Deliverable 2 - Assessing Data Sets for Population Health Management
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Smartinez_Deliverable1.CommunityNeedsAssessment.pptxCommunity Needs Assessment for Population Health Management (PHM) Program.
Sonia Martinez
Rasmussen University
HSA 5300 Population Health
Dr. Point-Johnson
1/29/26
Introduction
As Chief Population Officer, I am excited to share this assessment for our new PHM program in Miami-Dade County.
This presentation evaluates local healthcare needs and proposes KPIs to drive meaningful improvements.
We will explore the county's profile, conduct a community needs assessment, and identify key indicators.
As Chief Population Officer, I am excited to share this assessment for our new PHM program in Miami-Dade County. This presentation evaluates local healthcare needs while proposing KPIs to drive meaningful improvements. We will explore the county's profile, conduct a community needs assessment, and identify key indicators. We draw on reliable data to focus on efficient resource allocation and equitable approaches for better health outcomes. The assessment ensures data-driven strategies that promote equity in health interventions, aligning with local priorities for sustainable improvements in population well-being. It emphasizes collaboration to tackle challenges effectively and foster long-term community resilience through targeted, evidence-based actions
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Healthcare Profile - Population Overview
Miami-Dade County has approximately 2.8 million residents based on the 2024 estimate.
The population grew 5.1% from the 2020 Census.
Urban density is high in areas like Miami city with 70.3% Hispanic/Latino diversity.
Age distribution shows 19.7% under 18 and 17.2% over 65 with a median age of about 40 years.
Key demographics include 54.3% foreign-born residents and multi-ethnic groups like Cuban, Haitian, and Venezuelan.
Miami-Dade County has approximately 2.8 million residents based on the 2024 estimate (U.S. Census Bureau, 2024). The population grew 5.1% from the 2020 Census, reflecting ongoing urban expansion. Urban density is high in areas like Miami city, which includes 70.3% Hispanic/Latino diversity (Florida Department of Health, 2022). Age distribution shows 19.7% under 18 and 17.2% over 65, with a median age of about 40 years (Heenan et al., 2022). Key demographics include 54.3% foreign-born residents and multi-ethnic groups like Cuban, Haitian, and Venezuelan (Roorda et al., 2024). The overview highlights diverse needs that support targeted health planning and cultural adaptations for immigrant populations.
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Healthcare Profile - Socioeconomic Determinants
The poverty rate is 14.1% and higher in urban pockets.
Education levels show 83.1% high school graduates and 33.2% with bachelor's degrees or higher.
Employment includes 63.9% civilian labor force participation in a service/tourism economy.
Income inequality features a median household income of $68,694 with ethnic disparities like higher poverty among Black/Hispanic groups.
Social factors include a high cost of living 18.9% above the U.S. average and 75.2% speaking non-English at home.
The poverty rate is 14.1% and higher in urban pockets, impacting access to essential services (U.S. Census Bureau, 2024). Education levels show 83.1% high school graduates and 33.2% with bachelor's degrees or higher, influencing health literacy across communities (Florida Department of Health, 2022). Employment includes 63.9% civilian labor force participation in a service/tourism economy, which often correlates with variable income stability (Heenan et al., 2022). Income inequality features a median household income of $68,694 with ethnic disparities, such as higher poverty among Black/Hispanic groups that exacerbate health risks. Social factors include a high cost of living 18.9% above the U.S. average and 75.2% speaking non-English at home, creating barriers to equitable care (Chambers et al., 2025). These determinants influence health access and highlight the need for focused equity initiatives in program design.
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Healthcare Profile - Health and Medical Resources
Public Facilities: Florida Department of Health clinics; key hospitals like Jackson Memorial
Private Sector: Mount Sinai, Baptist Health; focus on urban and tourist populations
Resources: ~10 doctors per 10,000 people; Medicaid/Florida KidCare covers vulnerable groups
Competitive Market: Mix of non-profit and for-profit providers; medical tourism hub; ACA expansions improving access
Challenges: 14.8% uninsured under 65; urban-rural divides within county
Public facilities include Florida Department of Health clinics and key hospitals like Jackson Memorial, serving broad community needs (Florida Department of Health, 2022). The private sector features Mount Sinai and Baptist Health, which focus on urban and tourist populations to address diverse demands. Resources show about 10 doctors per 10,000 people, with Medicaid/Florida KidCare covering vulnerable groups for essential support. The competitive market mixes non-profit and for-profit providers as a medical tourism hub, where ACA expansions improve access overall. Challenges involve a 14.8% uninsured rate under 65 and urban-rural divides within the county, highlighting gaps in coverage (Chambers et al., 2025). These resources support varied populations but require enhancements to close disparities and ensure comprehensive health delivery.
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Community Needs Assessment - Framework and Approach
High-level CNA is based on CDC guidelines to assemble team, define scope, collect data, rate needs.
Data sources include U.S. Census, Florida DOH, local CHNA focusing on priority populations like immigrants and low-income areas.
Key steps identify risk factors like poverty, language barriers, assess major problems, prioritize interventions.
Scope covers urban diversity vs. suburban areas emphasizing preventive care for NCDs and access issues.
The high-level CNA is based on CDC guidelines to assemble a team, define scope, collect data, and rate needs systematically (Florida Department of Health, 2022). Data sources include U.S. Census, Florida DOH, and local CHNA, which focus on priority populations like immigrants and low-income areas for targeted insights (U.S. Census Bureau, 2024). Key steps identify risk factors like poverty and language barriers, assess major problems, and prioritize interventions to address core issues. The scope covers urban diversity versus suburban areas and emphasizes preventive care for NCDs and access issues to ensure relevance. The framework ensures systematic evaluation that aligns with best practices for effective community health planning (Chambers et al., 2025). It promotes data-driven decisions to maximize resources and improve outcomes in diverse settings
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Community Needs Assessment - Identified Needs and Risk Factors
| Category | Needs/Risks | Examples |
| Chronic Diseases | High diabetes (10%), hypertension, obesity | Poor diet, inactivity; socioeconomic stress |
| Mental Health | Depression/anxiety (high due to immigration stress) | Stigma, limited services |
| Maternal/Child Health | Low birth weight; infant mortality above state average | Malnutrition, prenatal access barriers |
| Access/Equity | 14.8% uninsured; transportation issues | Language/cultural barriers; income inequity |
| Environmental | Pollution, housing instability | Urban hazards; higher in immigrant communities |
The table categorizes chronic diseases with needs like high diabetes (10%), hypertension, and obesity, with examples including poor diet, inactivity, and socioeconomic stress (Florida Department of Health, 2022). Mental health covers depression/anxiety high due to immigration stress, with examples like stigma and limited services that hinder care (U.S. Census Bureau, 2024). Maternal/child health includes low birth weight and infant mortality above the state average, exemplified by malnutrition and prenatal access barriers (Heenan et al., 2022). Access/equity features 14.8% uninsured and transportation issues, with language/cultural barriers and income inequity as key examples. Environmental covers pollution and housing instability, such as urban hazards higher in immigrant communities that amplify risks. These identified elements guide prioritization for interventions that reduce burdens and promote equity.
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Community Needs Assessment - Existing Programs and Resources
Programs: Florida DOH initiatives (e.g., Healthy Miami-Dade CHIP); Medicaid expansions; community health workers
Resources: County health portals; FQHCs like Borinquen; NGOs for mental health (e.g., NAMI)
Gaps: Mental health providers shortage; affordability for uninsured; only partial coverage in high-need areas
Recommendations: Expand telehealth; integrate cultural competency; partner with employers for financial stability programs
Programs include Florida DOH initiatives such as Healthy Miami-Dade CHIP, Medicaid expansions, and community health workers to support broad access (Florida Department of Health, 2022). Resources feature county health portals, FQHCs like Borinquen, and NGOs for mental health like NAMI, providing essential services (Heenan et al., 2022). Gaps exist in mental health providers with shortages, affordability for uninsured, and only partial coverage in high-need areas, limiting effectiveness. Recommendations expand telehealth, integrate cultural competency, and partner with employers for financial stability programs to bridge these deficiencies (Chambers et al., 2025). Existing efforts address chronic issues and support access improvements through collaborative fixes (U.S. Census Bureau, 2024). These steps enhance inclusivity while building on community strengths for more comprehensive health strategies.
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Key Performance Indicators for PHM Program
| KPI Category | Indicator | Target | Rationale |
| Health Outcomes | Infant mortality rate | <5 per 1,000 | Measures maternal/child health |
| Preventive Care | Mammography screening rate | 80% | Reduces cancer burden |
| Chronic Disease | Hemoglobin A1c control (<8%) | 70% | Tracks diabetes management |
| Access/Equity | Uninsured rate under 65 | <10% | Ensures coverage progress |
| Behavioral | Smoking prevalence | <10% | Addresses lifestyle risks |
The table categorizes health outcomes with infant mortality rate as the indicator, targeting <5 per 1,000 to measure maternal/child health effectively (Heenan et al., 2022). Preventive care includes mammography screening rate, targeting 80% to reduce cancer burden in at-risk groups. Chronic disease features hemoglobin A1c control (<8%), targeting 70% to track diabetes management and improve long-term outcomes (Chambers et al., 2025). Access/equity covers uninsured rate under 65, targeting <10% to ensure coverage progress across populations. Behavioral includes smoking prevalence, targeting <10% to address lifestyle risks that contribute to preventable diseases (U.S. Census Bureau, 2024). KPIs focus on measurable goals that align with local priorities, driving equity and promoting prevention.
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Implementation of KPIs in PHM
Integration: Embed in program design; track via Florida DOH data and annual surveys
Benefits: Enables data-driven decisions; promotes healthy populations through prevention
Challenges: Data disparities in immigrant areas; need for multi-sector collaboration (e.g., with NGOs)
Next Steps: Pilot in high-need zip codes; scale based on results
Integration embeds KPIs in program design and tracks them via Florida DOH data and annual surveys for ongoing monitoring. Benefits enable data-driven decisions and promote healthy populations through prevention-focused strategies that reduce risks. Challenges include data disparities in immigrant areas and the need for multi-sector collaboration like with NGOs to overcome barriers (Chambers et al., 2025). Next steps pilot in high-need zip codes and scale based on results to refine and expand impact (Florida Department of Health, 2022). Implementation ensures monitoring that allows adjustments for better efficiency (U.S. Census Bureau, 2024). KPIs guide strategies addressing urban issues, with benefits reducing health burdens through partnerships that support equity goals and achieve broader community advancements.
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Conclusion
Miami-Dade faces urban health challenges like chronic diseases and access disparities, but strong programs provide a foundation.
It is important to implement KPIs to design targeted PHM interventions and prioritize vulnerable populations for equity.
This will help reduces burden, improves outcomes, and aligns with state health goals.
Miami-Dade faces urban health challenges like chronic diseases and access disparities, but strong programs provide a foundation for progress (Florida Department of Health, 2022). The call to action implements KPIs to design targeted PHM interventions and prioritize vulnerable populations for equity in care delivery (Heenan et al., 2022). The impact reduces burden, improves outcomes, and aligns with state health goals to foster sustainability (Roorda et al., 2024). Conclusion emphasizes prevention focus and highlights data-driven improvements that demand immediate action. Challenges require collaborative efforts, with programs building sustainable health through interventions that target gaps effectively (U.S. Census Bureau, 2024). Equity ensures inclusive benefits, supporting community well-being and long-term gains via aligned strategies.
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References
Chambers, D., Mawson, R., Mettle-Nunoo, J., Sutton, A., & Booth, A. (2025). A systematic review of international performance indicators and metrics relevant to UK general practice. BMJ Open Quality, 14(4). https://bmjopenquality.bmj.com/content/14/4/e003477
Florida Department of Health. (2022). Community Health Assessment: Miami-Dade County. https://www.floridahealth.gov/_media/miami-dade/community-reports/miamidade-cha.pdf
Heenan, M. A., Randall, G. E., & Evans, J. M. (2022). Selecting performance indicators and targets in health care: an international Scoping review and standardized process framework. Risk Management and Healthcare Policy, 747-764. https://doi.org/10.2147/RMHP.S357561
Roorda, E., Bruijnzeels, M., Struijs, J., & Spruit, M. (2024). Business intelligence systems for population health management: a scoping review. JAMIA open, 7(4), ooae122. https://doi.org/10.1093/jamiaopen/ooae122
U.S. Census Bureau. (2024). QuickFacts: Miami-Dade County, Florida. https://www.census.gov/quickfacts/fact/table/miamidadecountyflorida/POP060210
