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Appendix

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Appendix B — Measures

  1. Emergency Department (ED) Visits with Chronic Conditions
    • DEFINITION: ED visits with two or more chronic conditions per 1,000 population. Chronic conditions visits are identified by having an ICD-10 diagnosis code in any position for two or more of the following conditions: Asthma, Chronic Kidney Disease, COPD, Diabetes, Heart Failure, High Cholesterol, Hypertension or Obesity. Note, mental health and substance abuse disorders are not included in chronic conditions but are measured independently in a separate metric.
    • SOURCE: 2018 Uniform Billing Hospital Claims Data and United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 8
  2. Emergency Department (ED) Visits with Mental Health/Substance Abuse
    • DEFINITION: ED visits with mental health/substance abuse per 1,000 population. Mental health/substance abuse visits are identified by having an ICD-10 diagnosis code in any position in the patient record beginning with “F.”
    • SOURCE: 2018 Uniform Billing Hospital Claims Data and United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 7
  3. Emergency Department (ED) Frequent Flyers
    • DEFINITION: ED frequent flyers per 1,000 population. Individual patients who had greater than five visits to one or more hospital Emergency Departments in 2018.
    • SOURCE: 2018 Uniform Billing Hospital Claims Data and United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 6
  4. Low Acuity Emergency Department (ED) Visits
    • DEFINITION: Low Acuity ED Visits per 1,000 Population. Low Acuity ED visits are cases with minor problems and minimal risk. Many of these cases may have been able to be treated in a doctor’s office or other outpatient setting. The patients are identified through the Current Procedural Terminology (CPT) code of 99281 in any position on the patient record.
    • SOURCE: 2018 Uniform Billing Hospital Claims Data and United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 5
  5. Low Birthweight Babies
    • DEFINITION: Low birthweight babies as a percent of total babies born. Total babies with low birthweight. Due to low sample size, five years cumulative data is measured. Low birthweight is defined as less than 2500 grams (5lbs 8oz) at birth.
    • SOURCE: 2013-2017 New Jersey Vital Statistics Data, Birth Certificates
    • Lower values are desirable
    • Weight (out of 10): 1
  6. Teen Births
    • DEFINITION: Babies born to a teen mother per 1,000 population of female teenagers (aged 15-19 years). Total babies born to a mother aged 15-19 years. Due to low sample size, five years cumulative data is measured. Teen mothers are defined as aged 15-19 to align with the Census Bureau’s age breakout of the population.
    • SOURCE: 2013-2017 New Jersey Vital Statistics Data, Birth Certificates and 2013-2017 United States Census Bureau, American Community Survey 5 year-estimates
    • Lower values are desirable
    • Weight (out of 10): 1
  7. No Prenatal Care
    • DEFINITION: Mothers having no prenatal care as a percent of total babies born. Total mothers self-reporting no prenatal care. Due to low sample size, five years cumulative data is measured. Data on prenatal care is collected at time of admission for birth.
    • SOURCE: 2013-2017 New Jersey Vital Statistics Data, Birth Certificates
    • Lower values are desirable
    • Weight (out of 10): 1
  8. Fetal Deaths
    • DEFINITION: Fetal deaths as a percent of total babies born. Fetal deaths, as defined by the CDC, are “the spontaneous intrauterine death of a fetus at any time during pregnancy.” Due to low sample size, five years cumulative data is measured.
    • SOURCE: 2011-2015 New Jersey Vital Statistics Data, Fetal Death Database
    • Lower values are desirable
    • Weight (out of 10): 1
  9. Premature Deaths
    • DEFINITION: Number of premature deaths per 1,000 population. A premature death is defined as one occurring before the age of 65.
    • SOURCE: 2017 New Jersey Vital Statistics Data, Death Certificates, and United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 5
  10. Life Expectancy
    • DEFINITION: Life expectancy provides an average number of years a person is expected to live at birth by census tract.
    • SOURCE: Centers for Disease Control and Prevention, National Center of Health Statistics, USALEEP, 2010-2015 data.
    • Higher values are desirable
    • Weight (out of 10): 5
  11. SNAP Benefits
    • DEFINITION: Percent of households receiving Supplemental Nutrition Assistance Program (SNAP) benefits. SNAP is the largest federal nutrition program, providing benefits to low income individuals and families.
    • SOURCE: United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 4
  12. Food Deserts
    • DEFINITION: Percent of households living in a food desert. A food desert is defined as a census tract where at least one of the following is true: at least 100 households are located more than ½ mile from the nearest supermarket and have no vehicle access; or at least 500 people or 33 percent of the population live more than 20 miles from the nearest supermarket, regardless of vehicle availability.
    • SOURCE: United States Department of Agriculture, Food Access Research Atlas, 2015
    • Lower values are desirable
    • Weight (out of 10): 5
  13. Supportive Housing
    • DEFINITION: Residents in supportive housing per 1,000 population. Residents in supportive housing are identified as residents receiving rental assistance under programs from the U.S. Department of Housing and Urban Development (HUD). HUD assistance can be in one of the following categories – public housing, tenant-based and privately owned, project-based.
    • SOURCE: U.S. Department of Housing and Urban Development, Picture of Subsidized Households, 2018, and United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 2
  14. Limited English-Speaking Households
    • DEFINITION: Percent of households reporting limited English-speaking within the home.
    • SOURCE: United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 6
  15. Uninsured
    • DEFINITION: Percent uninsured is the number of civilian noninstitutional population in a zip code without health insurance as a percent of the zip code’s total civilian noninstitutional population. The civilian noninstitutional population refers to people 16 years of age and older residing in the 50 States and the District of Columbia who are not inmates of institutions (penal, mental facilities, homes for the aged), and who are not on active duty in the Armed Forces.
    • SOURCE: United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 8
  16. Percent Medicaid
    • DEFINITION: Percent Medicaid is the number of civilian noninstitutional population in a zip code with Medicaid as their health insurance as a percent of the zip code’s total civilian noninstitutional population. The civilian noninstitutional population refers to people 16 years of age and older residing in the 50 States and the District of Columbia who are not inmates of institutions (penal, mental facilities, homes for the aged), and who are not on active duty in the Armed Forces.
    • SOURCE: United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 5
  17. No High School Diploma
    • DEFINITION: Percent with No High School Diploma is the number of people in a zip code 25 years and older with less than a 12th grade education level and no high school diploma as a percent of the zip code’s total population 25 years and older.
    • SOURCE: United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 6
  18. Median Household Income
    • DEFINITION: Median household income is the median value of the average income of all people living in a housing unit by zip code. Median value indicates half of the households within the zip code have a lower household income and half have a higher household income.
    • SOURCE: United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Higher values are desirable
    • Weight (out of 10): 7
  19. Unemployment
    • DEFINITION: Percent unemployed is the number of people in a zip code 16 years and older who are unemployed as a percent of the zip code’s total population 16 years and older. Unemployed is defined as those who are not working, actively looking for work and available to work. The unemployed also includes those waiting to be called back for a job they were temporarily laid off from.
    • SOURCE: United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 8
  20. Disability
    • DEFINITION: Percent disabled is the number of civilian noninstitutional population in a zip code which are disabled as a percent of the zip code’s total civilian noninstitutional population. The civilian noninstitutional population refers to people 16 years of age and older residing in the 50 States and the District of Columbia who are not inmates of institutions (penal, mental facilities, homes for the aged), and who are not on active duty in the Armed Forces. Types of disabilities include hearing, vision, cognitive, ambulatory, self-care and independent living.
    • SOURCE: United States Census Bureau, American Community Survey 2017, 5-Year Estimates
    • Lower values are desirable
    • Weight (out of 10): 2