in and all the rents went up and they have never gone down.” Some apprehension was also apparent regarding the cost for handyman and chore maker services that allow seniors to remain independent. “Plus when you hire them, they charge $45 per hour. A plumber isn’t cheap either. Plumbers are $50 per hour.” Another added, “You can’t even get kids to help out with less than $25. You used to be able to pay $10, but not anymore.” Services to improve independent living In addition to expanding transportation services and senior housing, many participants felt there needed to be a cost-effective means for getting general housework and yard projects completed. Seniors felt this was an important service in maintaining their ability for independent living, and an issue that generated much conversation amongst participants. In defining the problem, one participant stated that one of the biggest issues facing seniors is simply, “Climbing up on a chair and changing a light bulb.” In discussing potential solutions to this issue, one senior stated, �We used to have a man that would help out with yard work, a sort of handyman. We need someone you can call on. For example I need a plumber or electrician to check on my water. We need a handyman that can do little jobs. Everyone wants big jobs, no one wants little jobs.” In describing a Good Samaritan who helps with these things, a participant noted, “I have an earth angel who seems to shovel. I still don’t know who does it. I try to catch him at it; I think I know who does it, but he won’t tell me if he is the one.” Accessibility Accessibility came up frequently as a topic in the focus groups and was one of the top three major issues for Wrangell seniors with limited mobility. Concerns were voiced regarding handicapped parking and ramps, both for those who are wheelchair bound as well as for ambulatory seniors with slightly limited mobility. As one participant described it, “There is more than one kind of handicap. You don’t have to be in a wheelchair to be handicapped. Those of us with arthritic knees have a hard time going up and down stairs.” Seniors mentioned several facets of the accessibility issue: handicapped parking, ramps, doors, and buildings with elevators. Regarding the


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parking issue, one participant stated, “Handicapped parking is rare here, and not near anything. We need more.” Though some seniors thought the ramps were only for wheelchairs, many ambulatory seniors used them anyways and were concerned about their design. “If they fixed the ramp so one side is smooth, people could walk on it. Lots of people have had strokes where they drag their foot and they catch them in those grates.” Another ambulatory participant also uses the ramps, since “[She’s] supposed to stay away from the stairs as much as possible.” Participants also affirmed that doors are not always designed well for those with wheelchairs and walkers. “My neighbor has a walker. She gets up there and can’t open though the door with a walker. And I don’t see how a wheelchair does it either.” Another suggested, “Down south the post offices have an electric eye and they will open and they will stay open until you can get in. They are for wheelchairs, for ambulatories, for scooters, everything.” Finally, participants voiced concerns about the accessibility of multi-level buildings that do not have elevators available. “The school has elevators, but other buildings don’t. They often have a ramp, but they aren’t really convenient.” Participants wish to see more coordination of the senior services currently available. They also voiced a desire for more planned recreational and educa-tional opportunities. A number of participants would also like to see more health services provided locally. Service coordination A new service that many seniors would like to see offered is that of a senior services coordinator who would help seniors to access existing programs, help locate holes in the current system, and advocate for senior issues. “We used to have a wonderful gal here that could help you access senior programs (reviewed eligibility, etc… if we had a local representative to tell a person who comes to town, not necessarily financial assistance, but tell them all the benefits for seniors (fishing permits, license plates, etc.), it would be great. Now, people only learn about this by word of mouth. People here are missing out on services.” Commenting on the issue that services are not always fully understood by beneficiaries, another participant stated, “No one knows where to go or who to ask. If we could have someone coordinating at the Senior Center they could compile this kind of information.” Planned recreational and educational activities There was widespread agreement that seniors would utilize more planned activities, both those recreational and educational in nature. “More activities would enrich and possibly lengthen people’s lives.” Another noted, “Right now we have no activities, because no one sticks around. We used to have bingo once in awhile or people playing cards.“ Many stated that such activities used to be available at the senior center, but were not currently part of the center�s events. Regarding potential recreational activities, one participant stated, “It seems to me that the senior center could be well utilized if they had some social events there. Despite shrinkage of the population, they could have craft classes, seminars, and other enriching things. It is difficult to not get depressed if you never get out of the house.” Many also suggested


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educational events, including seminars on taxes, living wills, social security benefits, and Q & A sessions with representatives from the IRS, VA, and other agencies providing benefits to seniors. Discussing such activities available in other locales, one senior stated, “In Northern California, they have guest speakers, info on taxes and legal benefits, discount meals, and other things. There is an information center to answer your questions.” Seniors generally agreed that if such activities were provided at the senior center, it would have the dual benefit of providing both needed services for seniors, while potentially helping to keep the senior center open and better utilized. “…It would keep the senior center open. It is at risk of being closed due to lack of use.” Additional medical services provided locally Many seniors stated the desire to be able to receive additional medical services locally, whether through specialists permanently located in the community or through extensions of clinics offered by visiting medical service providers. Discussing the need for senior foot care, one senior stated, “I think it would be good for Wrangell to have someone here to care for seniors’ feet. We can’t bend down and reach our feet. Consequently, they go bad on us. Care is only available through a visiting doctor, if you have a doctor’s referral or recommendation.” Others shared the desire for more eye care provided locally. Other Several participants mentioned the need for respite care. One senior summarized the problem, “Let’s say someone has a heart attack and goes away for care. When they return, and they don’t have a spouse or family in town, who is going to help them in their own home? We need respite care.” Another added, “It would be really nice if there was set-up for respite care. Someone here talked about a couple hours of care, but I’m thinking about weekend care.”

Appendix D

Thematic Analysis: Key Informant Interviews

Wrangell Senior Services Needs Assessment �Thematic Analysis: Key Informant Interviews� Appendix D

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City of Wrangell Senior Needs Assessment KEY INFORMANT INTERVIEWS

THEMATIC ANALYSIS

A. Current Home and Community Based Services in Wrangell The following home and community-based services were mentioned most frequently as being available to seniors and disabled persons in Wrangell: home health services, meal services, the long-term care facility, transportation services, senior apartments, assisted living, grocery services, and services through the churches. The following other services were also listed on a number of occasions: tax exemptions, the swimming pool, call care buttons; respite care, the Senior Center, the Loan Closet, and home visits by medical staff. Home health services Respondents listed home health services most frequently as a community-based service available to the elderly and disabled. Home health aides may help homebound individuals with shopping, cooking, cleaning, bathing, dressing, and assistance with medication. Respondents identified three organizations that provide home health care services in Wrangell: 1) Wrangell Community Services; 2) the hospital; and 3) the Center for Community. Wrangell Community Services: Wrangell Community Services organizes homecare for the elderly and disabled, and has four different programs for in-home and out-of-home services. Wrangell Community Services runs the Project Choice program, a home care program for people who would qualify for long-term care but choose to stay at home. Specifically, home health aides from Wrangell Community Services assist homebound individuals with chores, bathing, cooking, housecleaning, and shopping. �I have heard they do a very good job.� Alice Rooney, who heads the Wrangell Commu-nity Services, also does evaluations, including home evaluations, to determine what services an individual qualifies for. �She is the number one resource in Wrangell for arranging services.� Overall, respondents spoke highly of Wrangell Community Services. �I think Alice�s program is under appreciated. I really like working with Wrangell Community Services.� Medical Center: The hospital provides aides that assist homebound individuals with various tasks, including dressing or help with bedsores. �There are a lot of people in wheelchairs who have home care services provided. I think there is a very caring atmosphere for the elderly in Wrangell.� However, one individual said very few people qualify for this service. For one, Medicare requires that the recipient is absolutely homebound and has an acute condition rather than a chronic one. Another drawback is that the service involves a great deal of paperwork. �It seems like there is only two or three times a year that we are �allowed� to help homebound people, so occasionally our nurse helps people out in their homes.�


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Center for Community: The Center for Community is an organization based in Ketchikan that provides home health services to Wrangell residents. Home health aides provide household chores and shopping, but no nursing services.

Meal services A number of organizations in Wrangell provide meal services.The Senior Center provides lunches three times a week, and delivers meals to �shut-ins.� However, respondents said the meals are not very good. “I had one client who quit eating these meals and lost 15 lbs. The meals were delivered, but she wasn’t eating them. Nobody checked on her. I found five delivered meals sitting unopened in her fridge.” In addition, the Salvation Army provides meals on holidays, and the Pioneers cook dinners several times a year for seniors. Long term care facility Respondents repeatedly listed the long-term care facility at the hospital as a service available to seniors and disabled persons in Wrangell. Respondents praised the activities and general quality of the facility–“one of the best in the state.” However, the facility is currently beyond capacity. Transportation services Transportation services are available to seniors and disabled individuals. The Senior Center van provides transportation to seniors three days a week. “I think the senior center van is a good service to help people get around.” The hospital van also provides limited transportation to individuals using services�“but they only use it for people they consider in need.” The hospital van is also occasionally donated for community events. Senior apartments Senior apartments in Wrangell provide housing and activities to seniors. “Lots of people take advantage of these.” Assisted living The current assisted living facility is mostly geared toward the mentally and physically disabled (�high maintenance individuals�). A new private assisted living facility is scheduled to open soon. “I don’t know how much experience the owner has, but she is very capable and ambitious. She shouldn’t accept someone with advanced Alzheimer’s or other people requiring a high level of care.”

Grocery services Grocery stores provide discounts and free delivery services to the elderly and disabled. “They are good about this and they will even shop for you.”

Services through churches Churches offer services where there is community need. Various churches provide meals and food baskets to seniors. “The Presbyterian church gave out baskets earlier


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this year that contained things like fish, berries, home-baked cookies and so on. They delivered them to all the old people in the community.” The Baptist Last Chance Club meets once a month for a meal. “Lots of seniors go to this, including seniors from the senior apartments.” Churches also provide transportation to and from church, home visits from the pastors, and various activities. “Presbyterians get people out of their homes in the middle of winter.” Tax exemptions Seniors receive tax benefits and exemptions in Wrangell, including sales tax reimbursements and property tax exemptions—“on the first $125K of senior’s homes.”

Swimming pool The swimming pool provides special hours for seniors, has lap swim in the early morning, water aerobics, and an exercise room. “Seniors get free usage of the pool and weight room in town.” Call Care buttons Call Care buttons are used when an individual is in medical need. It works by signaling the hospital, then the hospital calls the person at home, goes down the call list, and sends EMTs to the home. “Call Care buttons are great.” Respite care Respite care is provided through Wrangell Community Services, the Wrangell Medical Center, and various individuals in town. Respite services are only provided intermit-tently at the Medical Center, when the long-term care facility has room. Senior Center The Senior Center is open three days a week and provides various services to seniors, including lunches and transportation for shopping. Loan closet The Loan Closet is an informal service that loans out wheelchairs and medical equipment. These items are stored in an airport hangar. Home visits by medical staff On occasion, doctors and nurses from the Wrangell Medical Center do home visits for homebound individuals. Other In addition, respondents mentioned the following other social senior services available in Wrangell:

• Mental health services through Wrangell Community Services • A library that is open in the evenings—“The librarian will get books for people they

don’t have from other libraries around the country.” • Free workshops and clinics at the hospital on health issues such as diabetes


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• An annual health fair, which includes blood pressure checks, $25 blood work-ups, and booths

• Free checking for seniors at Wells Fargo • Free newspaper subscriptions for seniors • Friends • Quality health services through the medical center • Visiting specialists, such as internal medicine, a podiatrist, and a dietitian • Alternative medicines through the public health nurse • Flu shots • Physical therapy services • A senior resource directory that is updated and mailed out to all seniors • Health services for seniors by the public health nurse�“These services vary over

the years depending on who is in the position at the time and what their focus is.” • Bingo at the American Legion • Benches around town for people to sit • The ramp into the Senior Center Respondents gave various reasons why they like the long-term care facility, the home health care program, senior apartments, Wrangell Community Services, grocery services, and the Senior Center. Long-term care facility Respondents spoke highly of the long-term care facility in Wrangell. In particular, they like that the facility is �informal� and allows visits from family members, children, and pets. “There is a dog that visits everyone.” The facility also holds parties and has activities, such as crafts, church activities, and lunch outings. “On a nice day, the residents go out to the park or on picnics.” Residents are also well-cared for, nour-ished, and don�t have bed sores—“it is better care than they would receive in Seattle.” Respondents praised the staff at the long-term care facility, stating that they are friendly and caring, and that there is a good staff-to-resident ratio and a low turnover rate. In other states, turnover is often quite high in long-term care facilities. “But the CNA position in the long-term care facility here in Wrangell is considered a “status position”. It has good pay and benefits. The pay is good compared to other entry-level positions in town.” In addition, respondents said the facility is a �nice size,� has good food, allows outside gardening, and has an outdoor area for people to smoke. “It is one of the better LTC units in the state.”


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Home health care program Respondents like the home health program in Wrangell because of the �spirit of generosity,� and because the home health aides provide company to seniors. “They usually know the person who works as the aide. This gives them a sense of trust, a sense of community.” In addition, the home health program reduces the workload of people who are caring for their parents. The program provides meals, bathing, help with medications, and blood pressure and blood sugar checks. Senior apartments The senior apartments are clean and allow people to remain in Wrangell and live independently, without having to maintain a house. “The apartments are a great addition; they’ve been here 15-17 years.” Wrangell Community Services Respondents appreciate the way Wrangell Community Services provides activities to residents at the assisted living facility three evenings a week, and the services they arrange for community members. “I really like working with Wrangell Community Services.” Grocery services Respondents praised local stores for providing discounts to seniors, and for delivering groceries. “[Grocery stores] are really good about it. People are supposed to spend a minimum amount before they deliver them, but they don’t really pay attention to that.” Senior Center The Senior Center provides seniors with the opportunity to �get out of the house,� offers programs that are informal and encourage community spirit, and has a generous staff. “I believe the caliber of people involved in a program is the most important part.” Other In addition, respondents said they like the following home and community-based services in Wrangell: • Medicaid waivers: Currently, Medicaid waivers are going well. “We’re able to

identify who qualifies.” Wrangell Community Services has 16 Older Alaskan Waivers in effect, with four additional waivers. People are allowed up to $90,000 in resources (excluding their house) to still qualify for a waiver.

• Public assistance: Public assistance workers are accessible to seniors—“They aren’t just nameless faces in a big building like they might be in a city. People are willing to help each other out here.”

• Transportation services: The van gets people out of the house, and the van driver picks up mail for people.

• Swimming pool: The swimming pool is reasonably priced and not crowded.

• Assisted living: New assisted living beds will help alleviate increased demand. “We’re full in long-term care right now, so more assisted living is needed.” In the


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past, the original assisted living facility tried to accommodate geriatric patients, but this did not last. “The new assisted living facility that is going in will have some experience with elderly patients, so we will see how that goes.”

B. Additional Home and Community-based Service Needs in Wrangell Respondents identified the need to make the following changes in senior services: expand low cost transportation services, expand and improve meals to seniors, expand home health care, increase activities and gatherings for seniors, educate seniors on the services available to them, expand the services and hours of the Senior Center, increase chore services, expand the long-term care facility, provide paperwork help for seniors, provide more respite care, establish adult day care, and improve accessibility into buildings. Expand transportation services Transportation services need to be expanded, which would allow seniors to get out more often. Respondents suggested the Senior Center provide van services for longer hours and for more days a week, including evenings. Currently, the van runs three days a week. “There are lots of people who can’t go anywhere at night or on the weekend because there is no van service and they don’t drive.” Respondents also pointed out that the Senior Center van does not feel safe to some seniors. Seat belts are not apparent, and some individuals have difficulty entering and exiting the van, which is high off the ground. “I know of one lady who had a stroke and has Parkinson’s. She literally needs to be pushed up to get into the van. The van driver has a bad back, so can’t help.� And, “Elders fall into your arms when they descend.” One respondent suggested the Senior Center get a car that seniors could request instead of the van. “Maybe a local business could donate a used car and use it as a tax write-off.” Others suggested setting up a program with the local cab company to provide vouchers to seniors�“something to cut the transportation costs for seniors so they could use a cab when the van is not in service.” Expand and improve meal services Meal services for seniors need to be improved and expanded in Wrangell. Respondents reported complaints about the quality and variety of meals provided to seniors. “I don’t think the lunches at the senior center or at the hospital are very inspired.” One individual suggested the local restaurants offer a �blue plate� special menu to seniors. Respondents also want to see meals provided more frequently to seniors. One suggested the senior center�s meal program increase from three meals a week to five or six meals. “Seniors need access to more meals and I would like to see them delivered on site, like maybe at the senior housing.”


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Expand home health care services More home health care services are needed in Wrangell. Respondents said many local elderly need help with various tasks, but are unable to find someone willing to do this. “Lots of elderly people in Wrangell just get by on help with friends.” Respondents said part of the problem is that there are not enough workers in Wrangell who are trained in home health care. One suggested providing initial training, on-going training, and mentoring. “They are not encouraged to do this currently.” More families are bringing parents into Wrangell to care for them, and more elderly are retiring in Wrangell, placing a higher demand on long-term care services. Respondents said there is a gap in services, especially between senior apartments and assisted living. “My mom lives in an assisted living with some other disabled adults. She couldn’t make it in senior housing. She needs someone to check in on her periodically, but she doesn’t really need assisted living.” This individual suggested developing a facility that has a live-in manager who checks up on residents and makes sure they are getting enough to eat. “I see lots of Elders that are on their own, but no one is really watching out for them.” In addition, one respondent suggested making Wrangell a more attractive place for people to retire. “There are lots of people in small surround-ing communities that might want to move here when they retire—like Coffman Cove, Point Baker, Port Protection.” Increase activities for seniors Seniors need more activities and gatherings. “All I hear about is people getting together for funerals. I’d like to see more fun interactions with seniors in the community.” Respondents suggested providing evening activities, taking the elderly fishing, and providing informative workshops on various topics, including living wills and the process of death and dying. “Seniors would enjoy this.” One respondent said the senior apartments would benefit from an activity program. “Betty doesn’t have time at the senior apartments to organize activities.” Increase education on available services The elderly need to be educated on the social services available to them in the community. “I think lots of seniors don’t know.” Currently, information is disseminated through word-of-mouth, the scanner, radio, the Wrangell Sentinel, bulletin boards, the hospital waiting room, and the church news. One respondent said the hospital newsletter could be used to educate seniors on services, such as on new Medicare services. Increase chore services Chore services are needed in Wrangell for elderly and disabled individuals who live at home but have reduced mobility. Examples of chore services might include: house cleaning, shopping, picking up mail and prescriptions, and chopping wood. One respondent suggested paying young people to provide chore services. Another suggested hiring volunteers. “I would like to see volunteers do this sort of thing.”


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Improve Senior Center A number of respondents commented on the Senior Center�s lack of funding and its need for improvement. “They are doing what they can with the dollars they have.” Respondents would like to see the Senior Center operate for longer hours. One individual said many seniors don�t feel comfortable going to the facility, perhaps because they don�t feel a sense of ownership. The senior center is currently under the control of the Southeast Senior Services, which is under the umbrella of the Catholic Social Services. “No one donates things to the senior center. The staff doesn’t have the skills to draw people in. They need local control.” Another individual said the Senior Center has a poor liaison with the community. “When we have interagency meetings with different organizations in town, the Senior Center staff do not attend and they have been invited.” Expand long-term care facility The long-term care facility needs to be expanded to include another common room. This would allow the facility to serve meals in a separate room from the activity room, or enable them to separate those individuals who have dementia or psychiatric problems from those who do not. Respondents said it would also be nice if the facility had some private rooms. “Residents are in double rooms, but some people don’t make good roommates.” In addition, respondents would like to see more activities available at the long-term care facility. Provide help with paperwork It would be beneficial to the elderly to have help dealing with the large amounts of paperwork required for Medicaid, Medicare, and social security benefits. One respondent also suggested having someone available to help or advise the elderly on legal issues such as wills, living wills, and guardians. This helper/advisor could be organized through the church, the hospital, or mental health. “They should have the names and contact info for everyone over 60, then contact them.” Provide more respite care More respite care is needed in Wrangell. Wrangell Community Services provides some, and the Medical Center will take patients for up to two weeks if there is room. “But when we are full we can’t do this. If we had more private rooms, this would be more of a possibility.” Provide adult day care Adult day care is currently not available in Wrangell, but would be beneficial to some elderly individuals and their caregivers. One respondent said there has been talk about providing it. “I’m not sure how many people would use this service, but it might be a need.” Increased access into buildings There is a need for improved accessibility into buildings like churches, the Senior Center, and the hospital. “The new sidewalks for wheelchair access have a ‘lip.’ It is hard to enter the hospital.”


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Other In addition, respondents identified the need to make changes in the following other senior service areas: • Develop a pain clinic in the local hospital�“There isn’t one in Southeast Alaska,

and if we had one it could be used by a lot of people. Right now, you have to get a prescription from a pain clinic physician somewhere else.”

• Increase access to a podiatrist�“We have an itinerant, but he visits too seldom. It would be great to train local people on toenail clipping.”

• Get more �fill-in� staff for the holidays—“I have my day job, and I care for my parents…it is too long for my folks to go without care.”

• Increase organization and coordination between senior service agencies—“Sometimes agencies work together, but not often.”

• Increase opportunities for Elders to �give back� to the community (i.e. �grandparent� mentorship program). Although the elementary school has requested senior traffic guard volunteers, few people have showed interest�“I know one 70 year old woman who helps clean the city hall and library, is active in church, and helped start a “Welcome Wagon” to greet new people who have moved to town. She is an active volunteer, but there are not a lot.”

Wrangell Community Services, followed by the Wrangell Medical Center, were the most frequently mentioned agencies that should take the lead in adding or expanding a variety of services. Wrangell Community Services Wrangell community Services was named the most appropriate agency for taking the lead in adding or expanding various services. “Wrangell Community Services does a lot here.” Specifically, respondents suggested this organization provide meals and transportation services, provide a shopping service, and inform seniors on the services available to them. “I think Alice Rooney would be a great person to coordinate some of these services.” One respondent suggested creating a task force that would coordinate services and provide a centralized source of information. “Maybe Janet, the Public Health Nurse, or Alice Rooney could head it up. I would not like to see another umbrella organization over Wrangell Community Services coordinate something like this.” In addition, one individual commented, “Wrangell Community Services make sense, but all they want is money.” Wrangell Medical Center Several individuals felt the Wrangell Medical Center should take the lead in providing meal services in Wrangell. “I have talked to [the Wrangell Medical Center administrator] about having the hospital provide meals and maybe even having an elementary lunch program.” One respondent said the hospital has talked about adding


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an assisted living facility. “It is a delicate issue politically in this community. There is a certain facet of people who think the hospital is a waste of dollars.” Other In addition, respondents identified agencies that should take the lead in a variety of other areas:

• Churches and the Legion Hall for making sure seniors know what services are available

• The City for mobility-related issues

• DHSS for chores

• The Senior Center for fresh meat—“The list could be at the grocery store.”

• The assisted living facility for adult day care�“I’ve been putting together craft supplies with this in mind. I will have two living rooms, one set up with a TV and another one as a place for people to gather and do activities.”

• Churches for coordinating volunteer programs, such as food baskets.

• A connection between senior housing and the meals and van program—“though I confess I don’t know the relationship between who uses the services and if they live in the housing.”

C. Major Health and Non-health Issues for Seniors in Wrangell The following were identified as the top health and social issues faced by senior citizens in Wrangell: isolation, financial issues, lack of access to buildings, impaired mobility, pride, perceived inferiority of local medical care, and general lack of health and fitness. Isolation Isolation, which leads to loneliness and boredom, was the most frequently mentioned health and social issue faced by senior citizens. Respondents said there are not enough social activities or places for seniors to go in Wrangell. “We have lots of ‘shut-ins’ that don’t get out.” One individual said residents at the senior apartments are not allowed to have their doors open because it is a fire hazard, which reduces social interactions. “I don’t think this town does much for seniors. I see them get taken out on the 4th of July and sit out in the rain.” Efforts, such as a monthly get-together at the senior apartments, have been made, but most have failed. Financial issues Financial issues was the second most frequently mentioned health and social concern for the elderly. “Costs are a big issue with seniors.” The elderly face a growing cost of living, the loss of the longevity bonus, and a high cost of medications and services. “I think most seniors are satisfied with the level of care, the doctors and the long term care facility here, but it is all very expensive and they complain about that.”


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Respondents said there needs to be a payment mechanism for lower level services, such as meals and transportation services, as well as aid like home health services for individuals who are not homebound and thus do not qualify for Medicare. In addition, several respondents commented that a number of seniors in Wrangell have money to pay for services, but �don�t want to part with their money.� Access into buildings Access into buildings is a problem for senior citizens and the disabled. “Handicap access is always a problem here.” Respondents reported that the hospital, local stores, and other buildings are difficult to enter and exit. “The sidewalks are narrow and the doors often open out…They’ve done work on the curbs in town, but not the doors.” One respondent said there is also not enough handicap parking in town. “We have very few spots.” Lack of mobility Lack of mobility prevents some seniors from performing tasks around the home, such as housecleaning and odd jobs, and also can prevent them from leaving their homes. “[My mom] likes to shop, but can’t get around inside the store. I’d like to see a service that would wheel her around inside the store.” One respondent said, in some ways, the elderly in Wrangell remain independent longer than anywhere else, “but ultimately the loss of the ability to live alone and making the transition is difficult for them emotionally.” Pride Some seniors may view accepting health and social services as a form of �charity.� Thus, they may avoid seeking the care they need. “There are lots of people who have trouble getting out of a tub or up off the floor, but they won’t admit this to you. They don’t want to appear frail.” One respondent described a dichotomy in Wrangell between seniors who have money and seniors who don�t: “People with money won’t pay for help; they want it free. People without money are too proud to ask for help.” Quality of local care Some seniors worry about the quality of medical care in Wrangell and choose to travel outside the community. “There is a perception that going to Seattle for care is better.” Health issues Seniors often face general health issues, such as lack of fitness and poor diets. “Seniors are in denial of their own health issues.”

Other The following health and social issues were identified as other top health and social issues faced by seniors in Wrangell:

• Heart disease • Diabetes • Smoking


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• Falls • Medication issues, such as remembering when and which medications to take. • Lack of health care services—“People often have to leave town and go to Seattle

and Anchorage, which is expensive.” • Lack of staff members to provide services such as meals and transportation—“We

tried to start a CNA program here but got almost no interest.” Respondents suggested ways to address health and social issues among senior citizens. These include organizing activities to alleviate isolation, instigating chore services to help seniors care for their homes, increasing transportation options to increase mobility, building assisted living facilities to meet intermediate long-term care needs, and developing activities to address fitness issues. Organize activities to combat isolation Respondents suggested ways to reduce isolation among seniors. These include: organizing potlucks, bringing more animals/pets into the long-term care unit, having computer classes for elders, providing more general entertainment, and doing crafts. “I’d like to see some sort of souvenir market where disabled persons could help in manufacturing Alaskan made souvenirs for the growing tourist industry.” One respon-dent said the Senior Center used to have regular bingo. “I think if that were reinstated people would come, as long as they knew about it.” Another said the Senior Center staff needs more training on how to motivate people to participate in activities. “No one knows what they do, and the facility is underutilized.” In addition, one respondent reported that women get together and make handicrafts for their church bazaar. “They have a sense of connection.” Develop inexpensive chore services to help seniors care for their home Respondents want more organizations, such as the hospital, to develop chore and home repair services to help seniors care for their homes. “Just having a reliable person available who isn’t too expensive would help with the odd jobs/chore services. This service would probably have to be subsidized to some degree.” One individual reported that Tlingit/Haida does some of the big home repairs, but not the �small stuff.� “We need someone who can hang doors, build raised beds, wash the outside of people’s homes, but the current people in town are just too expensive.” Increase transportation options to increase mobility Respondents suggested expanding access to transportation by increasing the availability of the senior van and setting up a program with the local taxis. “I’d like to see seniors get a book of taxi fares…Currently they have to pay a minimum of $7 for a taxi even if they only go a mile.”


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Build assisted living facilities to meet intermediate long-term care needs Respondents reported a gap in services for seniors between independent living and the long-term care facility. “We need an intermediate step for our elderly.” Building assisted living facilities would help fill this gap and keep seniors in Wrangell. “I know of three women who have been taken south by kids to move into senior facilities. They have had to leave all their friends. It’s hard.” Develop activity programs to address fitness issues Respondents suggested developing more exercise programs in Wrangell to help improve the fitness of seniors. “The Forest Service already has nature walks in the summer.” Other The following other suggestions and comments were made for addressing health and social issues of senior citizens: • Hire an individual to organize medications�“The person would set-up a person’s

medications for the week, and help plan the ordering of them. I haven’t seen it anywhere yet, and folks would have to pay for the service.”

• Fix the ramp into the Post Office to improve accessibility—“It took years to get the Post Office to build a ramp, then the door didn’t work for handicapped folks. It opens out, and anyone in a wheelchair will just roll back down the ramp…My daughter has MS and can’t get into the Post Office.”

• Increase the involvement of young people in community service projects�“Right now, high school seniors are required to do a ‘senior’ project.”

• Comment about senior participation in services: “I wonder, if more services were available, would people participate? These people have been independent and proud their whole lives.”

The following four health and social issues for seniors were listed most frequently as top priorities over the next five years: 1) in-home assistance, 2) isolation issues, 3) senior housing, and 4) assisted living options. The following other top priorities were also repeatedly identified: adult day care, update the Senior Center, expanded long-term care facility, increased retention of staff in elderly services, and expanded health care services. In-home assistance In-home assistance for seniors is of top priority. Respondents want to see more services offered that will assist seniors with nursing and chore services, including meals, housecleaning, and home improvements.


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Isolation issues Addressing isolation among seniors is another top priority. Positive social activities are needed to bring seniors together, such as a social center where seniors can drink coffee, play games, and visit. Senior housing More senior housing is needed to meet the growing number of elderly in Wrangell. “There’s always a waiting list for the senior apartments.” In addition, one respondents said the community needs to deal with the homeless people, some of which are elderly—“those people who fall through the cracks.” Assisted living Assisted living options for seniors was listed as the fourth top priority for seniors in Wrangell. Adult day care A number of respondents identified the need for adult day care in Wrangell. Updated Senior Center Several respondents want to see the Senior Center updated so it is �less rustic� and provides more meals and transportation. Expanded long-term care facility Respondents want the long-term care facility expanded to include private bedrooms and larger day rooms and bedrooms. Several respondents also said the aides and nurses on the LTC Unit need additional training on how to be more sensitive and caring. “Aides aren’t as sensitive with the ill as they should be.” Increased retention of staff Several respondents identified the need for increased recruitment and retention of staff. “It would be nice if we kept our doctors longer. We have a high turnover for physicians. It’s comforting for people to have the same doctor.” One respondent wondered where the staff will come from to support an increase in services for senior citizens. “Where will we find CNAs, PCAs, van drivers, and home care providers to provide these services in the community?” Expanded health care services A number of respondents said there is a need to increase access to surgery and health screenings for seniors. People have to leave Wrangell for MRIs and CATs, and visiting specialists are often unable to do procedures because of lack of equipment. “I’m not sure what can be done. We are pretty small to support a lot of services here.” One individual said it is a great concern that so many Wrangell residents are being medivaced out. “There is good primary care here, but when patients are medivaced out, there is no social support wherever they end up.”


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However, several respondents commented that access to health care in Wrangell is unlikely to increase. “Wrangell can’t have the range of services that larger communi-ties can offer.” One individual said, overall, the community appreciates the many modern services available locally. “Though there are people that have come into the community from other places and expect the same services they might get down south.” Other The following other health and social issues were identified as top priorities over the next five years in Wrangell: • Respite care

• Expansion of senior meal and transportation programs

• An individual trained to assist people in and out of a van

• Increased mobility of seniors

• Assurance that seniors get the benefits due to them�“Some people are falling through the cracks. Someone should wade through the volumes of paperwork seniors have.”

• Increased involvement of seniors in churches�“It is a ‘community comfort’ that isn’t being used.”

• New lane for bikes, golf carts, and wheelchairs

D. Funding Resources 1. The two most frequently mentioned potential funding source for establishing and maintaining senior services were grants and local or city subsidized funding, followed by Medicaid, the Nolan Foundation, and State funds. Grants and local funding The top funding sources listed for maintaining senior services were grants and community or city funding. One respondent said grants would be best for projects like remodeling a facility (i.e. �expanding the kitchen�). Others suggested ways the City could help, such as having a city-subsidized sliding fee scale to improve transportation opportunities for seniors. Another said the community would be willing to give if they were aware of the need. “One time we had a little boy who needed a blood transport for leukemia. The community raised thousands of dollars locally. I don’t think people know senior services are going down the tube.” However, one respondent said, “I don’t think the local community is interested in funding projects.” Medicaid, Nolan Foundation, and State funds Several respondents suggested obtaining funding through Medicaid, which offers grants to existing businesses, the Nolan foundation for a senior center or for �small


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things,� and State funds. “The State has been generous with dollars to the Pioneer Homes.” Don’t know It should be noted that a number of respondents could not think of any sources of funding for senior services. Other Other possible sources of funding include the Lutheran Church, the federal government, the hospital administration for food services, and private agencies for housing. “I would not like to see the city get into housing!”

City of Wrangell Senior Services Needs Assessment€¦ · PROJECT PARTNERS Wrangell Community...

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Transcript of City of Wrangell Senior Services Needs Assessment€¦ · PROJECT PARTNERS Wrangell Community...