Professional Documents
Culture Documents
Community Needs Assessment Report
Community Needs Assessment Report
PEOPLECARE
ATLANTA MEDICAL CENTER SOUTH
TABLEOFCONTENTS
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Community Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Community Health Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Access to Appropriate Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Maternal and Child Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Healthy Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Social Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Cancer (prostate, breast, colorectal, and lung) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Culturally Competent Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Sexually Transmitted Diseases (HIV/AIDS and STIs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Violence and Crime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Setting Community Health Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Primary Data and Community Input . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Consultant Qualifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Community Facilities, Assets, and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
This report utilizes a data-driven approach to better understand, identify, and prioritize the health needs of the
community served by Wellstar Atlanta Medical Center and Atlanta Medical Center South, a not-for-profit hospital
under Internal Revenue Code (IRC) Section 501(r).
The 2010 Affordable Care Act (ACA) requires all not-for-profit hospitals to complete a community health needs
assessment (CHNA) and implementation plan every three years to better meet the health needs of under-resourced
populations living in the communities they serve. What follows is a comprehensive CHNA that meets industry
standards, including Internal Revenue Service regulations set forth in the Additional Requirements for Charitable
Hospitals section of IRC 501(r).
EXECUTIVESUMMARY
Wellstar partnered with Georgia Health Policy Center to complete a comprehensive CHNA process, which
includes synthesis of:
As in previous years, Wellstar Health System worked with community and hospital leaders to identify the
top community health needs. Like in the 2019 assessment, the primary focus of data collection for this
assessment was on under-resourced, high-need, and medically underserved populations living in the primary
service area of the hospital. Some noticeable differences between the 2019 assessment and this one are:
● Health needs are assessed for residents in 74 zip code areas concentrated in Clayton, DeKalb, Douglas,
Fulton, Henry, Newton, and Rockdale counties. The footprint of the service area grew by 18 zip codes and
four counties.
● The prioritization process was different due to COVID, with community leaders identifying top needs
during interviews instead of a large community convening. As a result, the number of health needs have
grown (from 5 in 2019 to 6 in 2022).
● The COVID-19 pandemic has had an impact on all health needs—disproportionately affecting
historically disadvantaged groups.
● Comparisons are made between the 2019 and 2022 assessments when possible.
● The primary and secondary data have been updated, and more data have been included when available.
Data from Clayton, DeKalb, Douglas, Fulton, Henry, Newton, and Rockdale counties were reviewed. County
Health Rankings & Roadmaps was used to gauge counties’ overall health. (Rankings are in relation to the
159 counties in Georgia; a lower score indicates better health, with the county with the best health scoring
number 1). Clayton and Newton counties ranked below the other counties on all indicators except for
Physical Environment. Compared to other counties in the service area, Clayton County ranked especially low
in quality of life (95 vs. 13-54), clinical care (99 vs. 4-72), and social and economic factors (81 vs. 16-52). DeKalb
and Fulton counties ranked higher than the other counties except for physical environment. Fulton County
is near the top of the state rankings for health behaviors (6) and clinical care (4). (Table 1) (County Health
Rankings, 2021)
Clayton 74 69 62 95 37 99 81 97
DeKalb 15 25 16 25 10 17 29 159
Douglas 21 29 25 30 15 72 30 126
Fulton 11 12 12 13 6 4 32 143
Henry 20 15 24 32 14 15 16 131
Newton 55 62 58 54 53 71 52 157
Rockdale 47 39 42 48 36 29 40 129
Source: County Health Rankings & Roadmaps
Wellstar Atlanta Medical Center Needs common to all hospitals in Wellstar Health System
and Atlanta Medical Center South 1. Access to appropriate healthcare
service area
2. Behavioral health
1. Obesity
3. Maternal and child health
2. Access to appropriate care 4. Healthy living (including access to food, physical activity, and chronic
3. Behavioral healthcare disease prevention and management)
4. Educational awareness 5. Housing
6. Poverty
5. Equitable revitalization,
employment, and job training Additional needs in the Wellstar Atlanta Medical Center and Atlanta
Medical Center South service area
7. Education
8. Cancer
9. Culturally competent services
10. Sexually transmitted diseases (HIV/AIDS and STIs)
11. Violence and crime
In general, the community residents served by Wellstar Atlanta Medical Center and Atlanta Medical Center South
are younger and more diverse, with slightly more language barriers than is average for the state. All counties have
larger populations of Black residents, and DeKalb and Fulton have larger Asian populations. Clayton County is
the most diverse county with the smallest White population (10.1 percent). When the data were disaggregated
by race, ethnicity, and income, it was clear that these social determinants impacted health status. For example,
income is lower in single-parent homes. Poverty increased slightly in the service area and single parents constitute
the largest group of individuals living in poverty. Hispanic residents are nearly three times and Black residents
are two times more likely to be in poverty when compared to their racial and ethnic counterparts. In Henry and
DeKalb counties, poverty among Asian groups is high. These trends align with health outcomes. (Other social
determinants explored in the report are housing and education.)
● People of color, particularly Black, Hispanic1, and ● Individuals with pre-existing chronic conditions,
Indigenous communities. especially older residents.
● New American communities and those with limited ● Those experiencing homelessness or at risk of
English-speaking skills, including people without experiencing homelessness (e.g., housing cost
legal documentation and refugees. burdened renters).
● Members of the LGBTQ+ community, particularly ● Residents in rural communities.
students. ● Households without access to reliable broadband
● Lower socioeconomic status individuals, particularly internet.
single-parent families. ● Residents of Clayton County and pockets in Cobb,
DeKalb, Douglas, Fulton, and Rockdale counties
Many of these are the same populations that data has shown consistently experience more barriers to good
health, higher disease burden, and higher incidence of premature death in the Wellstar Atlanta Medical Center
and Atlanta Medical Center South service area, including those noted in the 2019 CHNA. Targeted investment is
needed to address persistent health disparities within these groups.
This assessment also found that many residents do not have access to the most appropriate care to meet their
needs for varied reasons, including insurance status, immigration status, the inability to navigate available
services, lack of available providers, and lack of transportation. There is evidence in both the secondary and
primary data of disruptions in the care continuum throughout the service area. Often, examples of these
disruptions include health professional shortages, high rates of hospital utilization, and inability to access care
because of COVID-19 restrictions.
Similar to the 2019 CHNA, there are several undesirable health outcomes in the service area. Most of the top five
causes of death in the service area are related to chronic conditions, lifestyle, behaviors (i.e., heart disease, stroke,
and lung cancer), or behavioral health and substance abuse issues. Across the service area, residents of Clayton
County have a higher disease burden and death rate. In most cases, Black and Hispanic residents have the highest
rates of poor health outcomes when compared to any other racial or ethnic cohort in the service area. These
health disparities are most notable among the following conditions:
Inequities Continuing from the 2019 Assessment: Inequities Identified by the 2022 Assessment:
• Hypertension • M
aternal and child health, including mortality and
• Diabetes low birth weight births
• HIV/AIDS • Assault
• Asthma • Stroke
• Cancer • Behavioral health
• Sexually transmitted diseases (HIV/AIDS and STIs)
1 W
ellstar Health System has chosen to use the term “Hispanic” to describe populations of Hispanic, Latinx, or Spanish origins due to the term’s universal
use in secondary data sources. Latinx is a gender-neutral alternative to Latino or Latina.
Common Health Issues Continuing from the 2019 Assessment: Common Health Issues Identified by the 2022 Assessment:
Investments in addressing these issues would improve the health of the community served by Wellstar Atlanta
Medical Center and Atlanta Medical Center South.
Below is an overview (Tables 3-5) of community leaders’ perceptions about what has improved, what remains the
same, and what has declined since the last assessment.
Access to Appropriate • T
here is a greater awareness of the safety net that school support staff provide
Healthcare for children. Community support for wraparound services has increased, including
through school-based grant applications.
• Increased funding, new partnerships, and a focus on community organizations
resulted in new and virtual programs that strengthen safety nets for residents in
need.
• Medicaid coverage was expanded from 6 weeks to 6 months for pregnant and
postpartum women.
Healthy Living • Enrollment in health and human service benefits has increased as demand has
increased; this includes Supplemental Nutrition Assistance Program (food stamps),
Medicaid, Childcare and Parent Services (CAPS), Temporary Assistance for Needy
Families (TANF), and Women Infants and Children (WIC).
• Collaboration between Cobb and Douglas counties’ transportation and community
development sectors resulted in positive community changes, such as sidewalks
and walking trails.
• Work-life balance improved for those who could work from home and manage
childcare.
• Services and resources for food, housing, and transportation increased.
• One leader noted that marginalized communities are more resilient and can be
hopeful about systems change.
Access to Appropriate • Services in Sandy Springs remain scarce, including low access to facilities that
Healthcare provide vaccinations, immunizations, and physicals.
Housing • W hile awareness about housing challenges has increased, the rate of homelessness
has not changed. There remains a lack of affordable housing, but there is little
“political will” or capacity to make significant changes.
• Accessing affordable housing remains difficult for low-income renters.
Environment • Environmental health remains unchanged.
Health Outcomes • The rate of chronic health conditions has stayed the same.
Inequity • Systemic issues influencing health, including racism, housing, and education, have
not improved.
• The COVID-19 pandemic highlighted existing disparities in access, unemployment,
and income that continue to influence health outcomes. (Community leaders
specifically mentioned the impact of inequity on maternal and child health,
diabetes, and cardiovascular disease.)
• It remains difficult for New Americans and uninsured residents to access services,
particularly in Sandy Springs.
Social Determinants • Most jobs available to those without a college degree are low wage.
of Health
Table 5 | Areas of Decline Since the 2019 Assessment According to Community Leaders
Declined
Access to Appropriate • Healthcare access was reduced during the COVID-19 pandemic.
Healthcare • New Americans were fearful and hesitant to access services because of the previous
federal administration’s policies.
• As Medicaid offices shifted to online services, those with coverage but lacking
technology skills had difficulty accessing care.
Housing • T
he cost of housing has increased at a higher rate than entry-level wages.
• Housing has become less affordable in Cobb, Douglas, and Fulton counties.
• While moratoriums on evictions helped those who have housing, it has become
harder to obtain housing for those who did not already have it.
Behavioral Health • COVID-19 has negatively impacted mental health and wellbeing.
• Substance abuse has increased in Cobb and Douglas counties.
• Many substance abuse recovery services transitioned to online service delivery.
Telehealth is not a good substitute for in-person recovery services.
• It is harder to access mental health services and resources that are not online.
• State hospital closures decreased residential mental healthcare. For juveniles in the
justice system, the use of contracted facilities further decreased the availability and
comprehensiveness of behavioral health treatment.
Environment • Septic system failures have increased in Cobb and Douglas counties, which are
related to changes in climate, such as more rain.
METHODS
Georgia Health Policy Center partnered with Wellstar to implement a collaborative and
comprehensive CHNA process. The following methods were used to assess the health
needs of communities served by Wellstar Atlanta Medical Center and Atlanta Medical
Center South.
The Wellstar Community Health Council provided oversight and guidance to the CHNA team by reviewing
and providing feedback on the assessment process and inputs throughout the assessment process. Wellstar
Atlanta Medical Center and Atlanta Medical Center South leadership, including the Regional Health
Board, were also engaged to inform the service area definition, list of community leaders for stakeholder
interviews, and final community health needs.
Secondary Data
April-August 2021
The secondary data included in this assessment are from a variety of sources that are both reliable and
representative of the community served by Wellstar Atlanta Medical Center and Atlanta Medical Center
South. Data sources include, but are not limited to:
Secondary data were analyzed at the zip code and county level. Most publicly available data are not
available at a sub-county level.
This Community Health Needs Assessment (CHNA)is being completed during the COVID-19 pandemic, which has
had a significant impact on most of the population-level indicators reviewed by this CHNA process. To address this
limitation, the CHNA team completed a comprehensive review of literature published during the last two years
related to the impact that COVID-19 has had on community health throughout the U.S. Specifically, more than 80
sources were reviewed related to the impact of COVID-19 on cancer (general, breast, cervical, colorectal, lung,
prostate), chronic disease (general, heart disease, asthma, diabetes), behavioral health and substance abuse,
access to and use of care, housing, food insecurity, education, access to technology, human immunodeficiency
virus/acquired immunodeficiency syndrome, sexually transmitted infections, maternal and child health, single
parents, obesity, violence, education, health equity, and New Americans.
The assessment team used the findings from the literature review to inform the creation of a 20-question survey,
which was administered online to nearly 1,000 stakeholders to better understand how the COVID-19 pandemic
has influenced the health of communities served by Wellstar Health System. Questions were asked about the
impact of the pandemic on community health needs identified for Wellstar Health System – i.e., behavioral health,
housing, access to care, healthy living and food access, and maternal and child health. Respondents were also
given the opportunity to identify other notable areas impacted by the global pandemic not mentioned in the
survey. Of the 204 responses received for the health system, 85 respondents represented Clayton, DeKalb, Douglas,
Fulton, Henry, Newton, and Rockdale counties. These findings have been added to this assessment to better
understand the health in communities served by Wellstar Atlanta Medical Center and Atlanta Medical Center
South in 2022.
Community Input
July-October 2021
To better understand the experience and needs of the residents living in the areas served by the hospital, several
types of qualitative data were used, including interviews with 41 key community leaders and two focus groups with
residents from the hospital service area. An in-depth summary of each qualitative process can be found in the
Appendix.
Data Limitations
Most of the data included in this assessment are available only at the county level. County-level data are an
aggregate of large populations and do not always capture or accurately reflect the nuances of health needs.
This is particularly important for Wellstar Atlanta Medical Center and Atlanta Medical Center South because the
service area includes areas with higher socioeconomic status, as well as much lower morbidity and mortality rates,
and areas with lower socioeconomic status coupled with higher morbidity and mortality rates. Where smaller
data points were available (i.e., for census tracts or zip codes), they were included.
Secondary data are not always available. For example, there is no secondary data source that offers a valid
measure of educational awareness in the context of healthy options and the availability of resources. In the
absence of secondary data, this assessment has noted relevant anecdotal data gathered from residents and
community leaders with lived experience during primary data collection. It is important to note that primary data
are limited by individual vocabulary, interpretation, and experience.
● younger (five out of seven counties have a median age younger than the state),
● more racially diverse (Georgia: 52.7 percent White vs. Service area: 10.1 to 46.4 percent White),
● experiencing greater limited English proficiency (3.0 vs. 6.3 percent), and
● average to above-average income earning (five out of seven counties have median incomes higher
than the state) (ACS, 2019).
Among the counties served, Rockdale County is the oldest, with a median age of 37.3 years and 14 percent of the
population above the age of 65 years. Clayton County is the youngest, with a median age of 32.4 years and almost
a third of the population younger than 17 years. Clayton County is also the most diverse county in the service area,
with the largest percentage of the population being Black or Hispanic (68.3% and 13.2%, respectively). Douglas
County also has a high percentage of Hispanic residents, 9.7%. Newton County is the least diverse, with White
residents comprising nearly half of the population. Compared to the state, Clayton, DeKalb, and Rockdale counties
have more residents with limited English proficiency (5.4% vs. 9.1, 8.7, and 5.6%, respectively). Clayton County has
a lower-than-average median income compared to the state ($47,864 vs. $58,700), while the rest of the counties
have average or above-average median incomes. (ACS, 2019)
Total
Population
GEORGIA TOTAL
POPULATION
Income
Distribution
GEORGIA MEDIAN
HOUSEHOLD INCOME
$58,700.00
Median household
$47,864.00 $62,399.00 $63,835.00 $69,673.00 $71,288.00 $56,316.00 $60,189.00
income
Less than $15,000 11.5% 9.5% 8.5% 10.7% 5.9% 10.8% 7.9%
$100,000 and above 14.0% 29.6% 26.7% 35.7% 30.6% 22.7% 26.5%
Median age in years 32.4 35.5 36.3 35.2 36.7 36.2 37.3 36.7
0-17 Years Old 28.1% 23.3% 26.1% 22.2% 26.0% 26.4% 24.9% 24.3%
18-64 Years Old 63.0% 64.7% 62.5% 66.4% 62.6% 61.0% 61.1% 62.6%
65+ Years Old 9.0% 12.0% 11.4% 11.4% 11.4% 12.7% 14.0% 13.5%
Racial/Ethnic
Distribution
Non-Hispanic
White 10.1% 29.1% 40.5% 39.6% 43.4% 46.4% 31.7% 52.7%
Limited English 9.1% 8.7% 4.5% 5.0% 3.3% 2.4% 6.0% 3.0%
Community leaders and the Wellstar Community Health Council were asked to identify community health
needs. The following section includes briefs outlining key findings by health need.
1. 2. 3. 4. 5. 6.
Access to Behavioral Maternal Healthy Housing Poverty
Appropriate Health and Child Living*
Healthcare Health
* including access to food, physical activity, and chronic disease prevention and management
Additional Health Needs in the Wellstar Atlanta Medical Center and Atlanta
Medical Center South Service Area
7. 8. 9. 10. 11.
Education Cancer Culturally Sexually Violence
Competent Transmitted and Crime
Services Diseases**
** including HIV/AIDS
Compared to the state, the service area has above average rates of hospital utilization and death due to
cardiovascular disease (ischemic heart and vascular and cerebrovascular diseases), cancer (prostate and breast
cancers), and behavioral health, including self-harm (Tables 7-10) (DPH, 2015-2019) (CMS, 2015-2016; CMS,
2015-2018). The following disparities are evident in health outcomes among residents served by Wellstar Atlanta
Medical Center and Atlanta Medical Center South:
● With few exceptions, Black residents have the highest rates of poor health outcomes, including hospital
utilization (often higher than state rates) when compared to any other racial or ethnic cohort in the
service area.
● With few exceptions, Clayton County residents have the highest rates of poor health outcomes when
compared to the service area and the state.
● The highest rates of morbidity and mortality for hypertensive heart disease and breast cancer occur
among Black residents.
● Hospital utilization rates are high in Douglas and Newton counties, which may indicate a breakdown in
community-based primary and preventive care.
Ischemic heart 78.6 52.8 68.0 54.4 52.7 64.5 71.3 57.6 55.5 63.9 26.5 29.2 78.6
and vascular
disease
Cerebrovascular 54.4 38.8 49.9 39.5 48.6 43.1 43.8 41.9 35.7 50.0 30.6 32.2 43.4
disease
Essential primary 51.0 34.9 18.2 39.7 50.7 32.8 26.2 38.0 26.6 22.4 16.6 14.2 31.2
hypertension
and hypertensive
renal and heart
disease
Alzheimer's 42.0 33.2 46.9 34.1 56.1 35.6 45.0 37.1 39.5 37.0 12.8 23.7 44.0
disease
Malignant 33.5 26.4 36.4 28.5 34.2 43.4 35.8 30.2 31.2 32.0 13.0 13.2 38.7
neoplasm of
the trachea,
bronchus, and
lung
Age-adjusted rates per 100,000 population. Racial and ethnic data is by all counties
Source: Georgia Department of Public Health Online Analytical Statistical Information System
“Measuring premature mortality, rather than overall mortality, reflects the County Health Rankings’ intent to focus
attention on deaths that could have been prevented. YPLL emphasizes deaths of younger persons, whereas
statistics that include all mortality are dominated by deaths of the elderly.” (County Health Rankings, 2021)
Assault is the primary cause of Years of Potential Life Lost2 in the service area (Table 8). Motor vehicle crashes and
heart disease are the next leading causes of Years of Potential Life Lost.
Assault, motor vehicle crashes, and perinatal conditions are the leading causes of Years of Potential Life Lost
among Black and Hispanic residents in the service area, and for the Black population, the rates are higher than
state benchmarks. For the White population, accidental poisoning is the leading cause of Years of Potential Life
Lost, followed by heart disease and then motor vehicle crashes. Among the Asian population, perinatal conditions
and heart disease are the leading causes of Years of Potential Life Lost.
Assault 739.4 624.8 308.8 513.0 309.4 516.7 430.5 538.1 96.9 934.5 83.8 345.4 330.8
Motor vehicle 589.4 387.6 511.9 332.1 441.1 633.0 367.3 408.6 265.8 551.0 125.7 398.3 482.2
crashes
Ischemic heart and 568.7 379.7 431.9 349.2 387.7 483.0 557.1 402.1 399.7 498.0 149.4 110.0 560.7
vascular disease
Certain conditions 605.1 426.7 345.5 329.0 335.0 417.2 488.2 397.2 119.2 604.8 215.6 352.0 366.2
originating in the
perinatal period
Accidental 284.7 346.1 571.8 435.8 393.7 305.2 362.7 389.9 698.1 280.0 77.6 137.7 415.7
poisoning and
exposure to noxious
substances
Age-adjusted rates per 100,000 population. Racial and ethnic data is by all counties
Source: Georgia Department of Public Health Online Analytical Statistical Information System
2 YPLL 75 represents the number of years of potential life lost due to death before age 75, as a measure of premature death.
Diseases of the 3,527.2 3,146.5 4,069.6 3,054.0 2,246.0 3,938.5 3,224.7 3,144.9 1,495.5 4,579.3 317.3 1,181.4 3,232.8
musculoskeletal
system and
connective tissue
All other 2,499.5 1,602.7 3,877.4 1,891.4 2,196.0 3,974.9 3,364.3 2,144.2 1,925.8 2,718.3 482.7 1,347.9 3,007.2
unintentional injury
All other diseases of 2,329.7 1,818.4 2,865.3 1,864.5 1,829.3 2,988.4 2,509.3 2,012.0 1,267.1 2,646.4 280.7 994.9 2,274.1
the genitourinary
system
Falls 1,293.2 1,088.3 2,327.9 1,243.0 1,371.8 2,290.7 1,969.4 1,345.1 1,536.6 1,342.4 424.9 870.7 1,891.60
Motor vehicle 1,482.1 1,047.0 1,777.5 954.4 1,285.2 1,761.4 1,770.4 1,165.8 592.4 1,771.6 236.5 676.8 1,143.8
crashes
Age-adjusted rates per 100,000 population. Racial and ethnic data is by all counties
Source: Georgia Department of Public Health Online Analytical Statistical Information System
Septicemia 757.2 418.0 678.5 480.3 613.2 492.6 393.2 506.4 440.2 585.7 200.1 301.5 501.3
All other mental and 380.8 475.0 542.9 458.1 171.7 246.0 262.0 417.9 330.6 533.7 34.9 112.1 435.5
behavioral disorders
Diseases of the 389.5 389.9 437.2 397.6 447.3 513.0 458.6 409.7 400.3 368.4 104.3 137.6 467.6
musculoskeletal
system and
connective tissue
Essential (primary) 373.5 320.8 357.6 319.5 262.4 382.3 336.6 325.8 195.8 547.7 94.1 143.5 272.7
hypertension and
hypertensive renal
and heart disease
Ischemic heart and 268.4 232.6 321.9 239.0 278.7 439.3 315.0 259.9 238.4 271.8 105.7 128.4 309.4
vascular disease
Age-adjusted rates per 100,000 population. Racial and ethnic data is by all counties
Source: Georgia Department of Public Health Online Analytical Statistical Information System
Obesity
High body mass index is a national and state-wide health issue. Table 11 displays obesity and diabetes indicators
for the hospital service region. Compared to the state, the service area shows less adult obesity (32.1 percent vs.
29.0 percent) and lower diabetes prevalence (11.2 percent vs. 10.3 percent) (CDC, 2017). The proportion of adults
with obesity and those living with diabetes is lower in Fulton (24.7 and 8.2 percent, respectively) and DeKalb (26.9
Table 11 | S
elect Adult Body Mass Index and Diabetes Indicators (2015-2019, unless otherwise noted)
Clayton DeKalb Douglas Fulton Henry Newton Rockdale White Black Asian Hispanic Georgia
Adults with BMI 36.6% 26.9% 33.2% 24.7% 34.2% 39.3% 44.4% ND ND ND ND 32.1%
> 30.0 (Obese),
Percent (2017)
Adults with 12.4% 10.7% 10.5% 8.2% 11.5% 16.3% 14.0% ND ND ND ND 11.2%
Diagnosed
Diabetes (2017)
Diabetes Discharge 239.6 226.4 225.4 198.6 175.9 203.0 223.8 108.1 303.3 31.5 86.2 202.8
Rate *
Diabetes Mortality 29.1 21.6 22.0 18.4 17.7 27.3 26.4 13.0 32.4 15.2 8.0 21.1
Rate*
Diabetes ER Visit 372.1 288.5 368.1 318.9 264.3 371.1 396.1 130.3 498.4 51.1 202.5 311.4
Rate*
Source: Georgia Department of Public Health Online Analytical Statistical Information System
* Age-adjusted rates per 100,000 population. Racial and ethnic data is by all counties
ND: No Data – Data not available for this population
Coronavirus
Prior to the global pandemic, economic conditions, social determinants of health, and community health were
improving for many people in the hospital service area. There is anecdotal evidence that many of the improvements
that were taking place have been set back and may be worse today than during the 2019 CHNA. There is some
evidence in recent literature that the following populations have been impacted most by the global pandemic:
● People of color, Black, Hispanic, and Indigenous ● Individuals with pre-existing chronic conditions,
communities; especially of older age;
● Lower socioeconomic status individuals and single- ● LGBTQ+ community; and
parent families; ● New American communities.
● Those experiencing homelessness or at risk of
experiencing homelessness (i.e., renters);
COVID-19 cases in Georgia have spiked three times during the pandemic, with the highest daily new reported
cases occurring in December 2021. The service area shows lower vaccine rates when compared to the state
except in DeKalb and Fulton counties (Table 12) (DPH, 2022). When compared to Georgia, the area shows lower
rates (per 100,000 pop.) of death (69.0 vs. 81.6) and hospital use (288.5 vs. 331.8) associated with COVID-19 as well.
Table 12 | S
elect COVID-19 Measures
Clayton DeKalb Douglas Fulton Henry Newton Rockdale White Black Asian Hispanic Georgia
Cases 57,370 126,828 28,074 182,721 45,348 17,959 14,908 843,714 559,458 52,112 196,892 1,916,379
Fully Vaccinated 46.0% 58.0% 48.0% 59.0% 47.0% 45.0% 53.0% ND ND ND ND 55.0%
Mental • T
he COVID-19 pandemic highlighted the need for mental health treatment.
Health • Stress is driving mental health needs as individuals experience unemployment and workforce
shortages.
• Increased behavioral issues related to isolation, including depression, anxiety, substance
abuse, and domestic violence.
• Although the number of virtual mental health support groups has increased, there is concern
over the efficacy of online versus in-person services in providing the same level of intimacy.
• Parents who work full time and support their child’s virtual learning are overstressed and
overburdened.
• School-age children have decreased resilience and ability to cope with transitions.
• Many students are facing academic challenges due to online learning.
• Substance abuse and mental health needs have increased in the LGBTQ+ community. During
the pandemic, LGTBQ+ individuals spent more time with their families and may have felt a
lack of support and acceptance.
Food Access • S
ome households experienced food insecurity throughout the pandemic.
• F
ood supply chain stress was unprecedented; some stores experienced continuous waves of
food shortages.
• L
ack of food access disproportionately affected those without transportation or those
unable to use online delivery services.
• F
ood pantries were unable to accept new clients.
Access to • T hose who were hesitant to seek healthcare due to fear of COVID-19 avoided emergency
Appropriate care and delayed preventative care and procedures.
Healthcare • H ealthcare systems were overwhelmed by the demand for COVID-19 treatment.
• H ealthcare capacity shifted to vaccination efforts and telehealth.
• The Sandy Springs WIC office was relocated to Alpharetta, which made it more difficult for
families to access.
• M any people lost their health insurance because of loss of employment.
• C OVID-19 pandemic stimulus packages may have incentivized some people to stay out of
the workforce and, therefore, lose health insurance.
Chronic • C hronic disease may increase due to stress, reduced physical activity, eating “comfort”
Disease food, and avoidance of wellness visits.
• The reduction of in-person healthcare appointments negatively impacted patients with
uncontrolled cardiovascular disease, hypertension, diabetes, and lung disease.
Social • C
OVID-19 exacerbated persistent disparities, with higher rates of hospitalizations and
Determinants mortality among marginalized groups.
of Health • M
any individuals were able to access education on COVID-19 prevention but did not have
the resources to follow all of the precautions.
• U
nderserved communities faced the brunt of pandemic impacts.
• S
tress related to unemployment can increase violence within families and society.
• M
any of the jobs available to those reentering the workforce were at call centers. These
types of jobs do not set individuals up for long-term career success.
• S
ome people that qualified for pandemic stimulus assistance did not need it. Some people
that did need it were unable to access it, including families experiencing homelessness and
working mothers.
Early and K-12 • There is a new lack of childcare facilities.
Education • S chool-age children are struggling to remain at or reach grade level.
Economy • M any small business owners were not able to afford needed safety changes.
• Unemployment especially affected part-time and blue-collar sectors.
Impact of Technology
COVID-19 encouraged the use of technology for a variety of health services. Some employers increased their
insurance coverage of telehealth services. Telehealth has increased both access and barriers to accessing
services. One resident called it “the best thing to come out of the pandemic.”
Community leaders felt that while telehealth could not replace in-person care, it did provide greater access to
providers, especially mental healthcare. Telemedicine could also replace the lack of healthcare providers in rural
areas if existing broadband issues are solved.
Telehealth is not a universal remedy. Those without smart phones, computers or computer skills, internet access,
sufficient bandwidth, and unlimited minutes – including many new Americans and senior residents – struggled
to use telehealth services. Online resources, social services, and telehealth are often only available in English and,
less often, Spanish. Residents’ trust was a factor in the use of telehealth services. For example, some residents were
concerned about the accuracy of virtual assessments, and others were suspicious of patients who were allowed
in-person visits versus those who were directed to telehealth. One resident said, “Telehealth is like getting a half-
baked diagnosis.”
Overall, the service area has higher provider rates than state benchmarks, but the rates vary among the counties.
● Clayton, Fulton, and Henry counties have lower rates of addiction/substance use providers compared to the
state (CMS, 2020).
● DeKalb County has lower rates of nurse practitioners but higher rates of all other providers (CMS, 2020).
● In Clayton, Douglas, and Newton counties, rates of dental, mental health, nurse practitioners, and primary care
providers are lower than state benchmarks. (HRSA, 2015; CMS, 2021; CMS, 2020; HRSA, 2017).
In Clayton and Douglas counties, a higher percentage of the population live in a Health Professional Shortage
Area compared to the state and the service area (45.8 and 34.4 vs. 30.2, and 18.2 percent, respectively). Across the
service area, more than half of the people living in Health Professional Shortage Areas are considered underserved,
and in Clayton and Douglas counties, the rates are 88.0 percent and 78.7 percent, respectively. (HHS, 2021)
The service area has a slightly lower percentage of uninsured population compared to the state, but a higher
percentage uninsured compared to national benchmarks (12.6 percent vs. 13.2 percent and 8.8 percent,
respectively) (ACS, 2019). Uninsured rates in Clayton (18.4 percent), DeKalb (14.0 percent), and Rockdale counties
(13.7 percent) are higher than in the state and service area (ACS, 2019). Hispanic residents are more likely to be
uninsured than the service area overall (31.9 percent vs. 12.6 percent) (ACS, 2019).
Percentage of Population 45.8% 12.8% 34.4% 19.8% 0.0% 0.0% 0.0% 18.2% 30.2% 22.6%
Living in an Area Affected
by a Health Professional
Shortage
Percentage of Health 88.0% 36.2% 78.7% 43.6% 0.0% 0.0% 0.0% 57.8% 56.1% 53.7%
Professional Shortage
Population Underserved
Percentage of Population 100.0% 20.7% 100.0% 35.5% 0.0% 0.0% 0.0% 36.0% 59.1% 44.6%
Living in a Health
Professional Shortage Area
for Dental Care
Addiction/Substance Abuse 2.1 6.0 8.4 2.1 1.8 9.3 6.7 4.1 2.3 9.1
(2020)*
Buprenorphine Providers 6.0 8.5 4.2 9.5 8.4 0.9 3.3 7.9 3.4 5.7
(2020)*
Dental (2015)* 27.0 56.6 41.9 68.4 33.5 17.1 74.3 54.3 49.2 65.6
Mental Health (2021)* 67.4 308.2 110.0 245.6 149.6 97.5 150.7 218.9 146.0 261.6
Nurse Practitioners (2020)* 16.2 30.0 19.5 53.3 29.8 36.7 27.1 38.8 37.1 39.7
Primary Care (2017)* 25.3 107.6 36.3 108.8 47.5 27.8 73.5 85.8 65.6 76.7
● Individuals have less disposable income to pay ● Dental providers are having difficulty retaining
sliding scale or reduced rates. dental assistants.
● Many residents with chronic disease and Hispanic Care-seeking behavior
individuals lack health insurance. ● Lack of trust in the medical community may
discourage Black women and New Americans
COVID-19
from seeking care. Hispanic women may not seek
● Individuals concerned with COVID-19 transmission in
prenatal care because they fear deportation and do
healthcare settings delayed preventative care and
not know how to access low-cost care.
elective procedures.
● Among New American populations, care is often
● Staff reduction and the shift of healthcare capacity
sought for children but not for adults. For example,
to COVID-19 vaccination and treatment and
there is a disproportionate amount of ovarian and
telehealth contributed to delays in emergency and
breast cancer among Hispanic women due to a lack
non-emergency care. These delays in care could
of screening.
affect future disability or death.
● Childcare responsibilities reduce Black women’s
● Children were unable to get physicals and
ability to seek healthcare.
immunizations for school.
● Individuals without paid sick leave may choose to
● In-person services are still limited, and telehealth
work instead of seeking healthcare.
services are not accessible to all.
● Individuals who experienced financial hardship
● Increased unemployment during the pandemic left
during the pandemic may have delayed care to
many without insurance.
conserve money, even if they were insured.
● Pandemic stimulus packages may have incentivized
some people to stay out of the workforce and, Other barriers
therefore, lose health insurance. ● Healthcare providers’ hours of operation are
incongruent with working families’ schedules.
Lack of service providers
● Lack of reliable public transportation, which
● Lack of healthcare facilities and poor distribution of
especially impacts access to care for low-income
resources especially impacts low-income residents communities
and Black and Brown communities. In these areas,
● While the Grady Card offers many benefits, there
first responders are the “first line of medical care.”
are barriers to acquiring a Card, including income
● Lack of providers that accept Medicaid and requirements, a complex application process, and
uninsured patients, including dental providers long wait times for appointments.
● Lack of primary and preventative care providers in ● Parents are not well educated on pediatric dental
Douglas and Rockdale counties needs, and elementary school-age children need
more dental health education.
● Medicaid reimbursements rates are too low,
especially for dental services.
● Support expanding Medicaid and the Marketplace in Georgia to increase access to affordable health
insurance options.
● Build and cultivate trust in the communities and leverage partnerships.
● Increase and improve strategic partnerships with different healthcare organizations.
● Increase access to care using an asset-based approach, including:
• Increase the number of providers and family health centers
• Work with providers to increase those that serve the Medicaid population and to serve undocumented and
uninsured patients
• Establish mobile clinics
● Advocate for better broadband access for telehealth
Compared to Georgia:
● Douglas and Fulton counties have higher emergency room use for mental health/behavioral disorders (1,102.4 vs.
1,322.3, and 1,387.5 per 100,000 pop.) and for drug-related disorders (318.2 vs. 338.2 and 493.3 per 100,000 pop.).
● Emergency room visits for intentional self-harm per 100,000 pop. (Georgia, 30.9) are higher in Douglas (83.8),
Henry (72.2), Newton (98.9), and Rockdale (112.4) counties.
● Clayton and DeKalb counties have fewer emergency room visits for mental health, drug-related disorders, and
intentional self-harm per 100,000 pop. (DHP, 2015-2019)
Community leaders noted that children generally end up in the emergency room for mental health concerns due
to a lack of pediatric mental health providers.
Drug overdose
From 2009 to 2019, age-adjusted drug overdose rates (Table 15) generally decreased across the service area.
In 2019, the service area had lower drug-related overdoses and opioid-specific overdose rates (12.0 and 6.9 per
100,000 pop., respectively) compared to the state (12.9 and 8.1 per 100,000 pop., respectively). (DPH, 2009 – 2019)
Within the service area, the age-adjusted overdose rates in Douglas County (18.4 per 100,000 pop.) are more than
twice as high as the rates in Clayton and Rockdale counties (7.6 and 7.8 per 100,000 pop., respectively), and above
state rates (12.9 per 100,000 pop.) (DPH, 2009-2019).
Community leaders are concerned about increasing substance abuse, and the opioid crisis remains a significant
concern in Douglas County.
Suicide
Suicide rates in the service area are lower than state benchmarks (10.6 vs. 13.7 per 100,000 pop.) but vary across
counties. Suicide rates per 100,000 population in Newton (14.6), and Rockdale (13.7) counties are average to high
compared to the state (13.7). In Clayton, DeKalb, and Fulton counties, the suicide rates per 100,000 population
are lower than state and service area rates (9.6, 9.3, and 10.4 vs. 13.7 and 10.6 per 100,000 pop., respectively). (DPH,
2015-2019)
Availability of care
● Mental health provider rates in DeKalb and Fulton counties are higher than the service area and the state
(308.2 and 245.6 vs. 218.9 and 146.0 per 100,000 pop., respectively). In Clayton County, mental health provider
rates (67.4 per 100,000 pop.) are four and a half times lower than DeKalb County, three times lower than the
service area, and two times lower than the state. (CMS, 2021)
● Compared to the state, the service area has higher rates per 100,000 population of addiction/substance use
providers (2.3 vs. 4.1), but rates are low in Clayton (2.1), Fulton (2.1), and Henry counties (1.8) (CMS, 2020).
Table 15 | R
ate of Drug Overdose (2009-2019)
Clayton DeKalb Douglas Fulton Henry Newton Rockdale Georgia
Figure 1 | E
mergency Room Visit Rate for Disorders related to Behavioral Health
1,400
n Clayton
1,200
n DeKalb
1,000
n Douglas
800
n Fulton
600
n Henry
400
n Newton
200
n Rockdale
0
n Georgia Disorders Related to Intentional Mental Health and
Drug Use Self-Harm Behavioral Disorders
Age-adjusted rates in the Wellstar Atlanta Medical Center and Atlanta Medical Center South service area, compared to state benchmarks (2015-2019)
Source: Georgia Department of Public Health Online Analytical Statistical Information System
Georgia has the second highest rate of maternal mortality in the country (48.4 per 100,000 pop.) (World
Population Review, 2022). Areas of concern include lack of “follow-up on cardiovascular symptoms… failure to
recognize and treat hypertension or hemorrhages soon enough” and lack of sufficient prenatal care. Black
mothers are most at risk with “Black mothers are more likely to die from pregnancy in Georgia than they are in the
rest of the United States” (World Population Review, 2022).
Community leaders were concerned about teenage pregnancy among New Americans. There is limited information
available for New American teenagers on health and reproduction. There is a need for more prenatal care access
and breastfeeding education for teenage mothers. Schools need resources to retain pregnant students.
Infant mortality
Compared to the state, infant mortality is higher in the service region (7.3 vs. 7.5 per 1,000 live births). Fulton
County is the only county in the service area that shows lower Infant mortality rates when compared to the state
(DPH, 2015-2019) (Figure 2).
Access to care
Community leaders reported there are limited women’s health services available. They also identified a need for:
● Free or low-cost prenatal and postnatal services for women lacking legal immigration status.
● More low-cost facilities and/or financial support for vaccinations, immunizations, and physicals, especially for
New Americans and uninsured individuals.
● Better provider follow-up to ensure that children receive vaccinations.
● More pediatricians in Douglas County, especially those that accept Medicaid or offer discounts for the
uninsured.
● More resources for pregnant women to understand early prevention of chronic disease.
● More Black and female OBGYN providers.
There is a higher rate of teen pregnancy (females aged 15-17) among Hispanic teens compared to White teens
and the service area population overall (22.1 vs. 3.6 and 13.0 per 1,000 live births, respectively) (DHP 2016-2020).
Community leaders felt that higher rates of teen pregnancy among New American populations are partially
attributable to the limited information available to teenagers on health and reproduction in languages other
than English.
Figure 2 | P
regnancy and Birth Rates per 1,000 live births, Infant Mortality, and Low Birth Weight
70 14
n Clayton
60 12
n DeKalb
50 10
n Douglas
40 8
n Fulton
30 6
n Henry
20 4
n Newton
10 2
n Rockdale
0 0
n Georgia Pregnancy Birth Infant Mortality Rate % of Low Birth Weight
Rate (All) Rate (All) (2015-2019) Births (2016-2020)
Per 100,000 pop. in the Wellstar Atlanta Medical Center and Atlanta Medical Center South service area, compared to state benchmarks (2016-20)
Source: Georgia Department of Public Health Online Analytical Statistical Information System
Community leaders recommended increasing the level of support that pregnant women receive from the
community, including:
● Early education, ● Intervention services for infants born to
● Support securing immunizations and follow-up care, incarcerated parents, and
● School retention services for pregnant teens ● Community care for pregnant prisoners.
attending high school,
Based on an inventory of community assets (see Appendix), there are 19 resources in the area to address maternal
and child health; however, additional exploration will be required to determine the capacity of resources to meet
identified needs. For example, it is not possible to determine the extent to which practitioners are accepting
patients using Medicaid, Marketplace, and self-pay options to pay for services.
Chronic Disease
Chronic diseases identified by community leaders included asthma, cancer, cardiovascular disease, diabetes,
obesity, and sleep apnea. Data show elevated morbidity and mortality rates associated with cardiovascular
disease and diabetes.
Figure 3 | C
hronic Disease Mortality Rates
70
n Clayton
60
n DeKalb
50
n Douglas
40
n Fulton
30
n Henry
20
n Newton
10
n Rockdale
0
n Georgia High Blood Obstructive Hypertensive
Stroke Diabetes
Pressure Heart Disease Heart Disease
Disparities:
Diabetes disproportionately impacts Black residents compared to White residents, with a diabetes mortality rate
of 32.4 per 100,000 deaths among Blacks and only 13.0 per 100,000 deaths among Whites (DPH, 2015-2019).
New American populations are unable to manage high blood pressure and diabetes due to their lack of access to
primary care and the high cost of medication.
Asthma
Compared to the state, residents in this area are more likely to be hospitalized (74.2 vs. 95.6 per 100,000 pop.)
and to utilize the emergency room (539.9 vs. 694.0 per 100,000 pop.) for asthma-related illnesses. Within the
service area, Henry County is the only county with lower rates than the state for hospitalization (61.8 vs. 74.2 per
100,000 pop.) and emergency room usage (406.1 vs. 539.9 per 100,000 pop.) due to asthma. Black residents are
much more likely than their White peers to visit the emergency for asthma (753.1 vs. 443.2 per 100,000 pop.) and
three times more likely to be hospitalized (99.3 vs. 27.1 per 100,000 pop.). (DPH, 2015-2019)
Residents discussed many factors that influence whether individuals consume healthy food, including:
● Lack of knowledge of how to locate or prepare ● Time constraints that limit grocery shopping and
healthy food, meal preparation,
● High cost of healthier food, ● Lack of transportation, and
● Prevalence of unhealthy food options and fast food.
All COVID-19 Pandemic Influence Survey participants acknowledged that the pandemic impacted people’s
ability to live healthy lives. The COVID-19 pandemic disrupted daily routines, such as going to the gym and the
availability of public transportation for activities like grocery shopping. Community leaders are concerned that
stress, less physical activity, eating “comfort” food, and limited in-person medical care during the pandemic will
contribute to increased chronic disease.
COVID-19 Pandemic Influence Survey participants identified the following groups’ access to food and healthy
living opportunities as most disproportionately impacted by the pandemic:
Community leaders were concerned about the lack of access to affordable, healthy food and food insecurity.
Leaders noted how it is currently difficult to make ends meet; the cost of food and other necessities have
increased while wages and/or fixed-income benefits have not. When healthy food is unaffordable, individuals
consume foods with more sugar, fat, and cholesterol. This is cost-effective at the moment but leads to high costs
long term. COVID-19 Pandemic Influence Survey participants identified food shortages and restrictions on public
transportation as further reducing access to healthy foods.
The number of individuals seeking food assistance through government programs or organized food distribution
events increased. In 2021, one statewide support organization assisted 1,139 households with accessing
Supplemental Nutrition Assistance Program benefits compared to 769 households in 2020. Some food pantries
were unable to accept new clients during the pandemic. Some people in need were able to utilize food delivery
programs.
Underserved communities may be food deserts in which there is limited public transportation, and grocery
stores are located several miles away. These communities are also targeted by fast-food marketing. Community
leaders identified individuals in the following areas as experiencing higher food insecurity:
Figure 4 | Percentage of Population with Food Insecurity and Low Food Access
50%
n Clayton
n DeKalb 40%
n Douglas
30%
n Fulton
n Henry 20%
n Newton 10%
n Rockdale
0%
n Georgia Food Insecure Population (2017) Low-Income Population with Low Food Access (2019)
In the Wellstar Atlanta Medical Center and Atlanta Medical Center South service area, compared to state benchmarks (2017-2019)
Sources: U.S. Department of Agriculture, Economic Research Service, USDA – Food Access Research Atlas, 2019.
Source geography: Tract; Feeding America. 2017.
● The Hispanic population is at risk for developing diabetes and lacks access to culturally relevant programs in
Spanish.
● There is a lack of knowledge about the risk factors for cardiovascular disease and death, especially poor eating
and lack of exercise.
● There is a lack of knowledge about the impact of excessive technology, like social media, on health.
● Supplemental Nutrition Assistance Program-eligible individuals and families would benefit from increased
exposure to “new” fruits and vegetables and education on how to affordably cook and store healthy foods.
Access to Amenities
Residents discussed how resources “infused into the community” could reduce healthy lifestyle barriers. Residents
valued the access to libraries with exercise programs, paved trail systems, walkable areas, parks, and gyms
with affordable membership options, like the YMCA. Residents found farmers’ markets in the area particularly
beneficial as they offer live food demonstrations, a greater variety of healthy options than grocery stores, and
coupons for fresh foods.
The social determinants of health prioritized by this needs assessment include poverty, housing, and education.
Data suggests that these social determinants of health were improving prior to the pandemic. Community
leaders have agreed that employment, wages, and the number of insured residents were all increasing before
the pandemic. While data are not recent enough to depict the impact of the pandemic on social determinants
of health in the hospital service area, current literature and all primary data included in this assessment suggests
that poverty, housing, and education have all grown worse since 2020.
A COVID-19 Influence Survey participant noted pandemic recovery funding increased investment in social
services, including rent and mortgage relief and food delivery services. Residents shared that community
philanthropy has increased access to free and readily available services for marginalized communities, but more
funding is needed. Community leaders agreed, noting that more economic investments that promote job growth
are needed.
Community leaders felt there is a need for increased partnership between community and healthcare
organizations to:
● Better align priorities to meet the needs of individual communities.
● Increase funding for community resources and partnerships that improve chronic disease outcomes.
● Increase investment in cross-system work.
● Better allocate resources in Cobb, Douglas, and Fulton counties.
Community leaders discussed inequitable systems that influence equity challenges in social and health outcome
indicators. Leaders recommended a systems-based approach and community collaboration to begin to:
● Increase awareness about race, generational trauma, and infant and maternal mortality.
● Address the emerging challenge of prioritizing mental and behavioral health for those experiencing systemic
barriers, like racism.
● Decrease race-based inequities in sentencing and behavioral diagnoses in the criminal justice system. Address
the overrepresentation of Black women in incarcerated populations.
● Enable effective partnerships between the Department of Corrections and outside support organizations to
solve problems.
● Eliminate discrimination against Black women in the healthcare system.
● Eliminate institutional racism against Black and Brown people who were unable to achieve higher education.
● Eliminate harmful policies against the LGBTQ+ community, such as the inability to choose the restroom of their
choice.
● Address the difficulty that transgender individuals face in accessing gainful employment.
● Increase opportunities after release for individuals who have been incarcerated for long periods of time.
● Reduce the systemic bias against children interacting with the justice system who have experienced trauma.
Walton
DeKalb
Douglas
Fulton
Rockdale
Clayton
Carroll Newton
Henry
Fayette
Coweta
Spalding Butts
Unemployed
(2018-2020)
Poverty 65+
Uninsured
Single w/
2020 CNI
Diploma
Children
Minority
No High
Change
Renting
Poverty
Poverty
County
School
Score
Kids
LES
Zip
At the county level, Clayton County has the highest needs score, followed closely by DeKalb County, while Henry
County shows the lowest needs score (Table 17). A closer look at zip code-level scores shows that there are pockets
of high socioeconomic barriers to accessing care in DeKalb and Rockdale counties (zip codes with needs scores
4.8-5.0) (CNI, 2020). Among the zip codes with the highest needs scores, poverty is high (between 40 to 65 percent
for single-parent households), as is the percent of the population uninsured (18 to 40 percent) (CNI, 2020). Housing
situations are fragile due to job loss, underemployment, and price increases across sectors. Residents believe
that the stress from housing insecurity will contribute to rises in chronic disease and COVID-19 Pandemic
Influence Survey participants believe it will impact both physical and mental health.
Table 18 | P
opulation Below the Federal Poverty Level (2006-2019)
Clayton DeKalb Douglas Fulton Henry Newton Rockdale
Total households 2006-2010 86,546 264,837 44,747 357,463 66,327 33,536 28,561
● People of color (highest among Black and Hispanic ● Single parents – single female heads of households
populations) – poverty levels in this region are higher constitute the largest group of individuals living in
among Black (18.3 percent) and Hispanic residents poverty, ranging from 15 percent in Henry County
(21.6 percent) compared to White residents (8.9 to 31 percent in Newton County. From 2006-2010 to
percent) and Asian residents (12.5 percent). However, 2015-2019, poverty rates of this group rose across
in Clayton County, poverty levels are higher among the service region except for in DeKalb and Fulton
Hispanic (23.8 percent) and White (21.0) residents counties (ACS, 2019).
compared to Black residents (18.4), and in Henry ● Residents 65 and older
and DeKalb counties, there are high percentages
● Women
of Asian residents living in poverty compared to the
rest of the service area (14.8 and 19.8 vs. 12.5 percent) ● Residents with limited English proficiency
(ACS, 2019). ● Those without a high school diploma (ACS, 2019)
30%
n Clayton
n DeKalb 25%
n Douglas 20%
n Fulton 15%
n Henry 10%
n Newton
5%
n Rockdale
0%
n Georgia White Black Asian Hispanic All People
Compared to Georgia, most of the counties in the service area have a higher median income except for Clayton
and Newton counties (ACS, 2015-2019). From 2015-2019 unemployment in the service area (5.4 percent) was
higher than in Georgia (4.4 percent) (ACS, 2015-2019). Overall, the unemployment rate doubled or tripled in the
service area between 2019 and 2020, which is likely due to COVID-19 (note: there are no 2020 data for Newton
County) (U.S. Department of Labor, 2020).
Some residents shared that poverty has a pervasive and rippling effect in the service area. Residents discussed
how poverty, housing, and healthy living are interconnected. One resident felt that resources are available for
housing and food assistance, while another found it difficult to afford basic needs.
Community leaders noted factors that contribute to financial insecurity:
● Employers decreased staff during the COVID-19 ● Most opportunities available to those re-entering
pandemic, especially in the part-time and blue- the workforce after experiencing homelessness do
collar sectors. not set individuals up for long-term career success.
● Prices have increased across sectors due to ● Some families experiencing homelessness and/or
pandemic recession. working mothers did not receive pandemic stimulus
● Lack of employment opportunities that pay a checks and/or unemployment benefits.
living wage.
Community leaders felt that individuals living in poverty were impacted by additional factors:
● Lack of access to free or low-cost legal support. ● Lack of community support for families in poverty.
● The political climate discourages undocumented ● Lack of safety-net services for seniors, such
new Americans from seeking support services. as support for caretakers, transportation, and
technology.
Housing
Across the service area, the percentage of families with cost-burdened housing (spending more than 30
percent of income on rent or mortgage) decreased from 2010 to 2019 (ACS, 2019). Despite these decreases,
almost 50 percent of renters and 25 to 30 percent of homeowners in the service area are still paying more
than a third of their income for housing (ACS, 2019). The mortgage burden is especially high in Newton County,
where almost 50 percent of homeowners are paying more than a third of their income for housing (ACS, 2019).
There is concern that housing outcomes will get worse as post-pandemic data become available.
Table 19 | S
elect Housing Indicators
Units Affordable at 15% AMI* 2.4% 1.6% 2.0% 2.5% 2.5% 3.4% 1.9% 2.9%
Units Affordable at 30% AMI 6.3% 5.0% 5.7% 7.1% 5.8% 6.9% 5.3% 7.6%
Units Affordable at 40% AMI 11.5% 9.0% 12.4% 11.8% 10.6% 12.2% 11.2% 10.4%
Units Affordable at 50% AMI 19.4% 15.5% 22.1% 18.9% 21.5% 20.7% 19.8% 21.6%
Units Affordable at 60% AMI 28.4% 25.2% 35.2% 28.1% 36.3% 31.7% 30.3% 32.1%
Units Affordable at 80% AMI 52.0% 47.8% 62.0% 46.8% 64.7% 55.0% 56.6% 52.6%
Units Affordable at 100% AMI 74.2% 63.9% 77.9% 59.4% 78.4% 75.5% 74.1% 67.1%
Units Affordable at 125% AMI 90.4% 74.4% 85.6% 72.2% 85.3% 84.0% 83.9% 78.0%
Median Gross Rent $991.00 $1,169.00 $1,087.00 $1,205.00 $1,181.00 $1,010.00 $1,056.00 $1,006.00
Households paying more 31.9% 27.6% 24.7% 25.0% 24.5% 47.9% 30.2% ND
than 30% of income for
monthly mortgage
Households paying more 51.7% 52.5% 46.3% 48.7% 46.1% 53.1% 48.1% ND
than 30% of income for
monthly rent
Households living in homes 24.1% 20.9% 17.4% 19.5% 15.6% 16.5% 18.6% 17.7%
with one or more severe
problems
* Area Median Income
ND: No Data – Data not available for this population
Sources: U.S. Census Bureau, American Community Survey, 2015-19; Community Health Needs Dashboard by KP CHNA Data Platform, Esri Business Analyst, 2020.
Housing situations are fragile due to job loss, underemployment, and price increases across sectors. COVID-19
Pandemic Influence Survey participants believe that stress from housing insecurity will impact both physical and
mental health.
Financial assistance is needed for rent, mortgage, utilities, and home maintenance to reduce safety hazards,
such as failing septic tanks. The complexity of the public housing system makes qualifying for assistance difficult.
There are long waitlists of people seeking long-term housing and not enough emergency housing, hotel vouchers,
and shelter options. Community leaders noted a need for more public housing in Douglas County for people with
incomes under $30,000. Small, independent apartment owners did not receive enough federal or state assistance
during the global pandemic.
Housing outcomes are worse for residents who are Black, single mothers, undocumented, and have a low income
(ACS, 2019). Zoning laws may be contrary to fair housing laws and inhibit the development of housing for people
with disabilities.
Survey respondents also identified the following groups as being disproportionately affected by COVID-19’s
impact on housing:
● Individuals earning a low income, ● Non-English speaking or proficient communities, and
● Racial and ethnic minorities, ● Individuals lacking documentation.
● People experiencing homelessness,
Community leaders are concerned that rising housing costs are contributing to homelessness. COVID-19
Pandemic Influence Survey participants shared that because of the lack of supportive housing infrastructure and
policies, at-risk individuals continue to cycle through displacement, eviction, and homelessness. Leasing agents
will not accept partial payments and renters can be evicted with debt. Because leasing agents and landlords will
not rent to individuals with eviction records, they move into hotels, stay with friends or family, or live in their car.
Without stable housing, these individuals are at risk of losing their job.
The homeless population is transitioning from Atlanta to DeKalb. One community leader attributed children
missing school to increasing homelessness. During the COVID-19 pandemic, those that were temporarily or
chronically homeless had a higher risk of COVID-19 infection.
The Point-In-Time Count of Homeless in the city of Atlanta was incomplete for 2021 due to COVID-19. In 2020,
there were 3,240 sheltered and unsheltered homeless people in the City of Atlanta, which is an increase from 3,076
in 2018. The majority of them were male (72.0 percent), over the age of 24 (85.0 percent), Black (88.0 percent), and
non-Hispanic (96.0 percent) (Partners for Home, 2020).
According to an Atlanta Journal-Constitution article published in December 2021, “Until late August, a federal
moratorium kept evictions in check. While that ban was in effect, monthly evictions in the five core counties of
metro Atlanta (Clayton, Cobb, DeKalb, Fulton, and Gwinnett counties) averaged about 7,500 – a little more than
half the pre-pandemic level. In the three months since the moratorium ended, evictions have averaged about
10,000 a month, according to data provided by the Atlanta Regional Commission.”
Based on an inventory of community assets (see Appendix), there are two resources in the area to address
housing; however, additional exploration will be required to determine other organizations that offer housing
assistance (e.g., placement, housing affordability). For example, some job-readiness organizations also offer
housing assistance to their clients.
● Incentivize the expansion of public-private partnerships to develop affordable housing that targets the specific
issues causing affordable housing challenges in rural and urban areas.
● Collaborate with organizations working on housing issues to strengthen resources.
● Advocate for policies that promote equitable and fair housing practices and abolish zoning laws that restrict
the development of multi-tenant and affordable housing units.
Transportation
COVID-19 Pandemic Influence Survey participants found that the pandemic impacted transportation through the
rising cost of gas and a reduction in public transportation options and routes.
Community leaders noted that during the pandemic, some individuals had difficulty accessing COVID-19 testing
centers and care due to lack of transportation. Seniors and individuals in rural areas need more transportation
options in general.
Education
Compared to Georgia, the service area has fewer adults without a high school diploma (12.9 vs. 9.9 percent)
and a higher percentage of the population with an associate’s degree or higher (39.1 vs. 48.5 percent), but there
is variation among the counties (Table 20) (ACS, 2019). Clayton, Douglas, and Newton counties have a higher
percentage of adults without a high school diploma (15.2, 12.2, and 13.4 percent, respectively) compared to the
service area (9.9 percent) and the state (12.9 percent). In Fulton and DeKalb counties, half of the population
has an associate’s degree or higher, compared to around one-third of the population in the rest of the service
area. Populations of color in the service area are less likely to have a high school diploma than White residents,
and Hispanic residents have the highest percent of population without a high school diploma (Hispanic 37.5 vs.
White 11.4, Black 13.3, and Asian 13.0 percent) (Figure 6) (ACS, 2019). Community leaders believed that institutional
racism plays a role in education outcomes, indicating that residents who have dark skin are more likely than other
races to have grown up in neighborhoods with lower socioeconomic status and were less likely to achieve higher
education.
Community leaders reported a lack of early care and education options. There was also concern about the quality
of public education and a disconnect between curricula and the skills needed by local employers. COVID-19
Pandemic Influence Survey participants were concerned that virtual school was not accessible to all students,
resulting in a “digital divide.” They felt that virtual schooling negatively impacted learning and behavioral health. At
the same time, the risk of COVID-19 transmission was higher in in-person learning environments, especially in schools
without mask mandates and testing or vaccination requirements. Residents discussed how many parents did not
have the knowledge to support online learning. School-age children are struggling to reach or remain at grade level.
Adults without a high 15.2% 10.7% 12.2% 7.4% 8.8% 13.4% 11.3% 9.9% 12.9% 12.0%
school diploma (age 25+)
High school graduate rate 73.0% 74.0% 87.0% 84.5% 87.0% 87.0% 83.0% 81.0% 85.4% 87.7%
Associate’s degree or higher 28.0% 51.1% 35.6% 58.9% 37.3% 27.2% 35.8% 48.5% 39.1% 40.6%
Bachelor’s degree or higher 19.5% 44.2% 28.2% 52.9% 28.5% 19.8% 26.3% 41.5% 31.3% 32.2%
Preschool enrollment (ages 47.4% 58.0% 49.1% 61.9% 43.9% 58.7% 52.9% 56.2% 50.3% 48.3%
3-4)
Source: U.S. Census Bureau, American Community Survey 2015-2019
50%
n Clayton
n DeKalb 40%
n Douglas
n Fulton 30%
n Henry
20%
n Newton
n Rockdale 10%
n Georgia
0%
White Black Asian Hispanic All People
Historically, the burden of cancer has been much higher in Georgia when compared to national benchmarks,
which in turn influences morbidity and mortality rates in the hospital service area. The communities served by
Wellstar Atlanta Medical Center and Atlanta Medical Center South have average age-adjusted incidence rates
for all-site cancers when compared to the state (468.4 vs. 467.0 per 100,000 pop.), and Clayton, Douglas, Newton,
and Rockdale counties consistently show above-average rates of morbidity, hospital use, and mortality (DPH
2013-2017) (Figure 7).
Compared to Georgia, the service area shows higher age-adjusted cancer mortality rates for breast cancer (11.7 vs.
13.0 per 100,000 pop.) and prostate cancer (8.6 vs. 9.8 per 100,000 pop.) (DPH 2013-2017). Within the service area,
colorectal cancer mortality rates per 100,000 population in Clayton (15.7), Douglas (15.4), Newton (15.2), and Rockdale
(16.3) counties are higher than the service area (14.1) and the state (14.6). Lung cancer mortality rates in Newton County
are higher than in the service area and the state (43.3 vs. 30.2 and 38.7 per 100,000 pop.) (DPH, 2015-2019).
Cancer is more treatable when detected and treated in earlier stages of the disease. As a result, community
leaders and COVID-19 Pandemic Influence Survey respondents agree that cancer-related mortality rates are
most likely to increase due to the decline in cancer screenings during the COVID-19 pandemic and later-stage
detection, with less effective treatment options. Additionally, leaders believed that breast and ovarian cancer
disproportionately affect Hispanic women due to lack of annual check-ups and early detection.
Mortality rates are higher among the Black population compared to the White population for breast cancer
(17.1 vs. 10.5 per 100,000 pop.), colorectal cancer (17.6 vs. 11.9 per 100,000 pop.), and prostate cancer (14.9 vs. 6.8
per 100,000 pop.) (DPH 2015-2019) (Table 21).
Table 21 | C
ancer Mortality Rates
Community leaders noted that some residents are pleased with their doctors, while other residents are
concerned about the quality of care and level of attention that patients receive. They felt that providers are
not in tune with patient needs.
COVID-19 Pandemic Influence Survey participants and community leaders identified the need for greater access
to culturally competent services. There is a lack of:
Compared to Georgia, the service area has higher age-adjusted rates for sexually transmitted infection overall
(762.2 vs. 1,196.8 per 100,000 pop.) and for:
● Chlamydia (607.2 vs. 797.8 per 100,000 pop.) (DPH, 2015-2019),
● Gonorrhea (195.0 vs. 298.8 per 100,000 pop.) (DPH, 2015-2019), and
● HIV/AIDS prevalence (624.9 vs. 1,257.2 per 100,000 pop.) (CDC, 2018).
Age-adjusted rates for sexually transmitted infection per 100,000 population are substantially lower in Douglas
(916.7) and Henry (777.3) counties when compared to Clayton (1,366.8) and Fulton (1,282.5) counties (DPH, 2015-2019).
In Fulton County, HIV/AIDS prevalence rate at 1,707.2 per 100,000 population is three times higher than in Douglas,
Henry, Newton, and Rockdale counties, which collectively have a range between 412.1 and 476.2 (CDC, 2018).
The age-adjusted rate of sexually transmitted infections for Black residents (1,148.7 per 100,000 pop.) is much
higher than for other racial groups (Hispanic 336.3, White 210.3, Asian 74.2 per 100,000 pop.) (DPH, 2015-2019)
(DPH, 2015-2019; CDC, 2018).
Figure 8 | Sexually Transmitted Infection Rate* and Incidence Rates for HIV/AIDS, Chlamydia*, and Gonorrhea*
n Clayton 1,400
1,200
n DeKalb
1,000
n Douglas
800
n Fulton
600
n Henry
400
n Newton
200
n Rockdale 0
Sexually Transmitted
n Georgia Infection Rate (2015-2019)
Chlamydia Gonorrhea HIV/AIDS
In the Wellstar Atlanta Medical Center and Atlanta Medical Center South service area compared to state benchmarks (2018, except as noted)
* Age-adjusted
Source: Georgia Department of Public Health Online Analytical Statistical Information System
Table 22 | H
IV Prevalence Rates
Community leaders identified a need to increase awareness of HIV testing and PrEP in Douglas County. COVID-19
Pandemic Influence Survey participants felt that social distancing guidelines may have significantly reduced STIs
and HIV/AIDS transmission. Additionally, during the pandemic, government infectious disease staff may have been
reassigned to support COVID-19 efforts.
Compared to Georgia, the service area has higher assault-related hospital discharge rates (16.0 vs. 27.0 per
100,000 pop.) and emergency room visit rates (247.6 vs. 296.8 per 100,000 pop.) (DPH 2015-2019). Fulton County
assault-related hospital discharge rates and emergency room visits are higher than the rest of the counties (34.1
and 341.1 per 100,000 pop., respectively). Serious offenses decreased across the service area* between 2006-2010
and 2013-2017, with a few notable exceptions in violent crime (Table 23) (UCR, 2017):
● Murder increased in all counties except for Fulton County,
● The rate of rape increased in Clayton, Douglas, Henry, and Newton counties, and
● Aggravated assault rates increased in Clayton and Douglas counties (UCR, 2017).
It is important to note that these data do not depict violence after 2019, which is the time when published
literature and primary data included in this assessment all indicate an increase in violence has occurred. Current
literature indicates that Black, Asian, and LGBTQ+ residents were more likely to be victims of violence during the
pandemic.
Community leaders, residents, and COVID-19 Pandemic Influence Survey participants were concerned about
increases in crime, assault, and gun violence across the service area. Increases in violence were attributed
to unemployment, stress between family members, the decline of social harmony, and increasing political
polarization. Cultural glorification of drug use and the prevalence of violent video games may also contribute to
crime and substance abuse. Residents voiced safety concerns for those who speak up against violence and felt
that there are limited crime reduction resources. Community leaders identified a need for a stronger community
support system for families living in poverty and more youth engagement infrastructure.
COVID-19 Pandemic Influence Survey participants were concerned about child abuse and neglect during virtual
schooling periods. Children at home without parent supervision were at risk for abuse from people outside of
the household. Child abuse and neglect cases likely went unreported during the pandemic due to children not
attending in-person school and limited social interactions.
All Part I Crimes 2006-2010 5,540.7 ND 3,727.4 7,798.8 2,743.2 3,156.5 4,333.4
Community health priorities were identified by the triangulation of community input, secondary data, and a
literature review of the impact of COVID-19 on community health.
● Indicators showing above average rates when compared with state and national benchmarks and increasing
or decreasing were noted.
● Community leaders were asked to identify the top three community health priorities for the communities they
serve.
● Areas where COVID-19 has impacted local community health were identified.
Figure 9 | P
rocess Used to Identify the Most Pressing Health Needs
Quantitative Poor
Data performance
Health Issue
(data platforms, against
other numeric data) benchmark
Prioritized
Overlapping
Community
Results
Health Need
Qualitative
Data
Themes Health Issue
(focus groups, key
informant interviews)
1. 2. 3. 4. 5. 6.
Access to Behavioral Maternal Healthy Housing Poverty
Appropriate Health and Child Living*
Healthcare Health
* including access to food, physical activity, and chronic disease prevention and management
Strategies were developed to address the following priorities during the implementation planning process:
1. 2. 3. 4. 5. 6.
Access to Behavioral Food access Housing Pediatric Women’s
Healthcare Health and chronic (Infant and health
disease (Maternal
child health) health)
management
Wellstar Atlanta Medical Center and Atlanta Medical Center South have chosen not to develop a strategy
targeting poverty in the communities they serve because there are many capable community-based
organizations and social service agencies meeting the needs of residents experiencing poverty. Wellstar
Atlanta Medical Center and Atlanta Medical Center South will address poverty through many of the strategies
they implement to address each of the selected priorities, and they will continue to partner with organizations
and agencies serving residents experiencing poverty.
Stakeholder Interviews
APPENDIX
Georgia Health Policy Center conducted interviews with community leaders. Leaders
who were asked to participate in the interview process encompassed a wide variety of
professional backgrounds, including 1) public health expertise, 2) professionals with access
to community health related data, and 3) representatives of underserved populations.
The interviews offered community leaders an opportunity to provide feedback on the needs
of the community, secondary data resources, and other information relevant to the study.
Methodology
The following qualitative data were gathered during individual interviews with 41 community leaders in
the area served by Wellstar Atlanta Medical Center and Atlanta Medical Center South. Each interview was
conducted by Georgia Health Policy Center staff and lasted approximately 45 minutes. All respondents
were asked the same set of questions developed by the Georgia Health Policy Center. The purpose of these
interviews was for community leaders to identify health issues and concerns affecting residents in the
communities served by Wellstar Atlanta Medical Center and Atlanta Medical Center South, as well as ways to
address those concerns.
When asked what has improved, declined, or remained unchanged in the past three years, key informants said
the following:
● Mental health needs have increased, including ● Economic investments are needed in communities
depression, anxiety, trauma, PTSD, and high economic (retail stores, grocery stores, and other healthy
stress. businesses that promote job growth).
● Mental health parity with insurance and healthcare Social Determinants of Health
systems. (including transportation, income and employment, food
● Lack of affordable or accessible mental health facilities, security, education, housing, family and social support,
technology, and structural racism)
specialists, and services, especially for residents
experiencing homelessness. ● Inequitable systems, need for a systems-based
● Need for more culturally competent providers for approach
LGBTQ+ community and Latino communities, including • Trauma-sensitive systems to prevent systemic bias
the need for Spanish speaking mental health services. against traumatized children
● Behavioral health needs of LGBTQ+ populations are not • Equity issues, systemic racism, including systemic bias
being treated. against traumatized children.
● Post-hospitalization housing or residential care ● Access to affordable housing and/or housing assistance
(National Alliance on Mental Health). • Need for more public housing, especially for those
● Increased substance abuse. with incomes of $30,000 a year and under
● The opioid crisis remains a top concern in Douglas • Need for financial assistance to reduce safety
County. hazards in the home, such as failing septic tanks, in
Cobb and Douglas counties.
● Higher prevalence of suicidal thoughts and/or suicide
● Access to affordable healthy food, food insecurity, and
attempts in all groups, especially LGBTQ+, school-aged
food access is a concern.
children, and seniors.
• Many children rely on schools for meals; need to
● LGBTQ+ populations need access to culturally
provide food to families if/when children are learning
competent care that enables individuals to work
from home
through issues without judgment or facing stigmas.
● Lack of livable wage jobs
● Mental health concerns specific to youth:
● Education
• Need for mental health messaging targeted directly
to teens • Lack of childcare and early education options
• Lack of in-patient beds for acute, crisis care for youth • Aligning education systems to address skill gaps in
real time. In south Fulton County, the curriculum in
• Increase in children’s hospital admissions for mental
the school system does not prepare students for
health and eating disorders
available career pathways in the area, while large
Chronic Disease and Disability (including cancer) employers struggle to retain and train employees.
● Asthma ● Transportation to access services
● Obesity COVID-19 Vaccination
● Breast cancer ● Getting people vaccinated, so they can continue going
● Cardiovascular disease to work and school
● Diabetes
• Amongst immigrant populations, high blood pressure
and diabetes are not managed due to lack of access
to primary care and the high cost of medication
Impact of technology
Key informants commented on the impact of technology on people’s ability to be healthy.
● Telehealth has increased both access and barriers to • Some seniors do not know how to use technology.
access: • Need for greater support for populations that
• Telehealth has its limitations and can worsen access. struggle with technology-based resources, such
• Access to telehealth during the COVID-19 pandemic as immigrants, and those with limited Wi-Fi
has been beneficial with increased employer access.
insurance coverage and greater access to providers, • Reliance on technology for COVID-19 information
especially mental health services. and vaccination appointments has been
• More people are willing to use technology and challenging for immigrants. Many do not know
telehealth than before, despite challenges for some how to use email.
populations. ● Chronic disease:
• Telemedicine for rural populations: • Middle- and upper-class Atlantans have more
• Telemedicine could replace the lack of access to technology, including the ability to use it
healthcare providers in rural areas, but existing to prevent chronic disease (track steps, heart rate,
broadband issues need to be solved. etc.), but also are more likely to overuse technology.
Underserved populations lack needed technology.
• Telemedicine for vulnerable populations, including
low-income residents, seniors, and Hispanic and ● Amongst the youth, technology is both necessary (for
other immigrants: school) but also detrimental to mental health and
proper socialization (social media).
• Language barriers in accessing social services
and healthcare. Programs, outreach, and ● Reliance on social media for social needs, but these
technology-based resources are often only aren’t reliable sources of social connection.
available in English and, less often, Spanish. ● Spreading misinformation on social media is especially
• Those without a phone and unlimited minutes detrimental to immigrants.
cannot access the benefits of telehealth.
● Higher frequency of alcohol consumption and heavy ● Telehealth has expanded access to behavioral health
drinking (81%, n=30 out of 37 responses) care, but its benefit does not extend to all, primarily
those without reliable internet access or who prefer in-
● Greater rates of substance abuse (79%, n=26 out of 33
person services.
responses)
Cancer
Ten participants offered the following primary insights
when asked to use the comment box to offer additional
thoughts and insights on the influence of the global
pandemic on cancer:
Georgia Health Policy Center, housed within Georgia State University’s Andrew Young School of
Policy Studies, provides evidence-based research, program development, and policy guidance
locally, statewide, and nationally to improve communities’ health status. With more than
25 years of service, Georgia Health Policy Center focuses on solutions to the toughest issues
facing healthcare today, including insurance coverage, long-term care, children’s health, and
the development of rural and urban health systems.
Georgia Health Policy Center draws on more than a decade of combined learnings from its experience with
100-plus projects supported by 75 diverse funders. The studies span the layers of the socioecological model and
include individual, multisite, and meta-level assessments of communities, programmatic activities, and provision
of technical assistance. Georgia Health Policy Center has been supporting hospital partners in meeting the
CHNA components of IRS regulations since their inception in 2010. Additionally, Georgia Health Policy Center
partnered with Wellstar Health System hospitals to complete the 2019 CHNA and Implementation Planning
Process, meeting IRS regulations at that time.
Health Departments
Clayton County Board The Clayton County Board of Health (CCBOH), located at 1117 Battle Creek Road in
of Health (CCBOH) Jonesboro, Ga., seeks “A Healthier Clayton in One Generation.” Our comprehensive
Clayton County Board of offering of health services, health education, and outreach programs addresses a
Health Comprehensive Health wide variety of community health issues, including infant mortality, child and youth
Facility
1117 Battlecreek Road,
development, obesity, sexually transmitted infections (STIs), food safety, unintentional
Jonesboro, Georgia 30236 injuries, infectious diseases, and emergency preparedness.
678-610-7199
www.claytoncounty
publichealth.org
DeKalb County Board At the DeKalb County Board of Health, we envision safe, healthy communities in which
of Health all individuals have access to quality, affordable health services.
Health Centers
Clifton Springs We offer many clinical, case management and outreach health services for children,
3110 Clifton Springs Road adults and seniors.
Decatur, Georgia 30034
404-244-2200 ● East DeKalb Health Center
● North DeKalb Health Center
● Richardson Health Center
● T.O. Vinson Health Center
Fulton County Department Fulton County Department of Health and Wellness (FCDHW) is the largest testing site
of Health and Wellness in the state of Georgia. Over 700 people each year learn that they have been infected
(FCDHW) with HIV in our clinic. Our clients are introduced to the HIV Clinic physicians on the
Fulton County Public Health same day they may learn their HIV-positive status. Enrollment in the HIV Clinic offers
10 Park Pl S.E., 5th Floor
Atlanta, Georgia 30303
an individual a full-service outpatient clinic with a TEAM approach to educate and
404-613-1205 support the patient and families living with HIV.
www.livebetterfulton.org
● Fulton County Department of Behavioral Health & Developmental Disabilities
● Fulton County Government Center
Cobb & Douglas Public Cobb & Douglas Public Health, with our partners, promotes and protects the health
Health and safety of the residents of Cobb and Douglas counties.
Douglas Public Health Center
6770 Selman Drive We work to achieve healthy people in healthy communities by:
Douglasville, Georgia 30134
770-949-1970
● Preventing epidemics and spread of disease
www.cobbanddouglas ● Protecting against environmental hazards
publichealth.com/
● Preventing injuries
● Promoting and encouraging healthy behaviors
● Responding to disasters and assisting in community recovery
● Assuring the quality and accessibility of health care
By excelling at our core responsibilities, we will achieve healthier lives and a healthier
community.
The Gwinnett, Newton, & The Gwinnett, Newton, & Rockdale County Health Departments work to protect and
Rockdale County Health improve the health of those who work, live, and play in our community, and continually
Departments strive to meet the varied health needs of residents and visitors.
2570 Riverside Parkway
P.O. Box 897 ● Rockdale Health Center
Lawrenceville, Georgia 30046
● Newton County Health Center
770.339.4260
www.gnrhealth.com
Family Health Centers Focuses on outreach, disease prevention and patient education regardless of
of Georgia insurance status of a patient’s ability to pay.
West End | Main Center
868 York Avenue, SW
Atlanta, Ga 30310
404-752-1400
Healing Community Center Health Education, Assessment & Leadership (HEAL), Inc., We are a federally qualified
2600 Martin Luther King Jr. Dr., health center. We offer a sliding fee scale.
SW,
Atlanta, Georgia 30311 School-Based Clinics:
404-564-7749
● LP Miles Elementary School
● Hollis Innovation Academy
Mercy Care at City of As your medical home, Mercy Care offers comprehensive services that meet the
Refuge majority of primary physical and mental health and wellness needs. Services are
1300 Joseph E. Boone Blvd. planned and delivered by a team that works together for your health. These services
Atlanta, Georgia 30314 include primary medical care for adults and children, primary dental care, vision
678-843-8790
care, mental and behavioral health assessment and counseling, prescriptions, health
screenings, and health education. Additional locations:
Whitefoord Health Center Whitefoord is the centralized community resource that connects diverse children and
1353 George W Brumley Way SE families to quality healthcare and education services that form a strong foundation of
Atlanta, Georgia, 30317 learning and support for long-term success.
404-373-6614
whitefoord.org
MedCura Health (formerly MedCura Health is a one-stop shop, offering a lifetime of comprehensive primary
Oakhurst Medical Centers) care services, from prenatal to senior care. Does your child need shots while you need
5582 Memorial Drive a check-up? You can take care of both at our facility. Do you need lab work done or
Stone Mountain, Georgia 30083 affordable medication? We strive to make your healthcare experience as efficient as
404-298-8998
medcura.org
possible, while maintaining the highest quality of care. We also bridge other needed
healthcare and behavioral health services through our community partners. Locations
in Decatur, Buckhead, Midtown, and Rockdale County.
Southside Medical Center Offering affordable health care and related services including: Pediatrics, Adult
1046 Ridge Avenue, SW Medicine, Women’s Health, Dentistry, Optometry, and Specialty Services.
Atlanta, Georgia 30315
404-688-1350 Southside Behavioral Lifestyle Enrichment Center (SBLEC) serves all men and women,
southsidemedical.net aged 18 and older, who seek to overcome the use of any type of drug or alcohol.
Transportation
Transportation Options TOPS provides transportation to medical appointments and “quality-of-life trips”
Program for Seniors (TOPS) anywhere around town for older adults who reside in north Fulton County.
470-760-3299
www.ssnorthfulton.org/senior- Who is eligible: Adults, age 60+ in the Senior Services North Fulton service area of
services/transportation/ Alpharetta, Johns Creek, Milton, Mountain Park, Roswell, and Sandy Springs. For those
with significant vision or other physical limitations, the service can include a 1-on-1
feature, where someone stays with them. The 1-on-1 service is currently not available
for seniors who need an electric wheelchair lift.
Non-Emergency Medical The Non-Emergency Medical Transportation (NEMT) program provides eligible
Transportation (NEMT) members transportation needed to get to their medical appointments. To be eligible
Schedule Transportation: for these services, members must have no other means of transportation available
Logisticare: and are only transported to those medical services covered under the Medicaid
888-224-7981 (Central)
888-224-7985 (Southwest)
program.
888-224-7988 (East)
Southeastrans:
866-388-9844 (North) and
404-209-4000 (Atlanta)
MARTA MARTA serves Fulton and DeKalb counties through a bus and rail system. MARTA maps
Route & Schedule Info: are available online or at any station.
404-848-5000
Customer Service: To advocate and provide safe, multi-modal transit services that advance prosperity,
404-848-5000 connectivity, and equity for a more livable region.
MARTA Mobility:
404-848-5826
www.itsmarta.com
Douglas County Fixed Route Connect Douglas is a commuter-focused program of the Douglas County Board of
Bus Service Commissioners through its Department of Multi-Modal Transportation Services.
8800 Dorris Road
Douglasville, Georgia 30134
770-949-7665
Behavioral Health
Positive Growth, Inc. This agency is one of the premier residential and community-based mental health
945 N. Indian Creek Dr. service agencies throughout the state of Georgia, dedicated to improving the lives
Clarkston, Georgia 30021 of children, youth, adults, and families during difficult life transitions by providing
404-298-9005 comprehensive residential and community-based treatment services. The services
www.positivegrowthinc.org
include counseling, education, intervention, residential, and other support services.
View Point Health This agency provides counseling, therapy, assessments, evaulations, intervention,
977-A Taylor St. treatment, and prevention programs.
Conyers, Georgia 30012
678-209-2655
www.myviewpointhealth.org
CaringWorks CaringWorks Treatment and Recovery Services provides exceptional mental health
2785 Lawrenceville Hwy. supports and addiction treatment to those in need because we believe everyone, no
Suite 205 matter their circumstance, should have access to quality behavioral health care.
Decatur, Georgia 30033
404-371-1230
www.caringworksinc.org
Ascensa Health at St. Serving metro Atlanta, St. Jude’s Recovery Center provides an integrated system of
Jude’s Recovery Center care that sustains recovery from the disease of addiction and co-occurring mental
139 Renaissance Pkwy. NE health disorders and returns at-risk individuals to their families and communities as
Atlanta, Georgia 30308 healthy, self-sufficient, productive individuals. Treatment services are based on the
ascensahealth.org
belief that addiction is a disease and that treatment must focus on the whole person.
Our evidence-based programs and services are designed to support the client over a
lifetime of recovery.
The Odyssey Family Odyssey Family Counseling Center is a community-based nonprofit organization that
Counseling Center provides mental health and substance abuse treatment as well as prevention and
1919 John Wesley Ave. education services to individuals and families. We serve all age groups, from children
College Park, Georgia 30337 as young as three years old to seniors over 65, and people from all cultures and
404-762-9190
www.odysseycounseling.org
backgrounds.
Mercy Care at CHRIS 180 As your medical home, Mercy Care offers comprehensive services that meet the
1976 Flat Shoals Rd. majority of primary physical, mental health, and wellness needs. Services are planned
Atlanta, Georgia 30316 and delivered by a team that works together for your health. Everyone receives
678-843-8600 exceptional care, no matter your insurance or income status. On a daily basis, taking
care of yourself is up to you, but we are here to help.
The Link Counseling Individual, couples, and family therapy, pro bono support groups for suicide prevention
Center and aftercare, the aging and their families, and children in crisis and grief. Counseling
348 Mt. Vernon Highway NE services are provided on a sliding fee scale.
Sandy Springs, Georgia 30328
404-256-9797
www.thelink.org
Samaritan Atlanta Provides counseling for grief and loss, anxiety, depression, adolescents, trauma,
1328 Peachtree St. NE addiction, social dysfunction, family systems, play therapy, crisis of faith, college and
Suite B317 grad students. Also for individuals, which can be spiritually integrated as the client
Atlanta, Georgia 30309 desires. Also offers sliding scale services
404-228-7777
samaritanatlanta.org
HIV/AIDS
AID Atlanta AID Atlanta offers a broad range of services and has grown to be the most
1605 Peachtree Street NE, comprehensive AIDS service organization in the Southeast. AID Atlanta currently offers
Atlanta, Georgia 30309-2955 HIV/AIDS prevention and care services, including (but not limited to) Primary Care,
404-870-7741 HIV/STD Screening, PrEP, Community HIV Prevention Programs, Linkage Services,
www.aidatlanta.org
Case Management, and a state-wide Information Hotline. The mission of AID Atlanta
is to reduce new HIV infections and improve the quality of life of its members and the
community by breaking barriers and building community.
Ponce De Leon Center The Ponce De Leon Center is one of the largest, most comprehensive facilities
341 Ponce De Leon Avenue dedicated to the treatment of advanced HIV/AIDS in the United States. Founded in
Atlanta, Georgia 30308 1986, the Ponce Center and its onsite affiliates provide various medical and support
404-616-2440 services to approximately 5,000 eligible men, women, adolescents, and children living
www.gradyhealth.org/
specialty/ponce-de-leon-
with HIV/AIDS.
center/ The Ponce Center integrates primary internal medicine and Infectious Disease
subspecialty care in the Main, Family and Transition Clinics. Staffed by doctors, nurse
practitioners, physician assistants, nurses, and more than 100 interagency staff. Our
care teams seamlessly provide onsite medical support and community services.
Someone Cares Someone Cares Inc. is a 501(c)(3) nonprofit community-based organization with two
236 Forsyth St., locations, Marietta and Atlanta, Georgia. For 23 years, we’ve being living the vision in
Suite 201 and 204 real time to eliminate all barriers to health services for all individuals who experience
Atlanta, Georgia 30303 health disparities related to sexual health in primary care, HIV testing, STD and
404-355-5044
s1catl.org
HEP C screening and treatment, and intensive mental health and substance abuse
counseling and treatment.
Clayton County Board This agency provides a comprehensive system of HIV primary medical care, essential
of Health support services, and medications for low-income people living with HIV who are
Ryan White HIV Clinic/CCBoH uninsured and underserved.
34 Upper Riverdale Rd.
Suite. 200
Riverdale, Georgia 30274
678-610-6555
www.claytoncounty
publichealth.org
North Fulton Community NFCC is a leader in north Fulton County offering assistance to over 4,200 families.
Charities Annually, food is distributed over 23,000 times, over 1,300 families utilize clothing
11270 Elkins Rd. vouchers, and $1.2 million is expended for direct aid to our clients in need of financial
Roswell, Georgia 30076 assistance. Our Education Center offers an array of classes and opportunities to help
nfcchelp.org
1,200 adults move toward financial stability and self-sufficiency.
Although the demand for these services has increased significantly since its founding,
NFCC continues to help hands on, one family at a time.
Covenant House Georgia This agency helps with college entrance exams, information for at-risk youth, GED
1559 Johnson Rd., NW instruction, clothing, crisis intervention, job assistance, life skills education, counseling,
Atlanta, Georgia 30318 a shelter, street outreach programs, subject tutoring, and workshops on youth issues.
404-589-0163
www.covenanthousega.org
The Center for Working We work to help unemployed and underemployed individuals gain family-supporting
Families, Inc. jobs and advance within careers. TCWFI leverages a robust network of Atlanta’s
477 Windsor Street, Suite 101 employers in various sectors, serving as a resource to meet industry demands for a well-
Atlanta, Georgia 30312 trained workforce.
404-223-3303
Atlanta Center for Self To empower financially vulnerable individuals in our community to become self-
Sufficiency sufficient, sustainably employed and economic contributors to society.
18 William Holmes Borders
Senior Drive NE
Atlanta, Georgia 30312
404-874-8001
www.atlantacss.org
Work Source Georgia Jobseeker services: Resource materials for career exploration and planning.
1300 Commerce Drive
Decatur, Georgia 30030
404-371-2000
www.dekalbworkforce.org
Bobby Dodd Institute BDI is an Atlanta workforce development leader with over 25 years of experience in
221 Stockbridge Rd. connecting people with disabilities and barriers to employment. We believe in the
Jonesboro, Georgia 30236 power of work to transform a person’s life, and each year, we help over 1,000 people
770-473-0071 take the first steps toward employment.
www.bobbydodd.org
The Urban League of Job Readiness (CORE) Training: A workforce job readiness-training program offering
Greater Atlanta courses in job searching techniques, resume writing, interview skills, mock interviews
229 Peachtree Street NE and job sustainability.
Suite 300
Atlanta, Georgia 30303
404-659-1150
ulgatl.org
Youth Programs
City of Atlanta Our mission is to provide quality professional recreational services and programs to all
Office of Recreation citizens of Atlanta through balanced, enjoyable and affordable activities. Our vision is
233 Peachtree Street, NE to enhance the quality of life for all citizens through nationally acclaimed recreation
Suite 1700 programs and activities.
Atlanta, Georgia 30303
www.atlantaga.gov/ (Multiple locations throughout Atlanta)
government/departments/
parks-recreation/office-of-
recreation
Fulton County Government Afterschool Program and Summer Camps at Burdett Gym, Cliftondale Park, Sandtown
Office of Parks and Park, and Welcome All Park
Recreation
141 Pryor St. (Multiple locations throughout Fulton County)
Atlanta, Georgia 30303
404-612-4000
DeKalb County Georgia Afterschool and Camp programs offered at various locations
Department of Recreation,
Parks & Cultural Affairs (Multiple locations throughout DeKalb County)
1300 Commerce Drive
Decatur, Georgia 30030
404-371-2000
www.dekalbcountyga.gov/
parks/recreation-center-
locations
Clayton County Parks and Afterschool programs and Teen Club at various locations
Recreation
2300 Highway 138 SE,
(Multiple locations throughout Clayton County)
Jonesboro, Georgia 30236
770-603-4159
www.claytonparks.com
City of College Park The Department of Recreation and Cultural Arts consists of three centers today:
Department of Recreation Wayman and Bessie Brady, Hugh C. Conley, and Tracey Wyatt, formerly known as the
and Cultural Arts Godby Road Center. Each center offers various activities for both youth and adults.
3667 Main Street
College Park, Georgia 30337
404-669-3767
www.collegeparkga.com
City of Hapeville Hapeville Recreation Department has learning and leisure time programs, a wide
Recreation Department variety of facilities, and dozens of services available, including sports and athletics,
3444 North Fulton Ave children and teen programs, fitness and leisure as well as adult and senior programs.
Hapeville, Georgia 30354
404-669-2136
www.hapeville.org
Union City Parks and Offering parks, trails, youth sports, and leisure services for older adults
Recreation
5285 Lakeside Drive
Union City, Georgia 30291
770-964-1236
unioncityga.org
Douglas County Parks & The Douglas County Parks and Recreation Department does not discriminate in any
Recreation programs or activities on the basis of sex, race, creed, religion, color, national origin,
12431 Veterans Memorial age, veteran or military status, sexual orientation, gender expression or identity,
Parkway disability, or the use of a trained dog guide or service animal and provides equal
Old Douglas County Courthouse
Douglasville, Georgia 30134
access to the Boy Scouts and other designated youth groups.
770-489-3918
Henry County Parks & The mission of the Parks & Recreation department is: To develop and maintain park
Recreation facilities and grounds while providing year-round activities, programs, and special
99 Lake Dow Road, events for leisure and wellness pursuits of Henry County residents.
McDonough, Georgia 30252
770-288-7300
secure.rec1.com/GA/henry-
county-ga/catalog
Newton County Recreation We proudly serve the citizens of Newton County, offering a variety of activities for
Turner Lake Park and people of all ages.
Administrative Offices
6185 Turner Lake Road NW
Covington, Georgia 30014
770-786-4373
Rockdale County Parks & Parks & Recreation strives to provide relevant and diverse family, arts, and cultural
Recreation programming while improving our park facilities through upgrades and amenities that
1781 Ebenezer Rd SW attract new and existing citizens, businesses, and tourism.
Conyers, Georgia 30094
770-785-5922
rockdalecountyga.go/
Family Life Ministries Food/Hygiene Resource: Assisting those most in need in our community with food,
612 College Street hygiene items, and basic life necessities such as toilet paper.
Hapeville, Georgia 30354
404-761-6302
Georgia Department of Providing online services and state programs such as Medicaid and PeachCare for Kids
Community Health
800-436-7442
dch.georgia.gov
Latin American Association The mission of the Latin American Association (LAA) is to empower Latinos to adapt,
Atlanta Outreach Center: integrate, and thrive. Services include immigration legal services, youth programs,
2750 Buford Hwy. family services, employment services, and education.
Atlanta, Georgia 30324
404-638-1800
Lawrenceville Outreach Center:
308 North Clayton St.
Lawrenceville, Georgia 30046
678-205-1018
thelaa.org
Solomon’s Temple Solomon’s Temple is a holistic emergency and transitional facility for homeless women
2836 Springdale Rd. SW and their children. Programs include:
Atlanta, Georgia 30315
404-762-4872 ● Emergency/Transitional Housing Programs
solomonstempleinc.org ● Education and Training
● Children’s Programs
● ACS. (2019). U.S. American Community Survey 2015-2019. Retrieved from https://www.census.gov/newsroom/press-
kits/2020/acs-5-year.html
● CDC. (2017). Centers for Disease Control and Prevention. National Diabetes Statistics Report. Retrieved from
dev.diabetes.org/sites/default/files/2019-06/cdc-statistics-report-2017.pdf
● CDC. (2018). Diagnoses of HIV Infection in the United States and Dependent Areas. HIV Surveillance Report. Retrieved
from www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2018-updated-vol-31.pdf
● CMS. (2020). Centers for Medicare and Medicaid Services. National Provider Identification. Retrieved from
www.countyhealthrankings.org/app/georgia/2021/measure/factors/62/data
● County Health Rankings. (2021). County Health Rankings & Roadmaps: Access to Care. Retrieved from
www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model/
health-factors/clinical-care/access-to-care
● DPH. (2015-2019). Georgia Department of Public Health Online Analytical Statistical Information System.
oasis.state.ga.us.
● Georgia Department of Public Health. (2016). dph.georgia.gov. Retrieved from Maternal Mortality:
dph.georgia.gov/maternal-mortality
● Kenya Ministry of Health. (2018). A guide to complementary feeding 6 to 23 months. Naiobi: Kenya Ministry of Health.
● KP. (2020). Community Health Needs Dashboard by Kaiser Permanente CHNA Data Platform. Retrieved from
www.chna.org/kp
● UCR. (2017). Georgia’s Uniform Crime Reporting Program. Georgia Bureau of Investigation. Retrieved from
gbi.georgia.gov/services/crime-statistics
● UN Women. (2018). Jamaica First National Survey on Gender-Based Violence Launched. Retrieved from UN Women
Americas and the Caribbean: lac.unwomen.org/en/noticias-y-eventos/articulos/2018/6/presentan-primera-encuesta-
nacional-de-jamaica-sobre-violencia-de-genero
● UNICEF. (2017). Communication for Development (C4D): Global Progress and Country-Level Highlights Across
Programme Areas. New York. Retrieved from www.unicef.org/media/47781/file/UNICEF_2017_Report_on_
Communication_for_Development_C4D.pdf
● United States Department of Labor. (2020). U.S. Bureau of Labor Statistics. Retrieved from www.bls.gov/regions/
southeast/georgia.htm#eag
● World Population Review. (2022). Maternal Mortality Rate by State 2022. Retrieved from World Population Review:
worldpopulationreview.com/state-rankings/maternal-mortality-rate-by-state