Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
2020-340-Minutes for Meeting September 09,2020 Recorded 9/21/2020
E S COG p g-� Q 2� AR F COMMISSIONERS 1300 NW Wall Street, Bend, Oregon (541 ) 388-6570 phi[/T1�1' Recorded in Deschutes County CJ2020_340 Nancy Blankenship, County Clerk commissioners' .journal 09/21 /2020 10:24:48 AM L(✓��1� F., � oGLR II � I I II I II'�I I� I I' I I �I II I I �I'II 2020-340 FOR RECORDING STAMP ONLY Wednesday, September 9, 2020 BARNES & SAWYER ROOMS VIRTUAL. MEETING PLATFORM Present were Commissioners Patti Adair, Anthony DeBone, and Phil Henderson. Also present were Tom Anderson, County Administrator; David Doyle, County Counsel (via Zoom conference call); and Sharon Keith, Board Executive Assistant (via Zoom conference call). Attendance was limited due to Governor's Virus Orders. This meeting was audio and video recorded and can be accessed at the Deschutes County Meeting Portal website http://deschutescountyor.iqm2.com/Citizens/Default.aspx CALL TO ORDER: Chair Adair called the meeting to order at 10:00 a.m. PLEDGE OF ALLEGIANCE: CITIZEN INPUT: The Board acknowledged the significant level of wildfire danger throughout Oregon and extended well wishes to Oregonians. Commissioner DeBone noted the importance of fuel reduction and encouraged citizens to create and maintain a defensible space around their homes. Commissioner DeBone announced the community can provide support measures with donations to our local Red Cross. Commissioner Adair explained she has the experience of a wildfire threatening her home and stressed the need to create a defensible space. BOCC MEETING SEPTEMBER 9, 2020 PAGE 1 OF 8 Doug Hoschek, resident of Sunriver, provided comment on his personal concerns regarding the draft Sunriver Community Wildfire Protection Plan (CWPP) and requested that the Board not sign the final document because he feels his home insurance was canceled due to the previous CWPP. Mr. Hoschek wants Sunriver to look like Bend. Mr. Hoschek pleads with the Commissioners and stated if they sign the CWPP there would be a lawsuit against Sunriver Owners Association and potentially Deschutes County. CONSENT AGENDA: Before the Board was Consideration of Approval of the Consent Agenda. HENDERSON: Move approval of Consent Agenda, minus Item 2 for discussion. DEBONE: Second VOTE: HENDERSON: Yes DEBONE: Yes ADAIR: Chair votes yes. Motion Carried 1. Consideration of Board Signature of Resolution No. 2020-055, Amending the Authorized Balance of the Change Funds - Community Development 2. Consideration of Board Signature of Document No. 2020-580, IMPACTS Grant Agreement 3. Consideration of Board Signature to Appoint James Getchell to the Newberry Estates Special Road District 4. Approval of Minutes of the August 26, 2020 BOCC Meeting 5. Approval of Minutes of the September 2, 2020 BOCC Meeting ACTION ITEMS: ConsentAgenda Item 2 as pulled for discussion. Consideration of Board Signature of Document No. 2020-580, IMPACTS Grant Agreement Commissioner Henderson pulled this item to highlight the positive impacts of the BOCC MEETING SEPTEMBER 9, 2020 PAGE 2 OF 8 program. Holly Harris, Behavioral Health explained the work done within our community. HENDERSON: Move approval of Document No. 2020-580 DEBONE: Second VOTE: HENDERSON: Yes DEBONE: D• 6. COVID19 Update Yes Chair votes yes. Motion Carried Justin Sivill, Chief Operating Officer and Scott Seros, Director of Laboratory Services of Summit Medical Group/BMC (via Zoom conference call) presented an update on COVID19 testing in the community over the past six weeks. Dr. Jeanne Young (via Zoom conference call) presented an update on COVID19 testing through her practice. CARES Act Funding: Chief Financial Officer Greg Munn (via Zoom conference call) presented the new funding requests for consideration. Tom Kuhn, Health Services (via Zoom conference call) explained the request for funding in the amount of $4,980 and the need for Spanish translation services through the program Take Med's Seriously translation to Spanish. The Board expressed support. Megan Norris, Central Oregon Childcare Accelerator (via Zoom conference call) explained her request for funding in the amount of $50,000 for childcare services through the Childcare Micro -Center. The Board requested communication efforts between all childcare agencies and organizations. The Board expressed support. HENDERSON: Move approval of the two presented CRF funding requests DEBONE: Second BOCC MEETING SEPTEMBER 9, 2020 PAGE 3 OF 8 VOTE: HENDERSON: DEBONE: ADAI R: Yes Yes Chair votes yes. Motion Carried 7. PRESENTATION: Suicide in Deschutes County: Trends, Risk Factors and Recommendations Health Services staff Jessica Jacks and Whitney Schumacher (via Zoom conference call) presented the trends, risk factors, and recommendations. Presentation attached to the record. 8. PROCLAMATION Recognizing September as Suicide Prevention Awareness Month Health Services staff Jessica Jacks, Whitney Schumacher, and Cassidy Brewin, along with Central Oregon Chaplain Joel Stutzman (via Zoom conference call) presented the proclamation for consideration of adoption. HENDERSON: Move adoption of Proclamation DEBONE: Second VOTE: HENDERSON: Yes DEBONE: Yes ADAIR: Chair votes yes. Motion Carried The Board read the proclamation into the record. 9. PRESENTATION: Government Finance Officers Association Popular Annual Financial Report Award BOCC MEETING SEPTEMBER 9, 2020 PAGE 4 OF 8 Chief Financial Officer Greg Munn (via Zoom conference call) announced the receipt of the award and announced once the award is received, it will be presented to James Wood, Accounting Manager. 10.Continued Discussion of Vacant Position List Deputy County Administrator Erik Kropp presented the Deschutes County position list for continued discussions. Human Resources Director Kathleen Hinman was present via Zoom conference call. The Board requested this item be presented at a future BOCC meeting and later at the December Mid - Year Budget Committee meeting. Commissioner Henderson will discuss positions in the Deschutes County departments that are led by elected officials. County Administrator Anderson will share the vacant position list with the citizen members of the Budget Committee. The positions will be reviewed in context with the monthly financial statement report. RECESS: At the time of 12:08 p.m., the Board went into recess and reconvened at 1:02 p.m. 11.Consideration of Board Signature of Order No. 2020-053, Whether to Hear an Appeal of a Hearings Officer Decision Approving a 10-Lot Subdivision in the UAR10 Zone Community Development Department Kyle Collins (via Zoom conference call) presented the item for consideration. The applicants appealed the decision requiring site plan review within 100 feet of the high water mark of the Deschutes River corridor. County Counsel Dave Doyle commented on challenges associated with gaining deference from LUBA. The Board expressed support to hear the appeal. DEBONE: Move adoption of Order No. 2020-053 to hear the appeal HENDERSON: Second BOCC MEETING SEPTEMBER 9, 2020 PAGE 5 OF 8 VOTE: DEBONE: Yes HENDERSON: Yes ADAIR: Chair votes yes. Motion Carried OTHER ITEMS/COMMISSIONER UPDATES: • Commissioner Henderson reported on yesterday's Deschutes Forest Collaborative meeting and of the need for funds for the outreach portion of the Collaborative that could possibly come from transient room tax. The City of Bend would also contribute funding. Commissioner Henderson requested support of $10,000 from Deschutes County. HENDERSON: Move approval of allocation of $10,000 of transient room tax for the Deschutes Forest Collaborative Project for outreach efforts. DEBONE: Second VOTE: HENDERSON: Yes DEBONE: Yes ADAIR: Chair votes yes. Motion Carried • Commissioner Henderson went to view Maxwell Bridge and Harper Bridge to witness the traffic congestion issues. • Commissioner DeBone reported on the East Cascades Works and funding is available to prepare to get people back to work. He also reported on the possibility that a Department of Motor Vehicles building could be sited in the La Pine Business Park. • Commissioner Adair attended the Sisters Visioning Project and met with the Governor's office regarding the hope of expanding indoor dining in restaurants (as the winter season approaches). The COIC Board meeting was held on Thursday evening. Included was review of community feedback on the Hawthorne bus station and review of proposed amendments to the COIC Bylaws. Commissioner Adair will share the staff report and proposed bylaw amendments with the other Commissioners. BOCC MEETING SEPTEMBER 9, 2020 PAGE 6 OF 8 • Commissioner Henderson commented on funding for forest projects through the Deschutes Forest Collaborative Project and stated Deschutes County has always been in support and that he also contacted Congressman Walden's office to express his support for the funding. County Administrator Anderson reported on a follow-up from Bend Chamber of Commerce for the State of the County Address to be scheduled on Tuesday, October 27 as part of the Chamber's noontime webinar. Commissioner Adair suggested Mr. Anderson contact the Redmond Chamber of Commerce as well and possibly the Sister's Rotary and La Pine/Sunriver. • County Administrator Anderson stated the City of Redmond has expressed interest in a joint Meeting on October 6 regarding the South Highway 97 Urban Renewal project. Mr. Anderson inquired if the Board would like a presentation prior to that meeting to consider a Resolution. Commissioner DeBone requested legislative history on the matter. Mr. Anderson reported that the City of Sisters will need approval from 3 of the 4 largest taxing districts (City, schools, Fire) in order to extend an existing urban renewal district; Anderson will ask Sisters to present to the BOCC next week. Deputy County Administrator Kropp reported on the Facility Review Committee applications received. The goal is to appoint 7 or 8 members. Commissioner DeBone offered to review the 14 applications. EXECUTIVE SESSION: At the time of 2:02 p.m., the Board went into Executive Session under ORS 192.660 (2) (a) Consideration of Employment. The Board came out of Executive Session at 2:29 p.m. to direct staff to proceed as discussed. At the time of 2:30 p.m., the Board went into Executive Session under ORS 192.660 (2) (h) Litigation. The Board came out of Executive Session at 2:57 p.m. to direct staff to proceed as discussed. At the time of 2:55 p.m., the Board went into Executive Session under ORS 192.660 BOCC MEETING SEPTEMBER 9, 2020 PAGE 7 OF 8 (2) (e) Real Property Negotiations. The Board came out of Executive Session at 3:14 p.m. to direct staff to proceed as discussed. At the time of 3:14 p.m., the Board went into Executive Session under 192.660 (2) (e) Real Property. The Board came out of Executive Session at 3:40 p.m. to direct staff to proceed as discussed. Commissioner Adair announced today is Preparedness Month and encouraged the community to be connected to emergency alerts through our 911 system. ADJOURN: Being no further items to come before the Board, the meeting was adjourned at 3:41 p.m. DATED this `- Day of 2020 for the Deschutes County Board of Commissioners. c/ A*1 A AI , CHAIR ATTEST: 1C RECORDING SECRETARY BOCC MEETING SEPTEMBER 9, 2020 PAGE 8 OF 8 BOCC MEETING AGENDA DESCHUTES COUNTY BOARD OF COMMISSIONERS 10:00 AM, WEDNESDAY, SEPTEMBER 9, 2020 Barnes Sawyer Rooms - Deschutes Services Center - 1300 NW Wall Street - Bend This meeting is open to the public, usually streamed live online and video recorded. To watch it online, visit www. deschutes. org/meetings. Pursuant to ORS 192.640, this agenda includes a list of the main topics that are anticipated to be considered or discussed. This notice does not limit the Board's ability to address other topics. Item start times are estimated and subject to change without notice. CALL TO ORDER MEETING FORMAT In response to the COVID-19 public health emergency, Oregon Governor Kate Brown issued Executive Order 20-16 directing government entities to utilize virtual meetings whenever possible and to take necessary measures to facilitate public participation in these virtual meetings. Beginning on May 4, 2020, meetings and hearings of the Deschutes County Board of Commissioners will be conducted in a virtual format. Attendance/Participation options include: Live Stream Video: Members of the public may still view the BOCC meetings/hearings in real time via the Public Meeting Portal at www.deschutes.org/meetings. Citizen Input: Citizen Input is invited in order to provide the public with an opportunity to comment on any meeting topic that is not on the current agenda. Citizen Input is provided by submitting an email to: citizen input deschutes.org or by leaving a voice message at 541-385-1734. Citizen input received before the start of the meeting will be included in the meeting record. Zoom Meeting Information: Staff and citizens that are presenting agenda items to the Board for consideration or who are planning to testify in a scheduled public hearing may participate via Zoom meeting. The Zoom meeting id and password will be included in either the public hearing materials or through a meeting invite once your agenda item has been included on the agenda. Upon entering the Zoom meeting, you will automatically be placed on hold and in the waiting room. Once you are ready to Board of Commissioners BOCC Meeting Agenda Wednesday, September 9, 2020 Page 1 of 4 present your agenda item, you will be unmuted and placed in the spotlight for your presentation. If you are providing testimony during a hearing, you will be placed in the waiting room until the time of testimony, staff will announce your name and unmute your connection to be invited for testimony. Detailed instructions will be included in the public hearing materials and will be announced at the outset of the public hearing. PLEDGE OF ALLEGIANCE CITIZEN INPUT (for items not on this Agenda) [Note: Because COVID-19 restrictions may limit or preclude in person attendance, citizen input comments may be emailed to citizeninput@deschutes.org or you may leave a brief voicemail at 541.385.1734. To be timely, citizen input must be received by 9:00am on the day of the meeting.] CONSENT AGENDA Consideration of Board Signature of Resolution No. 2020-055, Amending the Authorized Balance of the Change Funds - Community Development 2. Consideration of Board Signature of Document No. 2020-580, IMPACTS Grant Agreement 3. Consideration of Board Signature to Appoint James Getchell to the Newberry Estates Special Road District 4. Approval of Minutes of the August 26, 2020 BOCC Meeting 5. Approval of Minutes of the September 2, 2020 BOCC Meeting ACTION ITEMS 6. 10:05 AM COVID19 Update 7. 10:30 AM PRESENTATION: Suicide in Deschutes County: Trends, Risk Factors and Recommendations -Jessica Jacks, Health Services Supervisor 8. 10:45 AM PROCLAMATION Recognizing September as Suicide Prevention Awareness Month - Jessica jacks, Health Services Supervisor 9. 10:50 AM PRESENTATION: Government Finance Officers Association Popular Annual Financial Report Award - Greg Munn, Chief Financial Officer Board of Commissioners BOCC Meeting Agenda Wednesday, September 9, 2020 Page 2 of 4 10. 11:00 AM Continued Discussion of Vacant Position List - Erik Kropp, Deputy County Administrator 11. 11:15 AM Consideration of Board Signature of Order No. 2020-053, Whether to Hear an Appeal of a Hearings Officer Decision Approving a 10-Lot Subdivision in the UAR10 Zone - Kyle Collins, Associate Planner LUNCH RECESS OTHER ITEMS These can be any items not included on the agenda that the Commissioners wish to discuss as part of the meeting, pursuant to ORS 192.640. EXECUTIVE SESSION At any time during the meeting, an executive session could be called to address issues relating to ORS 192.660(2)(e), real property negotiations, ORS 192.660(2)(h), litigation; ORS 192.660(2)(d), labor negotiations; ORS 192.660(2)(b), personnel issues, or other executive session categories. Executive sessions are closed to the public, however, with few exceptions and under specific guidelines, are open to the media. Executive Session under ORS 192.660 (2) (h) Litigation and ORS 192.660 (2) (e) Real Property ADJOURN To watch this meeting on line, go to: www.deschutes.org/meetings Please note that the video will not show up until recording begins. You can also view past meetings on video by selecting the date shown on the website calendar. Deschutes County encourages persons with disabilities to participate in all programs and activities. This event/location is accessible to people with disabilities. If you need accommodations to make participation possible, please call (541) 617-4747. Board of Commissioners BOCC Meeting Agenda Wednesday, September 9, 2020 Page 3 of 4 FUTURE MEETINGS: Additional meeting dates available at www.deschutes.org/meetingcalendar (Please note: Meeting dates and times are subject to change. All meetings take place in the Board of Commissioners' meeting rooms at 1300 NW Wall St., Bend, unless otherwise indicated. If you have questions regarding a meeting, please call 388-6572.) Board of Commissioners BOCC Meeting Agenda Wednesday, September 9, 2020 Page 4 of 4 N (D v (D C rD 0- u N W o O O O cr (D CD UU fl] UU (D a7 (D : (D N V7 W N I {/} Z Cl i/). -n v), -% m m v} n i./1 Z 2 t/1• (/? (N Q O.. N A n 4 ;)o fQD OO < (n O OO < N � f I < O —O 17) O.rD _ a) '0 S O rD r -a D O Q Q Q O O -xa o O Q n O* O= 0 0 SZ° Q O 0 = 3 n j Q o w O' LA (D O cn O N 07 A - ,may O .+ (D co S (D (D O A (D r+ -h O (D in o3 a CL r O c v �' c m -' 3 C: rD - < (D c� "a '=r -O (D 0 O < S� O 3 - n. O! 2- N p r O a r< C cn v m ( m' A (D O °; ' T v (o N p' XQ O (A N �' h (D v N A a m v' (D O O N r•r (D �! n O H r+ In P W N F v? A V) 'p v} v 70 D TI O v} O FA 0) (A O n O(DQ (A n v} r* F.AcSWOX Z rD C (A (/? "a Z T V)MO ;00 LA v O C O DO O O + O � -a�'5+3L OO W x< O CSrD M On OO C aq O N O 00 M ONO Q OS O Q O C O X�- O S 2 Z Q q O� u'. (A � O O��� CA1 O --` �M Q� (D Z y O F-A � < 0 O (D X z O v y 3 O "O 3 O 'O Q Q �• y W p r 3 — m O n v n v fD - crq O =r N Cq O Cr G ,< 01 3 's 0 N n On iF N rr (D 3 0O y * C, 3 O N< N ju O� (D r,• to CA Q �' O Cl Cq O C Oq A -h s '"' v+' CA (D O O UQ n rr On (D ,' (DQ D 3 d � , va s yr p A v} n --� W v* o' N n N tr�- m 7o to w VA v�- -a m p A A iN F" N= F" O 7" '+ O V7 `< 3 N W to 7 (p 0) (D .A n X S O< V7 'I C Cn 3 O O � O O n w Q— N p n v< N "t b� O (D O rrD O OO O = d Q f�a Q X= O 3 ac (D O< o- � n O O Cr 3 C O -s O�� r, C O + (D '+ � O(D O �- �^ O C 0 LA. p) p� 'a O O O -i O0 O ado Q Ln c 'n o o n O Lo o, rt n o_ W M n 'O N Ln 3 m v O O aq m (D A� T N A S O v As O O O -t (D O Z `° (D n �, o S CL) H O O O O (SD (D 0 A-F v* (D 00 L n Q n c) -0 -* 3 o '^ D O n F" C O N O 'i �. a A 'z (D -n o p O r+ rr v rAr o A (D 7 O A 00 * O < Ccr C O -+, Q Ort n 3 c — rt _ _ cn Q OMX A pxq v m a° `" c o >� rD N A_ rF n X m A O !" m Cl C O �• 0'q `LG A n O r�-r (D ,. r (D' - I (D 3 fD (A `n A O N S O v (A A S a rt m N O rt r) n CL m m rt LA D D D -� a' O O N .. n _ CL v, O v N O O O N IQ— O r+ < v. s (D 0 N O r� O v r(o Q X (D '^ 0 r r O Ut1 q < v v n -n C Q to O 00 O v N O N I-� v lD A W LO N N O 01 O o I- A �I to 0 Oo Ln P O 0 O O A :r Cn O Ul In O c e* m N c� O i r* n n "n Q. OrQ O rh 3 m rh N i O O (D N o 0 0 ID (D (D 0) (A' rD CL 0 0 N N O W O w CL M 06) 0 N 'O O rt N m 'a m r rt 4 o =3 rt oO M 3 x " o v = y 0 Z r+ m n! (D � Q- N N O N 0 N fYO N (D C7' rD N om v aO rD N c rrDD 7 n fD 0 z 0 O (o CL 0 3 :-r W Ln ro ro CL ro CL CL ro N n O O O- fD CEO. a 3' M O !v UQ (D m Lrl 3 ro tv ro 3 -�v(A - �r c 3 E. 0 rt v x N D, (Dro l0 S G .a DJ O a 3 a' r+ O y fv Ln C N ON ,_ `�• m ro C O S to C N C p p 0 N fl. N *< O �, Oro! 0) d Q 03 a r p (D G ro a �' a- O m= n m 3. (D an � Q 3 ro fD ° 3 p -o O ro Q p ro o In a ro p D z �' v v o m D. 0 N\ ro a- ro N+ a N v Q= 0 O N M (D ao 'n+ n O - 3LA D o O In 1+ 0 0) (rtD 3a+ v n -s O a _ O a D(D n LA:3n s FA'p3 Ln (Dro - a °N'fD . cro = fDD � O CDa) ::r r+ O ro n' ro N(D .+ aq a 'a n o LA r+ C o O a c n rD a 3 ° ro a rD ao ro O o ro 3. a 0 (D t ro r+ sv t '* O 3 O n O" K a (rD Q- a p. O 3 S N rD y T N o ~? a O 0 M a' N T O-< 00 CLO n a O n m ,+ ° o- + ago � c v r%o a ro rr p 0 q a O a" n p S n ro a ro p ro IA. o s v n O o O N (D N CU (rD =r '� a'3 3 (A o) n o Ln ro -1 O n O `G (D v a a p N n O (A a ro v ro c ro ro m O< N m, O 0-a' (SD � 0) p y O -s N = " 0 m ro c 3 �' C r ro ro .+ fD ro N O m N 0 fD m p N (n0 O O m rr =3 4�;- o N p a C O ty Q N ro S -Nro A CL m \ � a n 3 N. ,'A -a tv O (D ro CA a rD rn+ n m + < 3 c ms w3• ro ro rD 3 c -1 a n 3 a , a' -0 a O <aroa- N' O r.+ p (D ' r (D s -n '•+ O ro OJ O- ro a (D O O C rD m o o CA n N a ro ro O a = ro 7r a X, -,cu fv N (nrD w ro D Iv a N 'a y + O o O r'' !v rDD Q O N O LA O Q O O nai i 0 N G dQ O n a o n 3 3 maw a tv a s 3 ro -. ro � 3 n a- (D (D n 0) ro ro m w m 0 =3 =r m a ro W n g • • O r. n O p N O ((DD � -0- 0— . o �. v v ro (D3 D-0 a d A- O v; In N rD 3 0` (ND `O* m m N CA wa- n CL (A =r o 0 3 ro rD �w.+ O ro n' n A - ro N a p� Iv 3 (D - (Dv fu �' N C '+ rt O (A N UU n ? O- ro ro �. m N ro m n fD O,-o N !v 3 O 'G O 3 n O- -O LA' Q° + (onO rD O 4 O a c 3 ro W n, n ii N <^ 3 R' O rt n 3 In (D a v 3 ,-+ =mammvom>" -< G n Iron N O ro S IL n a d 3 ID 3(A O w v o ,01+ v a n a N N _S O a Uq cr n (D a 'o tin O v z O(D 3 0 3 0 3 LAu, O (30 rDD r+ � (D g ro Z N O _, w N -r C< — r + lD mro A ro w(D O ro n a- N v O 2 ro �. 3 In p ro m x -� ro _ a n -a z a s n ro 3 r' a (D NJ 3 ° oq a °' O< m O fD N m 'O CL ro o4 O O (SD CL n z 3 -O N a m (D OrD ro O c o: " N. n 3 r+ 3 ro v N fD 3 N m m 0 n 3 v < a ro N -S o -0 p D. tv o 3 `-° c n n M 0 3 (D CO n C ro m ro (A vNi O rD 3 O ' m e oN 3 3 M3 fD c Q ((DD O in. a v O 3 Sr(3p � � N In c 3 ,+ 3 0 � s O n(D O ro (D G N O. 0) `n o O N ro ro v sv n N n P a m n0 m e I a v' ro N O z CA a 3 In a r+• (D Uo �, — 3 O a < x 0 + ro 3 Ln Q O Q m Q. n( x ~ ro r+ N <' N In O � O INiI S V r3 N r o ro no0O � N 0 _03 p On. 3 ID n• -a II 3 x 7 ro -I S O S mrD (D cn O- w O _ = ro r+ O Imam (A r+ Iv z O m 0 R O rt a) nc a N A r_ r+ m N O ems+ ,n "n i O 3 3 3 m 3 P!' N .A * W (ND QC D O S N (WD A o C- m p 3 CD 'a =3 (D O . O O O O II � 3 O r+ O_ CLv� CL3 -G 'A r* m rD ID W Z+ O, r p lD n-s r* >y O m, 3 O rD n ( (D O x x 7C a' =rm O N N N N + (n U1 5' 3 s I I 7 UO Q' • (rtD f�D W (D O 3 O ; \ \ m CL II 3' �+ X x o r« v o as N p Ln CL n. m � II O m rD rD (AW Ln 0 cn Ln A o(D O Q m n 0 o 3 N x Ln g to p o 3 0 0 (D o -e, c m 3' 3 n -0 rD PQ x O r0f W t/> X r+< N as 3 moo 3 tNn -t3 � O n ram+ p O< II II 00 00 m II C C .� O O (D n Cl) (D m N O o w m W C- (^ o e-+; o0 � _ W r, O o (D D cr (!U W m a' rW+ < O c r+ W rD O O rD N 3' W r•r W N O < m rN+ cr (D s CD O rD 7 (nD rD O = N (D m O Q Q- W cn n < SD 3 Q n m 3 rD �. 3 iS :;o N � m v W � 2 < r m = W rD 3 SZ iS W m O D '+ O c O = m Q U'1 m _,, _,; -O p m -O - ? () W � oo O < W r+ n W S - c o c rDm m 3 m 3 r s d_ -* p N r+ n�'i n m � N' S m X 3 rD O O cr 0 O< O H O LA O 7 O m -a < �. ((DD (D. 6_ C 3 o W m W LA rD 3 N N rD 3 ,v Q rWr O O O r-, O m 3 rD C m a r3+ CL1Z y 30 _, 0 (D 3 < WO H �G A E r+ rD rD =- , "O ED _rrD r rt m (MD 3 n UO rm+ -r r+ n rNr W m m O m rD W N• O n n oa N Ln_ '+ c r+ W O N O rD =r N aI fl v m rD o N 0 � om 0 i O 3 =r (A m 0 0 �- 3 CL Q >Z O_ 0 m p :3 S O D W< - N W * 0) (Arr -3 cr c l0 CL c — W (A OrD � < m cr a W Q W y Z o r Cr -n0 N � 0- O 3' a4 3 N �, m ago ° o N c W 3 m LA m Q va rD �' m m O coi "° om o Qo = E c O r+ r - r+ CL 3 (n rD _. c Q' -0O m N " W 1+ 3 r�D W O Ui -0 0 (<D rD rD M CD WC: m ,, rn+ m 3 W 7 O rN+ O' O 3 'O Q (DS rD rD rDm O< rD r+ 0O) UG• S Ln 0 — :3O (n o Ln Q p o p D Q O O < :3 c (� O_ (n O_ (p rD O W n Z rD rD 3 n-r �' r'r �r O O -I r n UU 3 30 p (DW m p Lm r+ p q r+ W -h F r O � 0 W rD N O0 r+r+ (D t� ((DD < 0 n, CLLn 0 m C N L' 3 (D O r+ <n O W O rD W �• 3 m n O O (D (� W N W< 3 o O W r+ m 3 (Np rWr m O n a m m a- r* m (1• N CL v rD 3 c 3 = — Ln rD r+ Oq (nD Vrt7 � r•r O (D 3 + W 3Ln cr W rD o Q. = m -a <. < cu ❑_ W W 3 ss W m rD CLrD 0 rD W O < 3 Q o °�' -oa f Dn o m rt rD r* IZ W BOO O =rO m Q '* W rc+ c 's (D 3 n m 0q m 0 Q 1+ N < O Cr m (D< 0 rt 0 m ( N m < (n (3D '2 3 S '+ v v CL r+ O �' Q S QG '�'+ rD LA CA N m _ rD _ n 3 + rD c p O c O 3 O O< CL W 3 a r 3 m Q N m 3 m r-F N O c O m W = m -0 r+ rD O rt• rD CL a �'. Li NJ- = 0-(D 6: UO 3 • -O rD Uq p 0 (D O 3 0 0 3 m c r* 0 c c m 3 m �, Q �+ W rt Ln CLUO rD N' r= r+ O m m O O C n can m v m -a -< cn Z a n LA N Q (D (D a -� rD (A v O� n N d O. O CL (D 3 m m m n 3(D r) 3 x 0 O v m =r o LA n m 3 _ S W c n LA m W 3 CL (D '< !^ >] Ln C7 Ln o� �aq rD (D (n - O 3 r+ c 3 0 O h p Cr . 0 D c O rD O �' �" a (D m :3 (D m sz rW 0 vi ( W c (D Q O '+ O t� c O n (D O O W C(D Q N D 3 g Ocr d rD O �• + < n O O CD W r+ =r LA CD p n r+ O 3 p f+ O W m 3 Ln O c 0 W "O m 3 3 CL rD-• a ss (A =ry < m m "a D -a a� 3 O W m < c m rD r<D C. W O Q m LA r+ n O W ^ CD -++ O �cmn v `^ (rD rD 3 W 5. (A ai m Q m < m m !Wn m W Ua v -+ m O m r+ LA N 0 Ln A i r+ m Vf O r+ 'n 'n CL rF m rF V1 NrD < W S N a � p In c Z 0 in' Z� rD m� rn Obi ? N S 0 (rD N N� <?� n a� N `�= O0�� LU 0 Q n O F) N O O rD rD rD O. rD -a rD rr rD (n N (n (n O (D O O O O- rD O n c Os - O O (D Uq Q N OQ < OU (D ti (D a 3' a' rD CL O O < ,y n O 3 < (D 3 .� c to c O rr O v < 0 O 0' a- 0 3- lD a- rD 7 O 0 n (-D O N0. n cc11 A ° rD rD < N 7 3(A m < o a- o '' Cr o fD n -O X" c^ c^ Q t/, O CL (n r+ D) ,y., O v rr to G ° < (n O O rD O n O , r 0 = v o ° fD ° c fl' O< ° rD ° (D °' a- < Cr M. r' 3 0< v N 00 -. cm rD �_ -a te-, v m vrti` < O 'a p v -* ((D p v, ao v _r; to p a° -O+, rD aQ o� f D M o vi o m° n 3 0 0, o o, ° o _. 3 (D a, �, O < O OT cn (D (D M. can -(i �+ Q C 3 Q < 3 r v — r+ �' (D (D + (D v ID Q o G1 v �' o rt N r° Q Q" +< m m= y v,' o °, O v O 's y Oq r+ O =r ? -I * 3 cn v (D 3 Oq O (n W 3 0 �* (D -,, d Q 3 O (D c W 3' < � 0 rD bi, Q- in 3 ,. Ui aq -ems d '+ N 0O 3 p ((A :n O- e-r ((DD -y, cu ° c Or n 'ND 3 0l Q o ° N o0i 3 Cr O a 3 7r -r r+ O° 3" n �, Oq O n. (n O D a a' O Q ° 3- m Q d N o Q Z (SD �. N ° (D o< ° Q ° <' V' 41 nOi cc (D Ln v rr , r ? 0 3 ,< rD (D 'ter v H cn cu 'r fD N O < O (D O 1 3" MrD �• < rD (D -•a, Cr o rt < (, -a c rD rD O 3 rr Q m -a `^ O v rD O ° ? =` m + cn * rD N m a" o cn Om (0 41 ^ fl, ° < °' A 3 o < cr n Q n O (D ((DD cn' rt O 3 rD rD �' rt j- ((DD 3 (D O� `D c c` (D -a m o rD rD v c 1 n 3' fD -a m� Q 3 N rn o s 1+ 3 1 C m° v o O o' c, � '* °� °' 0 O Q � �3 OfDq c 1 N + ��+ fD oo-��+ m o °' QQrrDD �'rD 3 Q- v(A — f7 Q� p 0 '+ N c, r d H' O o O (n '*+ (D n (D 0 v 0 13v O v c° LA f D °- d o o+ �' o o a- p -(+ m d r* °' -• rD c rD ° Q 1+ m o° °'-+ n (A v o -' o cn (D N v O V' rD 00 rt O (Oi v m° Q CA O' n+ v 0 v O -+, O 00 ° D °+ n vrD, 3 c ami s Q- c m rD n m -,, 3 rt o, N X O m �" �• (D S" M w ((DD A LA O O °1 (A (D Q N (D �^ -, to o N N r0+ r3+ O� =° S v cn `n r r v 000 3— 0 0 Q N: n rD O (D 'a v D a cu rD rD n r r -� Q °- o r- rD cu , ( o � O m+ FD• ° ,�+ m D N '^ 7 O v, O 3 rD H rt to o (D `^ o° o p (D r3+ < y n n 3 C N nr CC 0 S< O O Oq 3 (DD O Q (D N rD 03 Q (QD t^ ,3c S rD rD 3' 3 G c fD p 3 rD N• O fD y H 3 o x o O o v-+' Oq -* Q °�' m Q- 3 f D 1+ 0 d 3(D FD o �- o o cn (D 3 v r+ n (D 3' lD (D N 3'* 3' G -+ e-r N N O 3 O S o r-r 3" fD o Q O (D CU 3 S11 6) = '+ � �m CL ° o y � fD 3 O O ® � (D -h O 3 Oq d rD 3. o rD Q H 0 y - C a °° � < .((D °—' cu �' rD rD m < 3 __ (D N rNr rl v N v' ((DD -n 3 cr 3 a' Z r+ rt }p N a 3 fD O <-0 a ((nn rt O (D cn 3 3" A rD 3 O Oq n c 3 0 (D rD 0 o N X OQ Q (D -s• N ° O O N 3r v 3 ' �' Q 0) 0) a" Ort ? p 3 4_4 N < rt cu N n t=ic rcNr N (D (�D 3 3" (Np O a Q �' ° o) 3 W (D rD Q OOq =r r+ '+ 3 (D v O < Q (D (p a- rD o f O x rD U% (D .-* 3 rD (D (n n (ni r r fD Q 3 3 Q Q H' a) 1-' 3 < (^ O 3 3'o °rt Qmo• ,^* z,rt �,•Q3 3 �,•'A oC'.0 of (D o1+ (A 0 o v Q a (D r, 3 r+ H' 3- rD m o -a X- rD o 3 a. = 3 0 (D �, r, rD <' °- Q s Oa 3 c c c c- <' Q o o- * O" ° a m o o a v N O rD (D rD C: 3 n' rDrD . + r r v o r+ rn rD Vf (D 3 a -I rD O n Q rD n rr r ((DD = ° °—' 3 j rD j �• Q ; ° 3 y rD = rt' ° rt ((DD (CA M 3D ° O0 o rD N N ((DD (D c 5- Oq o 3' W "a N (QD 1 a CL M. 0 -3,, CL c 3- rD < (n r�-r Oq Q' O< =- c 3 Q O M a O �' 3 (n 'a N N ,"�, O w o n 73C rD (n 'n'c'. rD : 3° rDrD rD o r° m Q c o n 5' 3 h rD c o oLn Q cn O� c 3 0,+ rD v rD 0 3- Q r+ m rD O (n rD In o O 3+ (n c (n + m 3 ram+ N to 3 aF O O 3' 0 x m oj vA Q a rr (D C N -s 3' 3 N `n 3 * a N N' rD y c rDr+(n N Q rD to n 3 c -a rr A O (D 3" (D (D 3- H' o N ,, r-+• N r•r 'i' n N cn O + O ri w 3 n 3- v O (D O 3. rr 3 3 (� Q O O= 'a -}+ "c a Q 3 D -a Q -. O 3 -a " D N '+ 3; rD Q rD c 3 -'' (ND n c o Q Q 7r a' -a D) N D (A ` cn w o C Q 3' O 3 (n a O -s 3 fl -• cuv, (A(� O n c o a- r) (Arr (D * �: (D rD °� rD rt rD N rD 3 0i — °� � 3- 0 3. 3 � r v, 'T Q- n rD rD N— CLo rD -h 1, rD cCr fDD o a3i -� Q c o 0 3 3 ru D _ �; ,� ate* v -' m� rr�, � D n'� � 3 c 7r 0'o S (n Q (n N O) (n cn ° rD Vf <• -0 Q Oq' p o O C (D Q (D' Er rD I Q 3 3 c - to rD (n `n r+ rD (n (� rD n a a (D (n rD Q v (A rti 1 a- _ N ON a q 000 rD N m N O m m N + (A 7 N n mO 3 c Q y° 0O <' o O rD rD CL rD o >Z O--r °- arD ct `� � 0 3 c, s � CL o- Q m , v '* m ,, v rD + rD < < (D r+ O c '^ rt 0 0 r0 3 o rD rD v o r<D c rD O c rD p 3° Q o 0 rD rD Q o< �� 3 N Q < rD oa < a�i o rD n a�i 3 a a °—' o ° ni ((np + 3f Q o 0 0 'N, � s °�' O' N N m (n rD 0 o rD m < ° ? C. rDD CL 7 (D h -h m fl 3 (A (A 0 3- rD 3 v V1 A r+ m O O 3 r+ 'n -n O CL O r+ 0 rD m -i Z O -1 D O 'O O CO m l0 m 03 Q co Un m O a CL -I Z A < O �^ Q (0 N fD -� o O oa S (D ° t� �-+ O N ° 0- v Q x m (p N Cr r+ v + fD G v `° - m r, o C °+ `° (D a 0 (D fl. < 0. '.,., CL m (D = N (D �+ fA N A m N 0 v Q Q v� S n O O arti -a (D p O Q. m v Q r+ rr O A ds 3 (p NO m m r+ p N (D MQ ' n ai 7 cn r0-+ — p <• i �. O r+ rNr C) =" 0 �, OQ m o O Q = m_ 3 p Q N O < N '� O cr N -w = r+. M r M. w C N W O Gq M N rD N _ � `, < o C) = � m :^ cn O UG r+ N `< O — N< m v rmr C '+ S N o O W ' a� =' rt Q O s � -. C. LA v Q o S O rD n rnr C (OD -0 0- O r+ m d C r+ p h m -h r+ s? ^ N In m 0) 7 ram+ N in' G1 O m O O" p 0U rn+ N e+ -. fl. ,O Q ut W O 3 GJ Q p H m _. n, m �< t� o `�' O Q- cn D -s n, 3 d -a rt rt Q 3' c v_n cn o �' o O 3 -a p CD m 3 O N `�° `^ , * v oa o � v -�i, c p �' o m 3 0� O -a `° N m N 3 s m cn 0 O -a <- 3 � = N O 0 m c ,`^+ + cn Q OrQ p � Q Q -+ UA O : Q m � UQ fl7 O < < cn O O ani v, < m o (D ? N m (D Oq o- -h C 4 Q m a rnr -h o -s = N o_ to 0 =; o � D �, 3 < o- Q" c Q � v 3 p D fD o � O, -0 � � < 0 Ln N Vf H _O �- o Q O 0�Q fD O. O O m CA O , Q (D n n = n .O O f<D l0 O m h N 7 N rD 3' Q' O N C 0< O< Q- O (D O ((D n rNti v m r+ n, v S -. Q, L < CL s 0 p s 3 C" m- CU n (D3 -1 O A m r+ S < � (D �- fD (1 A �< n� - fD `n r} n (mD ,C+ D) n m m W = Q � '� v UU � N � � mf 3 c�i+ n cu 7 � � (D- Q m N : Q m Q. fD n -t O fD <' _� A m 'e v -t ' c Ci .py, t/1 Q- rD (p rt Q p v O< 3 0 O Uq Q 0 Uq — -+, rt s O,n-r < rt O C 3 m =+ m S N m -s -Q< 0 < Q=Q W Q= rD 3-Q C � = NNo o M. � rt O N m (A:3 �0 rF 3S CL (/f G rD rDD (D Oq O rDO O — i N •0 m N_ (D c� -z N M. N S rmF m O p p v p m p q9. C (D O O O < (D `G _S fn -h Q 3 �'+' (D N 0 '�, -r, cn m 0'4 rt r+ ut �• 3 as ID r+ N 0 n o N' m 0 3 Q � cn o \ A 0 Q n 7 cD (o Vf r+ N Q— 0 (A m� r-h ut r'�' CML 3 (D 3 V ® Q Q m m Np� (D O Q N p O o m(D O O 3 Q -c O ai v O r+ o O 'O m rr rt S R. `A I — p- � -I N - N < O -0 (rD O S C m O 3 N O O• ❑" O N m (� (D O ''� O N O p LA U 0 Q 0 S '* p o n O< O• Vf S n m m CL O S m N on �` r* = m M. � O �? v� _ N n O cr a m UU S -�' (D (D (D Q -t+ m O p' vi S. O< (rD 3 (<D co r+ -+ m N 0 �• p O< m -` O X� M 3 O N CL rN+• rDD a m EH v Q O O m CL(D (D= (D � O 3" m N LM S r+ Cn C N in0 O O a_ :3 C O e-F � n 6 C 3 m O- 0 m S rD 0. O O r+ S m 0 ;: � r+ O S 0 �• o v �, n :3 :3 Q 3 O (D < m O m: 0 m m m N n N O v m a X °� v C rNr r+ ti, O N H S O r+ O O C Cl 'X-r S m k Cr r+ O pi Q -_ _. 3 CA0n v m 0 Zn O m m O_ Q m Q- h m C (D O m r+ + �' O i^ ( Q fZD 0 v p Q m-r \ N < m "O C) 3 rD O 0U �, _. O o0 0 to d o' p -s m rt< p O. -S O Q Q o m CrO y C 0, v m p W (D O 00 Q (D � �• p `< -3o < (A -, O N m -h C Q Q m s 1 oq -0 — = r•F ry' i '�-r `< -0 • Q O O N n A m Q d C1 � O m 3 7 __ 'a rD `"— m' C � p S O" s 0 Q N Q S <^ r+ Q Q- N N Q m LA N �- -s m" * m 0 � (mD � Q +; �I N D 6 vOi Q c 0" 3 (D N (�D m O� Q �/! S (D cn O S` J r+ O -. 3 N 3 m O S -h m m o o r* r+ n a c Q. 0 .s m n v= m m 3 < m rr -� N S cro O m fl m N S O .< 01 Q s CL 1+ rNr O p -� m O 3 m (D < m 0- N C O N r+ m m J C Z A O Uq QQ rD N D) C V1 r) -a C VI 0 O y � .p rF, ram+ -o r* Q (v O in' 0 S Q D A '•r (D C N ct rD � r t Q 0- � 0 p 0- ai m (/� m N `G 3 r+ o v 0 3 N N M (DD �• V m H 3. v N A i rF m N O r* In In O 3 m r+ N N Co ii W M Q = C -< O � to G A d O Q 0co (D N (D Gi CL �. W n F-� (D (i S 00 p7 (D rD (D N (1 =- - 0 m� C 3 :3rD = Q Q Q S O �Qv � (� O rD (D s m\ m Q Q rD O m Co rt rD ou (D s+ w � Q "h Ln (n 7 0 S Z N 00 y cn a. 0) O � Q OR = = O o Nw Vf rr O O 00 + C O. ((A 0) cro O a' Q v M(AD n NJa 0 0-Sq Q O C O O n O- 0 W (D < 6(S 0 fl! H O T (D N DG C ((A 3��, n 0- 0 m r�•r 'NA 0 N j N aq rb 00 �� 'A O. H Z V M p 4_J'j. 'a rD Ln Q (moo 7 N Q. O N W (D y- 3 G °�O r�i -n —-s y 0 ON Nul O OLn 2 V1 C Owl 4 V N7 0 Q. 00 N 0 m -I Oa, -0 0 ' v n < O r+ (D 0 r+ (D (D (D W Q N O n Q p�^ O N O 'a 0 N (AD co N O S N O f7 Oq v �-n" (D s- (D (D (D�< N N O? �'° < n O nLn rD O O =— O O (D -n a)O Uq In O < 3 N O ((DD x- E rrf v N S. Oq (n -a N O x- O 4 (D Ln -r, (D 0) O 0. rD pi u°�q 3 rD Q-1 m LAPz,s 1+ N S o m ai 3 N < (D cn _ ,< N w 4 a rD CL n 0 WrDO 3 C L CL ° O a- N O n as < S :3A S aq Q 'a p (D - X- (D N. O O Ln N /�'-+ fl (D r+ O O 'aa v O Q C < Gri 3 rD-a rD N �- fD n`+i Ei.LAf7 rD O Q. O � d r•1+ � (� O ri (D (D X f1 Q- O -, < (D (D LA— Ln (n n �_ a- X s (D °' + S m (n r.+. 3 O � C (D (D h 0) N _ (D a �' 3 LA O. a ° ° =r C fD Q. rr (D 0q O O Q- N N ULl r+ (D (� Ln C -�S tn' (D GICE• S rrD D C p Q r+ O I< (D (rD O_ d S (D 'a (n `D rt (D rD O � M (D r+ (D fD to n S O — O (D O -t (D 'a N= O O-a O O S LA o O o a<°o o D r rD r+ s (D X a' cu O n m N (D -a n O_ (� A 'a r) � 0 arD ' (D = � .a O Q. cn (D S rLA 3 =r Ov = rt S O A S A O r+ Q O O ? n N O (D fi O O -a 0) r+ S O (D 0_ � rD O `< an -i ((DD Q oa _ Q. o -a arD O_ =rr �'* O rD m W rD O N O 0) a- -all O -t r+ "a ? °r,' n v cn o s .a Oo a)CL rD Q -z n'+ r+ S (D ° a` ° S rD = O fD X g r+ (D °" rD o °� o srDv Oq s 3 fD n r* a- (n rN+ rn ° r LA rD 0 O (n LA N Uq Q m O (D O `-r r+ N O D1 rig O O m S O C LA D w O_ (D (D O (D N -a -a W (D n ,a• r++ v r+ O 77. (D .s °+ O s 3 (D 3 O (D O O O (D (p X. a- :3 O j' S Uq c N s (D (D S O 3' G N' (D 3. (�D O c- c O N N O � N S O s N :. f7 Q O rD 3 N (D n (D W CL O O d � s O ° (D 0) S C (D 7 N rt (D (D N Q O � O n (D O (Nn O 0 D N r+ (D o o � s � Q- (D r+ O v Nl A rt m N O rF In "n O. OIQ m rh N LA (D rD 0- rD r+ d m� CL CL rD N -a' r+ o' s aq ao 70 (D LA (D Q O O N N O v c_n ::3N Q- m D 3 (A=r Q rD rD� �, � _ rD c 0 W m (D o (D rD v N N r cn 3 (D 7o N oo m W m 00 (D c(D, 3 rD Q' f D n. o- rD _s N Q 3 n (D O O O O (<p m y (D nri Of v Uq rn n vCL Q CL !D - rQr -Q v O �, m (D m (D r" O O CLd s rt Q- of 70 O m (Qii (D O Q (D 3 rt Nr Nt A .pO p O Op NO N CL D p O" O_ � CL(D ? Uq m NN O O UNJ ET A O(n + r Q- Oq r+ (AN 3 VG m C7 i p dq (1 UO _S 7 3 (Drt C (D (D v�i (D j rD (�D (OD v a (OD CL O Q V > 0- m CL Q' awn w c p 70 --I -a S p 70 O -4 �+, '^ S p 70 -a -1 a' C: m+ O. O N 0 M CL (ND UQ O (D 104 Oti1 O fD rt O1i O 0 p ,O < Ol 7 Otii Q p �Oy < Ll 7 Oq H Q S p ,O+ < D) a (D N n O C D) On A p<) ((DD ? lN1[N1 C H A C A 3' nkn N = Q A O n w = = Q" K -� O A O O< (D �-r IoL '+ O -h (OD (D r+ .* O f3D n (D ,+ tOn ,_+ �' O aQ VOO (OD (D rr vOi ._+ 3' O (np (OD (D .+ vOi _+ O crQ O N (D c N Q. O. fD 3 eN-h N O. yOj 7 N �. N eN4 y O. y 7 r+ n -n - a' p n uq �, n g n ° ° rt in rn � A °"° r+' <n � � A as T. .t„ Q � A as + -CA to N O i/f N < < O W W �' O. O V► v l0 3 O. O O N O �' Q. O N C i/� O N �' O. O SD 00 O Q N (Np Q C 0 dq �A c O H O Uq O W(A_ 7C Cq T K N ,O.f 7C s 7C -+ (Ni 7C 3 m' C y °i C -,; — O G O0 �- O �- v O O O N (D (m N .a N < N wo p 's -t o O .t 3 T. O N -t. O c<i �, ,+ -S �. O r+ -t 3 E. O -++ (D C (D 3 Q- 3 N n1 Q O Q- lD (D N p _ O O N -s O - — 81 O O N O O fl. H N O 3 (D O O 5' N (D n n nQQ v (D A S C r+ m N O r+ r) "n TI C 0 (D m r+ Vf T m m n. 0 0 N 0 -a Di OQ m N O � LA v c s (D ( °" W o w D O (/1 O O-, = m n r+m n `< n Q c =r W E-L LA m (D -j m nO O inO� " O r++ r+ m (D = Uo rD — �. v O '+ m Q m fm1 f�D OQ m n r-+ r+ uQ m m O m m � y' ,< 0q m �' <' rD CM. w Q o- N v 0' Q m Q Q m r+ � -mma cn a rN+ n rD N ET Lin Q S < O O �+ m S m O r+ O -n- -S r+ a UQ o(D rr r) Q 0. Cr C m x CL Ln N m m N S o = Q �' 0 =r a v— m Q (D m rr O ec+ m -S ? c m O O m Q m + L.) N m Q A �. m 7r Q 0 Ln o rD v N a Q- O <- m m o (D Q Q c m m= O o OLA W v' � °° o o 0 CL o 3 a m _ O �' O (D n. cu o w-3 � 3 (D Q m fD a R. -h W C rt N, (D rt rD WOOP pp O v, ffv O ILD_ rD(D p 3 m �+ N r CU m w -tea o s 3 — O O M -. S m c rD 3 S CU N < m m N C N A O n _ O O p� m v, O o v cu *= o Ln Q 3 c m (D 0-'< c r+ o N aq r'+' 1+ n (D to MO "a m O O rD Q 0- a0i y (mi s = -* 0 o rt o Q s o m n o m o m m va, m 'o Q C N � Q. r O (D Q (DN Q cr .< LAlD m a- 000 (D �- m A W < r+ � O � 'a O LA m m Q a" w— "s < OQ v N n A E m to O ID ID fl1 v O L^ ? S N m S 0- m Ln w S Q � • v rr+ cr a -.3 (D N CU (D LA (D `< v UCI Q m " O r+ S m C O A 0 W m O Q. A m p V r A (A .G i 'C N 0 O r+ O ; � o M Q 0) 0113 o O Q = O m pmj � A CL ram+ M rt r.M 0 CL 3 G® rF .a M 0) H C p 003'^ Q. H M t, o_N H m' o' Z 3 m N O ch � un o � 0 � , o a- c {R Q Q m 7 Q -n (7 -s m n O (D Q 0 cn LA m n c cr O C LA m + a cn m LA CFQ S m (D Q Q 0 N 0 ° D cn c u, '* A < rt .c --1 A m m -+, G H Qv M N "4�- n N � Q o ?� O ? r+ _ HMD v m Q ct a. OQ v N A C r+ m N O eat .n -n C C_ GQ O m r+ N * NN (D ♦ r t v ♦ v v ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦A;-n ;a Q Ql -i W W W - 0 O ID O O O O V'i U'1 U't rD fD m m 4� 0W :3 _ Q' C N m rn rn O'Q N (D CD O 2 S= to N !! (( p { ` ( V1♦IA"♦'N♦ C D c (D O :'N♦��vI"1 W" N♦(Nv.Kl'vIN♦.INv'to♦!N♦�t'j" w O N ..t r+ — : V V V V V V V V V V V V V V V V .y A A A A A A A A A A A A A A A A Oq O O "D N C S� ' W W W W I W W W W W W W W W W W W� a O = O r-F F•+ W N H !-� 1-� N N W Y N N N W W W d m Q. -a ,W W W W W W W W .W W 'W W W W W W S (D O TI W\ W♦ W♦ tt�u1 W♦ Wv Wv W\ W♦ {{.vv♦ W♦ W t Wt�.�♦ W♦ W't WN O O '+ A A A A A'.A A A.A A A AA.a'.:-fi Ll �' (D (D vi to w N N N N to N N to to N N N N kA N N tJt N 10 O (D (D w N N Ln kn N to to NNo yf Jt-A..,.0'O.�'� ,O N-ON.N N N O'fANW �• lJ1.CD D• V vi 00 N 0) t+ 00t'j � O rD rI"1' O O : O i O O N (D rD A m m m m m m m m m m m m m m m m or) m x x x x x z x z> a x x x x x z A t�f 70 v 70 V Cf v -n -n n C7 < O H H :, Q d - d o to V Ln W Ln N M A° wa x; n 7 n ro O W m n•' .+ .a. d N O C W l0 iD Q1 r A ro i�� O W ` a ^. `� 5 ro ro n G O a q a p M a H v ro ro N ro :i /a W < CL N• O O oil o N WA' r oi Owl oWo yr 0N0 4.n m tD N Ol W N to Npp ' a A O ppApp W .P O O tlt W A tp 00 O O 00 V N V O N888 8Lcq> s'9Lon 899 jlS v m N A rF m N O C ✓r+ Q :3 (IQ l ) 3 3 3 rh 0 Central Oregon Childcare Micro -Center Pilot Concept Need The economic fallout of COVID-19 in Central Oregon has greatly exacerbated an already critical situation, with a 25 percent closure of existing childcare facilities due to the inability to stay financially afloat. While Central Oregon has an ongoing severe shortage of child care, with only one in three children from ages 0-5 having a slot in the region, COVID has left thousands more children, families and employers wondering what to do as they reopen for business. It also puts our families and children at risk more than ever before. With recent announcements of at-home learning from school districts there is high demand for school aged child care as well and the need for healthy and safe places for children to go. Pilot Concept Create high quality, affordable and accessible childcare locations throughout Central Oregon. Initial focus to be in Deschutes County. o Hire a Micro -Center Hub Agency that will work in collaboration with the Accelerator and Steering Committee to facilitate shared staff recruitment and hiring, HR benefits, child enrollment, billing and financial services, fundraising and assurance of quality care, safety and licensing requirements. o Locations are a one -classroom child care in an existing space which could be an office building, a home care setting, a community facility, a higher education facility, a hospital or school and more. o The Hub is responsible for providing or subcontracting the care to these various locations. o Average location size would be 6-16 children. o Support Micro -Center Hub Agency with Childcare Accelerator position to assist in partnerships, streamlining permitting, and cost -saving. Accelerator Progress to Date The Accelerator and Steering Committee have been thoughtfully developing this concept with a COVID response in mind. We believe this concept is scalable and can offer emergency relief to families in need. We also have been working in close collaboration with Better Together staff, Becca Tatum to address school age needs. • Request for Qualifications developed with release in mid -September 2020 • Identifying potential providers • Securing locations for the micro -centers • Securing partnerships with employers 1 Time Period • Time period for pilot concept is 2 years • Launch initial sites in 2 phases throughout the next 4-9 months with goal to expand locations. Funding Request $50,000 to fund the following: • Provider incentives to launch first locations Expedited licensing fees 2-3 months of Accelerator time developing pilot concept in response to COVID needs 2 Central Oregon Child Care Steering Committee REQUEST FOR QUALIFICATIONS to support a Micro -Center Network Scope of Services The scope of this Request for Qualifications is to identify an entity/organization to serve as a Micro -Center Hub to grow and support a network of Micro -Center locations across Central Oregon. Information from this RFQ will be used to identify core competencies by potential contractors to 1) provide services to independent providers, and/or 2) provide services to providers employed/governed by the Hub organization. The RFQ corresponds to lessons learned by Opportunities Exchange regarding the establishment of successful Alliance Hubs in numerous communities across the country. Compensation for services will be determined based on core competencies and model of operation outlined in this RFQ. Compensation and Partnership The backbone agency that is selected to deliver services will have the support it needs to be successful and will include the following: 1. Partnership - Both the Central Oregon Childcare Steering Committee members and the Accelerator will offer expertise in their respective fields and will help secure locations, partnerships with sites and funding. In addition, the public -private, local, regional and statewide connections that our steering committee members have will help secure ongoing support for the pilot concept. 2. Compensation/Funding - The Steering Committee and Accelerator will help to identify and secure funds to assist with start-up costs up to a total of $20,000 for the pilot locations. As well as secure partnerships and adopt shared services models where appropriate that will help reduce overhead costs. 3. Licensing/Approval process - Established relationships and commitments with state, regional and local government officials and staff to help streamline the approval process for locations. Timeline Request for Qualifications Released September 15 Responses due October 7 Review and notification to respondents October 21 Agreement negotiated/finalized Background November 4 Decades of research confirm that high quality early childhood education has lifetime positive benefits, and is particularly impactful for children experiencing multiple risk factors associated with persistent poverty. However, market conditions and the lack of stable and sufficient public resources for childcare costs have created widespread challenges in the childcare sector, as evidenced by uneven levels of quality, high staff turnover and low wages in the workforce, lack of affordability for families, and insufficient supply. COVID-19 has exacerbated this condition and lead to an acceleration of piloting new programs to address the dire need for childcare during the pandemic. In Central Oregon, the supply of quality childcare has not kept pace with demand, even before COVID. Designated a child care desert, pre -pandemic, the economic fallout of COVID-19 has greatly exacerbated an already critical situation. Thousands of children, families and employers are now left without options as they reopen for business. It also puts our families and children at risk more than ever before. With recent announcements of at-home learning from school districts across our region there is high demand for school aged child care as well and the need for healthy and safe places for children to go. Central Oregon Childcare Steering Committee This is why a group of public private organizations and community leaders came together in 2019 to tackle the childcare crisis in Central Oregon. The mission of the group is to create and retain affordable, accessible and quality childcare, increase the number of childcare openings by bringing together communities and employers who invest in Central Oregon's children. To achieve this mission, the Childcare Accelerator position was created to facilitate business and childcare partnerships, navigate barriers in local land use and development codes and elevate solutions to employer workforce needs across the region. Steering Committee Members: Megan Norris, Central Oregon Childcare Accelerator Katy Brooks, CEO, Bend Chamber of Commerce Brenda Comini, Director, Early Learning Hub of Central Oregon Karen Prow, Director, Neighborlmpact Child Care Resources Donna Mills, Executive Director, Central Oregon Health Council Annette Liebe, Regional Solutions Coordinator, Office of Governor Kate Brown Amy Howell, Director, Early Childhood Education Dept, Central Oregon Community College Kelly Sparks, Assoc. Vice President for Finance & Strategic Planning, Oregon State University Cascades Carolyn Eagan, Director, City of Bend Economic Development Department Bruce Abernethy, Bend City Council Jon Stark, Sr. Director, Redmond Economic Development, Inc. Stephanie Beamer, Executive Director, Better Together Key Partnerships to this project include: Bend Chamber of Commerce: Accelerator Position, contract oversight, fundraising, business partnerships. Neighborlmpact Child Care Resources: Quality Improvement support in SPARK Quality Rating System, individual professional development and training, pedagogical coaching and peer networks. Central Oregon Community College: Professional development pathways and support toward certificates and degrees in Early Childhood Education, internships, the Small Business Development Center, lendable resources and other programs. Better Together and The Early Learning Hub: Provide assistance with data collections and analysis, project evaluation, facilitation of contracts including contract review for compliance with state standards. Coordination on school aged care needs. The Project The goal of this project is to identify a Micro -Center Hub to grow and support a network of micro -center locations across the region. The role of the Hub is to improve child outcomes by strengthening the capacity of Early Care and Education (ECE) providers in both business and pedagogical leadership. Strong business leadership focuses on building a cost-effective administrative team to maximize resources and ensure sustainability while also improving teacher wages, benefits and working conditions. Strong pedagogical leadership remains focused on effective teaching and learning —so that every child has a reflective teacher and every teacher has access to reflective supervision. The formation of a Micro -Center Hub enables ECE providers to share these costs, to build and sustain strong organizations that are able to focus on their mission, create positive work environments and growth opportunities for staff, and offer high -quality early learning services. Our pilot concept will create high quality, affordable and accessible child care locations throughout Central Oregon. These micro -center locations are anticipated to serve 6-16 children per site. A Micro -Center is a one classroom child care in an existing space which could be an office building, a home day care, a community facility, a higher education facility, a hospital or school and more. The locations or "host sites" assist with overhead costs by supplying the space rent free or at a reduced rate and cover maintenance and janitorial costs, they also offer or secure donations for furniture, equipment and other supplies. Given the facility, the host sites employees are often the clients of the facility. The various locations are operated or supported by one hub that generally includes one director who manages staff, enrollment, human resource benefits, business management, fundraising, assures compliance with licensing and quality care[l] standards. Based on national best practice research in quality, affordable care by the Opportunities Exchange, more information on Micro -Center management can be found at: https:Hopportunities-exchange.o[g/wp- content/uploads/OpEx 2019 MicroCenterNetworkStrategy.pdf As part of the due diligence for this exploration, the next step is to identify an organization and/or create a partnership among organizations to function as a Micro - Center Hub in Central Oregon. This RFQ is a tool to help us identify the appropriate capacities and characteristics for a successful micro -center Hub. It is important to note that while both business and pedagogical leadership are necessary supports for a successful Hub, this RFQ is focused on building capacity for shared business leadership. Respondents are encouraged to provide evidence of organizational capacity in pedagogical leadership and to describe strategies to boost teaching and learning, however proposals will be evaluated based on respondent's administrative capacity and ability to provide business leadership to a network of micro centers. Your organization has been identified as one that may have the capacity to contribute to a successful Hub model. Please complete the attached to indicate your interest and your qualifications for this opportunity. Please indicate the model that you are: Micro -Center Hub to independent providers Micro -Center Hub and provider services Mission Driven 1. A successful Micro -Center Hub must have the desire to work with other ECE organizations to improve childcare business performance and see this as part of their mission rather than as an opportunity for increased funding. In other words, provide high quality, affordable child care. The model allows for reduced overhead which we are expecting to be passed on to families. a.) What is the mission of your organization? b.) How is the work of supporting early care and education compatible with the mission of your organization? c.) What is most compelling about the potential of serving in the role of Micro -Center Hub for the community? Fiscally Sound, Efficient and Effective The Hub agency must be in strong financial shape. There are a variety of scenarios in which an applicant may demonstrate capacity in this area, including: 2. For child care providers: fiscal health is measured by the criteria by keeping all classrooms fully enrolled, collecting all revenues in full and on time (including family fees), and having fees and third -party funding that cover costs (requires knowing the cost -per -child in every classroom). a.) How would you describe the overall fiscal health of your organization? b.) What indicators do you use to monitor your status? c.) If you intend to revise/update%xpand technology in order to better manage ECE funding, please tell us more about your intentions. d.) How do these tools improve your organization's fiscal management practices and overall fiscal health? e.) What practices are used to address elements of fiscal health in terms of full enrollment and timely revenue collection, and third party funding? f.) Please provide a sample budget for these pilots. 3. For entities not providing direct child care services: a.) Describe how current financial management practices exhibit the skills and practices described above. b.) How are these transferable to the child care sector? 4. A Hub agency may choose to partner with a strong, stable child care provider who demonstrates capacity in financial management. In this case: a). Describe the capacity of the partnering agency (using the metrics described above), b.) Describe the capacity of your organization. c.) Describe the nature of the partnership. 5. Additionally, the Hub agency should have automation systems in place (ideally, an automated child management system designed for the ECE sector) and experience with, or the ability to quickly get up to speed in managing, a wide range of early care and education funding streams — including: PreK, Head Start, foundations, private fees, etc. a.) Describe your organization's technology infrastructure. What tools and resources does your organization use to manage program funding (track revenue%xpenses, maximize collections, reporting to funders, etc.)? If you use an off -the -shelf technology product, please provide the name of that product. b.)Does your organization currently administer any direct service programs? If so, what are the sources of revenue and funding type (fee for service contract, grants, etc.) for those programs? c.) What, if any, experience does your organization have with revenue related to ECE programs and services? (Child care subsidy, Head Start, PreK, other?) d.) Experts have described child care as a "challenged business model". Describe how you would address this. Willing to Innovate and Grow 6. A successful Hub agency is not rooted in the status quo but willing to explore different models and methods of sharing staff with other centers/ECE organizations to attain both economies of scale and economies of specialization. a.) Provide some examples of how your organization has advanced new approaches to the provision of services. b.) How would you describe your organization's "risk tolerance" level? c.) Describe a situation where your organization has had to pivot or change due to project/partnership demands? d.) What is your capacity to expand Hub Shared Services beyond the initial pilots? Supportive Governance 7. A successful Hub agency should have a governance structure that is supportive of Micro -Center in both concept and practice, and willing to support it as a mission rather than a revenue -generator. a.) How would you describe your governance leadership's current understanding of the role and purpose of a Micro -Center Hub? b.) Explain why you believe they would be willing to engage in this work. c.) How would you envision the relationship between the Central Oregon Child Care Steering Committee and your organizational leadership in advancing this project? Effective, Qualified Staff 8. Launching this pilot requires staff that understand the concept of micro -centers in general and fiscal/program management in particular, are willing to innovate, and excited to be part of a new, national movement. Staff does not need to be on -board currently; but the agency needs to be able to recruit the right leadership. a.) Do you envision staffing from existing personnel, or the recruitment of new staff? How would you identify staff to manage this project (current or future)? b.) What characteristics would effective staff need for this work? c.) Are you willing to recruit staff and student interns from programs like COCC, Early Childhood Education Program? d.) Please share the wage structure for positions key to your proposed Hub model? Trust Within the Community 9. The Hub agency must have, or be able to build, trust among small ECE centers and/or homes in the community, local funders, policy makers and others. They should be viewed as a collaborator and have skilled management able to navigate the politics of ECE provider communities. a.) Describe your relationship/role with childcare in Central Oregon. b.) List agencies and a brief description of collaborations with whom your organization currently partners. Equity 10. Equity and accessible to all is incorporated in our mission statement. a.) Describe ways that your organization practices inclusivity. b.) Describe how you plan create equity in the childcare spots that will be offered as part of this pilot. c.) Describe how you plan to create equity in the staff that will be hired to participate in this pilot. Please attach the following documents to your submission: 1. Independent Audit for the previous year 2. Current operating budget and YTD financial statement 3. Annual Report for the past two years 4. List of current Board of Directors or Governance Members (including affiliation and position) if applicable. 5. Organizational chart 6. Statement from governance leadership that they understand and support the organization's efforts to lead a Micro -Center Hub. AGENDA REQUEST & STAFF REPORT For Board of Commissioners BOCC Wednesday Meeting of September 9, 2020 DATE: September 2, 2020 FROM: Jessica Jacks, Health Services, TITLE OF AGENDA ITEM: PRESENTATION: Suicide in Deschutes County: Trends, Risk Factors and Recommendations RECOMMENDATION & ACTION REQUESTED: Information only, no action requested. BACKGROUND AND POLICY IMPLICATIONS: None. Suicide data from 2000 to 2017 in Deschutes County will be shared. FISCAL IMPLICATIONS: None ATTENDANCE: Whitney Schumacher, Suicide Prevention Coordinator; Jessica Jacks, Prevention Programs Supervisor, via Zoom meeting participation z<® 0 4-J Ln 4-J 4-J tA 4-J 4-J ou Ln d' d' + N Ln Ln m VI N LD 0 N Ln ci O N P4 co 0 O N O O O N N 0 0 N 0 O 0 N o vi o .n o n o vi o saeaA £ AaaAa aad suosaad 000`00T aad syzeaa O F� G v E V) LM v w Lo a U a c 0 a, N v U L O a C3 a O E E U- O C swalgoad leuosiadaaiul E v T E m U- O C N 4- O N u Ln L, co Ln 0 V) N m E cca G v LL x O 0 AA '' �W V .0 O � O � N � M � O v O � N -0 O V •� N � buo = V O E N CD �s tA N of W O L T v .Q v � 0 N v � � iA Q LO 0 `O `O W @ '' CL bO a bD LL. ai O J C: L.L �_ N t 0 E O a U siossaals ajil O Ezi Oi C w cc a N O c v 0 Q v LO v 0 a r3 0 Q a, co au E aJ � m LL Ln .41 tw to 0 en 0 0 0 N c-i (/) sluapa:)ad appinS jo uoilaodoad ow- Un —00Lniri d ''T (m(Y)(NNNe--c---_--<-.---N(N N Ln If z S9 Ln r j a) N (Y) M (Y) O r- d' (N Qu v Q) CE LID6a `0 u O a a) C rcs O O Q) C b0 u Y3 C O O> O Q) c/1 ® 'u O n L � u v Q) (n p > _ u_ C .� w QJ ® v) C -0 M .� c� e6 O u C m u � b�l V i� u N L O c O O B -q m uw to Q) i-0 � C QJ c: E C m O 0) C 2-0 -0 bA ,v J C u C 4. u® E C �- _0 C C C C o ro W -p r6 r6 C QJ ate, O Q C C a (Q Q1 V B l/1 ® Of � O a' Q •— C O' 0 f°„ V Q)j C Q ro v n Q p v C Qul Q)C o� C O LJ N O .a c- u ea Q) •N v c y O C O N ® O p O LJV1a- LLo co ¢ma-u<uu._a_ui 0 >, 0 i 0 v cc Q N O c v 0 c 0 n, O ci u 0 0 Ln C3 a Q cn _0 4-J 4-J Ul 0 u aj Ln 0 u < tA 0) _0 C: ce :3 0 0 OEM u :3 tA th OEM% tWo 4-j V) a) C) C w r IN .IS Rl I �w � � 0 M 0 6p VI I 1-R P !I 9 t�1 Suicide in Deschutes County 2000-2017 Trends, Risk Factors, and Recommendations The following data represent actual deaths by suicide within Deschutes County. These statistics have been portrayed with anonymity in order to protect the identities of the individuals and their families. One death by suicide is one death too many. Deaths by suicide are circumstantial to each individual, often leaving loved ones questioning 'why?' However, these questions may never be fully answered, as often the deceased take the answers with them. It is important to note that death by suicide is not uni- causal. Rather, it can be influenced by the risk factors present and the protective factors not present. Because of this, we aim to mitigate the prevalence of suicide within Deschutes County by using comprehensive, evidence -based suicide prevention practices. It is of the utmost importance to acknowledge those who have lost a loved one to suicide in Deschutes County. This report serves as one of the records of that loss. Deschutes County Health Services intends that this report can be used as a source of hope —because with data comes better -informed solutions for preventing suicide. Acknowledgements Deschutes County Health Services would like to express immense gratitude to the hard-working state and local professionals who respond to and investigate violent deaths, to the teachers, coaches and mentors who engage our young people and to the staff and volunteers who give expertise, passion and soul to saving lives. A large shout out to the leadership and technical assistance of Lane County Health and Human Services, which helped to make this report possible. Thank you to the Oregon Health Authority, who creates and maintains the data sources in regards to violent death and helps provide statewide support and leadership. Suggested Citation Schumacher, W., Bailey, K., & Brewin, C. (2020). Suicide in Deschutes County: Trends, Risk Factors, and Recommendations 2000-2017. Deschutes County Health Services, Deschutes County, OR. Suicide Prevention Program Contact: Whitney Schumacher, MPH, Suicide Prevention Coordinator, Deschutes County Health Services, whitney.schumacher@deschutes.org Deschutes County Health Services Public Health Service Area — Prevention Program 1130 NW Harriman Street, Bend, OR 97708 www.deschutes.org/suicideprevention Deschutes County Health Services September 2020 TABLE OF CONTENTS Executive Summary 4 Key Findings 4 Recommendations 5 Introduction 9 Why do People Die by Suicide? 9 How Do We Prevent Suicide? 11 Methods 13 Analytical Findings 16 Prevalence and Incidence of Death by Suicide in Deschutes County (2000-2017) 16 Circumstances and Characteristics of Suicide in Deschutes County (2003-2017) 20 Demographic Characteristics 20 Mental Health and Substance Abuse 22 Interpersonal Problems and Life Stressors 26 Mechanism of Death 29 Toxicology Results 31 Occupation of Decedents 32 Place of Death 33 Geospatial Analysis 35 Discussion and Recommendations 37 General Public 37 Businesses 38 Media 39 Primary Care 39 Behavioral Health and Other Social Services 40 Schools 41 Substance Abuse 42 Higher Risk Populations 42 Lethal Means 44 Regional Disparities within Deschutes County 45 Suicide Prevention Resources 46 Appendix — Tables for Select Populations 47 Veterans 47 Children, Adolescents, and Young Adults (524) 50 Adults (25-44) 52 Middle Aged Adults (45-64) 54 Older Adults (65+) 56 Deschutes County Health Services September 2020 3 EXECUTIVE SUMMARY Suicide is a complex public health issue that has a ripple effect across communities. There is no single cause; therefore a comprehensive, data -driven approach is required to prevent suicide. The approach must be one that not only uses data, but also one that leans on community partnerships and the power of Collective Impact. This report presents the first analysis of suicide mortality in Deschutes County and provides recommendations to help prevent suicide. Key Findings "rends and Demographics Between the years 2000 and 2017, 534 people died by suicide in Deschutes County. In 2017, on average, one person died by suicide every week in Deschutes County. The vast majority of suicide deaths occurred among men —about 76% (N=393). Deaths by men exceed deaths by women every year of the report period, which is consistent with state and national trends. As men aged, the rate of suicide increased, with the highest suicide rate occurring among men 65 years of age and older. For women, the suicide rate increased until the 45-64 age range. The majority of suicide decedents were married, in a civil union, or domestic partnership. Suicide decedents were more likely to have a Bachelor's Degree or greater. One -fifth of suicide decedents were Veterans. Dental Health and Substance Abase Approximately 43% (N=228) of all decedents had a mental health problem, meaning they were diagnosed or demonstrated unambiguous evidence of a diagnosable mental illness and/or substance abuse disorder preceding their death. Nearly one-third of all suicide decedents were engaged in current mental illness treatment at the time of death (N=179, 34.1%) with 52.2% of these decedents being female and 28% male. One-third of all suicide decedents had a problem with any substance use at the time of death, (N=175, 33.3%); the proportion of females and males was similar, 34.1% (N=45) and 33.1% (N=130) respectively. Females were less likely to disclose intent to die by suicide when compared to males, 30.3% and 35.6% respectively. interpersonal Problems and Life Steessors The interpersonal problem that affected the most Deschutes County suicide decedents was an intimate partner problem (N=161, 30.7%); meaning that problems with a current or former intimate partner appear to have contributed to the death. Male suicide decedents experienced an intimate partner problem that contributed to their death 20% more than female decedents (32.3% vs 25.8%). The life stressor that affected the most Deschutes County suicide decedents was a financial problem (N=193, 36.8%); meaning a financial hardship appears to be a contributing factor to the death. Female suicide decedents experienced a financial stressor 21% more than male decedents (42.4% vs 34.9%). Deschutes County Health Services September 2020 Mechanism of Death Lethal means varied among suicide decedents in Deschutes County, however over half of all decedents used a firearm (N=298, 56.8%). Nearly one -fifth of suicide decedents died by poisoning. Among suicide decedents that died by poisoning, prescription drugs was the most -used substance (N=57, 56.4%), followed by carbon monoxide (N=24, 23.8%). occupation of Decedents During the report period, occupations among decedents varied greatly. Nearly a quarter (24.5%, N=129) of all decedents were not actively participating in the workforce at the time of death ("Not Currently in Workforce"); this includes individuals that were retired, unemployed, or a homemaker. The occupation with the highest number of suicide decedents was "Construction" (12.4%, N=65). Place of Death A vast majority of suicide deaths during the report period occurred in a decedents home (68.1%, N=358), demonstrating the critical need for family, friends, and loved ones of those at risk for suicide to be aware of suicide warning signs and how to effectively intervene and refer the person at risk to appropriate resources. Geographic Distribution Deschutes County's age -adjusted suicide rate is 25.3 deaths per 100,000 people. Nearly 61% of suicide deaths during the study period occurred in Bend (N=318). The age -adjusted rate of suicide in Bend was higher than the rate for Deschutes County as a whole with 32.1 deaths (SMR: 1.4; 95% CI=1.3-1.6) per 100,000 people. Redmond's age -adjusted suicide rate was 26 deaths (SMR: 1.2; 95% CI=0.9-1.4) per 100.000 people. All other Deschutes County Areas Combined includes rural areas, which had a lower age -adjusted suicide rate than the suburban and urban areas in Deschutes County-15.9 deaths (SMR 0.7; 95% CI=0.6-0.9). special Populations One in five deaths by suicide in Deschutes County occurred among veterans (19.7%, N=103). Although not analyzed in the current report, lesbian, gay, bisexual, transgender, and questioning (LGBTQ+) youth and Alaskan Natives/American Indians of all ages are known to experience increased risk of suicide in the United States. Recommendations The following recommendations are based on evidence -based constructs for developing a comprehensive approach to suicide prevention as well as key findings from this report. It is important to note that a successful suicide prevention approach requires consistent leadership and coordination. The Deschutes County Suicide Prevention Program includes a braided funding model, which shows strong collaboration across the Deschutes County Health Services agency. Moreover, the braided funding model leaves staff responding to multiple funder requirements and focused on resource development and maintenance at the expense of program implementation. Adequate financial support to maintain program staff is imperative for decreasing the rate of suicide attempts and deaths in Deschutes County. Deschutes County Health Services September 2020 General Public The majority of suicide deaths in Deschutes County occur in the home, and over 50% of suicides are completed by firearm, all firearm owners and their loved ones are urged to practice collaborative firearm safety in order to create a protective environment for those at risk of suicide. The general public needs important knowledge, training, and skills on how to recognize suicide warning signs, how to ask someone about suicidal intent, and how to connect someone to appropriate, professional help. Therefore, it is recommended for continual maintenance of funding and capacity to offer evidence - based trainings in Deschutes County, such as Question. Persuade. Refer. (QPR), Mental Health First Aid, and Applied Suicide Intervention Skills Training (ASIST), and Counseling on Access to Lethal Means (CAMS). In addition to increasing knowledge and skills for suicide prevention in the general public, it is important to increase general awareness around suicide prevention resources in Deschutes County. Businesses The occupation with the highest number of suicide decedents in Deschutes County is the construction industry (12.4%, N=65). Efforts should be made to engage with local construction companies to implement suicide prevention policies and protocols as it relates to occupational health and safety. Given that nearly a quarter (24.5%, N=129) of decedents were not engaged in the workforce, efforts should be made to engage with unemployment agencies to implement suicide prevention policies and protocols. All businesses in Deschutes County are encouraged to follow the U.S. Surgeon General's National Strategy for Suicide Prevention, specifically, the goals and objectives outlined for workplaces as well as implementing appropriate suicide prevention protocols when employees are fired, laid -off, and when employees resign. It is understood that nationally, a majority of suicide decedents have visited a primary care physician within one year, and one -fifth of decedents within one month, preceding death. During the report period every one in 5 Deschutes County suicide decedents had a physical health problem, showing a strong case that primary care settings have an important role in suicide prevention. Further, clinic settings are a critical component toward facilitating patient connection to behavioral health. It is recommended that primary care clinics adopt Zero Suicide, which is a model that guides health care organizations through systems -wide transformations change toward safer suicide care. The Zero Suicide model, coupled with the locally developed Primary Care Toolkit provides practices for addressing at -risk patients. Further, it is also recommended that collaboration between primary care and specialty behavioral health care continue to be strengthened in the Central Oregon region through the Advancing Integrated Care (AIC) project, which is a project of the Regional Health Improvement Plan and the Central Oregon Health Council. Behavioral Health and Other Social Services A majority decedents with a known mental health problem were engaged in mental illness treatment (78.1%); it is imperative to note however, that when an individual dies by suicide, it is no one's fault, including a behavioral health provider. Behavioral health providers and other social service providers, who have not already done so, should engage in training around screening and managing suicide care. Multiple suicide screening tools exist, and many entities in Deschutes County have already implemented the Columbia Suicide Severity Risk Scale (C-SSRS); a tool that is also supported by the Substance Abuse and Mental Health Services Administration. Training in using the C-SSRS is available at no cost online and personalized trainings can also be requested. Clinical behavioral health clinicians are encouraged to Deschutes County Health Services September 2020 engage in various suicide -care trainings, such as Collaborative Assessment and Management of Suicidality or Assessing and Managing Suicide Risk. Further, it is recommended that providers use effective, strengths -based safety planning with people at risk for suicide, such as the Stanley and Brown Safety Planning Intervention. Schools During the report period, the youth suicide rate in Deschutes County nearly doubled. Schools play an integral role in helping prevent youth suicide. Because suicide is a complex public health issue, it is not schools' responsibility alone to prevent youth suicide. It is recommended that Deschutes County School Districts continue to strengthen their comprehensive approach to youth suicide prevention that includes collaboration with, and connection to, community -wide suicide prevention efforts. A comprehensive approach should include suicide prevention, intervention, and postvention strategies that not only target students, but also parents, staff, and administrators. Further, a comprehensive approach should include strategies that span beyond knowledge attainment and awareness raising. In other words, suicide prevention curricula or mental health awareness days alone are not sufficient. Skill -building, care coordination, and policy, systems, and environmental change strategies should also be incorporated into a compressive approach to prevent youth suicide. Not only is a comprehensive approach to preventing youth suicide evidence -based, but it also mandated by Oregon law. It is recommended that Deschutes County school districts collaborate with one another as well as Deschutes County Health Services in order to comply with Senate Bill 485, Senate Bill 52, as well as the Student Success Act. Substance Abuse Given that increased substance use is a warning sign for suicide, it is imperative that behavioral health professionals that treat individuals experiencing substance use disorders be trained in screening and t—oting ciiiridaii+„ in clients This is nnrticularly important for people at risk of relapse or those who have relapsed after a period of sobriety. Multiple suicide screening tools exist, and many entities in Deschutes County have already implemented the Columbia Suicide Severity Risk Scale (C-SSRS); a tool that is also supported by the Substance Abuse and Mental Health Services Administration. Training in using the C-SSRS is available at no cost online and personalized trainings can also be requested. Higher Risk Populations Over three-quarters of all suicides in Deschutes County occurred among men; further, the occupation with the largest proportion of suicide decedents was the construction occupation, which is a male - dominated industry. It is recommended that behavioral health professionals find culturally relevant ways to engage men in services through targeted outreach and partnerships with industries that primarily employ men. Further, the report also shows that males are more likely to use firearms than females for dying by suicide, therefore it is recommended that mental health promotion and suicide prevention professionals in Deschutes County engage with local firearm retailers in order to promote and normalize mental health resources. Veteran suicide decedents accounted for one -fifth of all suicides during the reporting period. Given that veterans are engaged in a wide variety of sectors in Deschutes County, it is recommended that all suicide prevention efforts include culturally responsive components to reach veterans. Further, because there is a wide variety of veteran -serving organizations in Deschutes County, it is also recommended that a unified veteran suicide prevention taskforce emerge in order to coordinate efforts and provide resource mapping in order to ensure equitable access to resources for all veterans in Deschutes County. Deschutes County Health Services September 2020 In the United States, people who identify as American Indian/Alaskan Native (AI/NA) have the highest suicide rate compared to the general population and other racial and ethnic subpopulations. Medical, behavioral health, and other social service providers are encouraged to develop and adopt culturally responsive, evidence -based and tribal practices to support people who identify as AI/NA at risk for suicide. National research shows that young people who identify as LGBTQ+ have higher rates of suicide ideation and attempts than the general population. This disparity also exists in the state of Oregon; young people who identify as LGBTQ+ have reported significantly higher rates of contemplating suicide in the last 12 months than students who identified as straight. Medical, behavioral health, and other social services providers should be aware of these disparities and also integrate culturally responsive practices to meet the needs of LGBTQ+ youth at risk for suicide. Further, youth -serving organizations, including schools, should ensure that safe environments are being fostered for students of all identities, especially those that identify as LGBTQ+, to feel safe, welcomed and supported. Lethal Means It is recommended that safe storage efforts be implemented and expanded widely in Deschutes County. This should include a combination of evidence -based approaches, including community awareness campaigns around safe storage, engaging with firearm retailers on training, and increasing access to safe storage means. Safe storage efforts should include approaches for firearms as well as prescription medications, as these were the most -used means for suicide decedents in Deschutes County. Further, it is recommended that there be increased collaboration between suicide prevention and substance abuse prevention efforts to ensure continuity of efforts and cross -promotion. Regional Disparities Geospatial analysis in this report shows that the city of Bend's age -adjusted suicide rate higher than all other cities in Deschutes County as well as the total County rate. It is important to remember that each city in Deschutes County is unique and therefore a one -size -fits -all approach to suicide prevention in Deschutes County will be ineffective. In order to appropriately and effectively prevent suicide in Deschutes County, it is imperative to target specific suicide prevention approaches culturally relevant to the Bend area as well as additional culturally relevant approaches for Redmond and the other rural areas of Deschutes County. Authentic engagement in community organizations and residents from throughout Deschutes County is vital. It is recommended that Deschutes County staff work to engage more community partners and organizations in the Central Oregon Suicide Prevention Alliance. Deschutes County Health Services September 2020 8 INTRODUCTION Suicide is a leading public health concern across the globe that affects people of all identities and backgrounds. Over 800,000 people die by suicide each year globally.' In the United States alone, suicide is rated as the tenth leading cause of death? Research suggests that 1.4 million adults reported a past attempt of suicide nationwide, and 4% of U.S. adults, approximately 9.8 million people, seriously considered taking their own life.' Over 160,000 Oregon adults above the age of 25 have reported having serious thoughts of suicide; and over the past three decades, Oregon has had a higher than average rate of suicide when compared with national data.',4 The Centers for Disease Control and Prevention has found that the state of Oregon has the 15th highest suicide rate in the nations Additionally, the rate of hospitalizations from suicide attempts among children and adolescents in Oregon was greater than adults, with 75.2 attempts/injuries per 100,000 people.6 Why do People We by Suicide? interpersonal Psychological Theory of Suicide Comprehensive suicide prevention is key to mitigating the increasingly high rates of suicide across the globe. Suicide can be premediated, giving health professionals a calculated window of time, to act and J a + h« f life. Th'o L..��.�w.00 harderfor cases that are �f an imnnlcivo intervene, In order to prevent a rdJJ or nrc. -his becomes aide .,pulcivi - ' World Health Organization. (2019, September). Suicide. Retrieved November26, 2019, from https://www.who.int/news-room/fact-sheets/detail/suicide. 2 National Institute of Mental Health. (2019). Suicide. Retrieved November 26, 2019, from https://www.n i mh.nih.gov/health/statistics/suicide.shtm I#part_154968. ' Center for Behavioral Health Statistics and Quality. (2017). 2016 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD. 4 Drapeau, C. W., and McIntosh, J. L. (for the American Association of Suicidology). (2017). U.S.A. suicide 2016: Official final data. Washington, DC: American Association of Suicidology, dated December 24, 2017, downloaded from http://www.suicidology.org. 5 Center for Disease Control and Prevention. (2019, January 10). Stats of the State - Suicide Mortality. Retrieved December 10, 2019, from https://www.cdc.gov/nchs/pressroom/sosmap/suicide-mortality/suicide.htm. 6 Oregon Health Authority. (2015). Youth Suicide Annual Report. http://www.oregon.gov/oha/PH/PREVENTI0NWELLNESS/SAFELIVING/SUIClDEPREVEN TION/Documents/youth- suicide-annual-report.pdf. Accessed on Feb 21, 2018. Deschutes County Health Services September 2020 nature. Because of this, a comprehensive approach to suicide prevention is vital, which must include policy, education, and environmental systems change. According to the Interpersonal Theory of .Suicide, suicidal desire relates to the interplay of two interpersonal constructs, 7 The constructs of thwarted belongingness and perceived burdensomeness can drive an individual to contemplate suicide.7 IfVhen these constructs are paired with the capability/means to engage in suicidal behavior, there rrray be a stronger desire to do so.7 This Interpersonal Theory of .Suicide explains that when the capobility for suicidal behavior emerges, it is often derived from deeply rooted traumatic experiences, which impact daily thought processes and overall mental health. I Interpersonal Psychological Theory of Suicide' Lethal (or near lethal) Suicide Attempts Risk and Protective Factors of Suicide Risk and protective factors aid in understanding the likelihood of individuals' behaviors or health outcomes. It should be noted that risk and protective factors offer a way of understanding likelihood, however is not wholly predictive of an individual's behaviors or health outcomes. Risk and protective factors can be biological, psychological, familial, communal or culturwal factors that the individual has present in their lives.° Risk factors are the characteristics of an individual that are associated with a higher prevalence of poorer health outcomes; meaning in terms of suicide, could make it more likely for individuals to consider or attempt suicide.' Alternatively, protective factors are the characteristics that are associated with a higher prevalence of positive health outcomes for the individual; meaning in terms of suicide prevention, make it less likely for individuals to consider or attempt suicide.' Risk and protective factors can be both fixed and variable; the variable factors are subject to change, such as socioeconomic status, employment status, or social circles. Fixed factors do not change, such as genetic predisposition and family history.' Some risk factors that are commonly associated with a higher risk for suicide include; a previous suicide attempt, violence victimization, violence perpetration, and substance abuse. Conversely, some protective factors that are associated with a lower risk for suicide include; perceived social connectedness, access to effective behavioral health care, and a sense of purpose in life.1OSuicide prevention efforts that target a combination of risk or protective factors are more likely to have positive outcomes than compared to addressing a single factor alone.' When more protective factors are present than risk factors, the population is more likely to have a lower rate of deaths by suicide. ' Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E., Jr (2010). The interpersonal psychological theory of suicide. Psychological review, 117(2), 575-600. doi:10.1037/a0018697 8 Substance Abuse and Mental Health Services Administration. (n.d.). Risk and Protective Factors, 1-4. Retrieved from https://www.samhsa.gov/sites/default/files/20190718-samhsa-risk-protective-factors.pdf Deschutes County Health Services September 2020 10 Preventing suicide in a community is no single entity's responsibility; rather, an effective, comprehensive approach to preventing suicide requires targeting efforts at multiple levels of a community and also harnessing the collective impact of community stakeholders. The Social Ecological Model helps communities organize where to target efforts and the Collective Impact Framework provides a road map on achieving efforts. Preventing suicide requires multiple efforts beyond the behavioral health sector. Everyone in a community has a role in helping to prevent suicide. The Social Ecological Model Using a singular approach will not effectively prevent suicide community, therefore a framework is needed in order to organize and align multiple strategies. A central tenant of the Social Ecological Model (SEM) is that all levels of influence are important. Meaning multilevel interventions generally should be more effective than single -level interventions. The SEM is an appropriate and effective framework to use in preventing suicide by addressing associated individual, relationship, community, and societal factors. The individual level of the SEM includes demographic, Le_1__•__1 J holo -ical IaCtOrs hick affect like UIUIU�Itrdl, aflU �JJyl.11VIVS�LtlI IQ�.IVIJ VVIIIL.11 �.ait a11e�.L LIIG t, of a person dying by suicide, such as age, mental health statub, VI physical health status.' The relational level of the SEM focuses on interactions between people —such family, friends, or co-workers and how those interactions can either increase, or decrease, the risk of suicide.' The community level considers factors such as physical environment, organizational policies, or school -based policies that can affect the risk of suicide for individuals.' Lastly, the societal level of the SEM addresses large-scale factors that affect every individual in a society, such as stigma associated with talking about suicide, discouragement of help -seeking behavior, or laws and policies that affect the availability of heath care services.' The Collective Impact Framework The Collective Impact Framework, according to the Stanford Innovation Review, is premised on the belief that no single entity alone can solve complex social problems.10 Suicide is a complex public health issue that requires stakeholders within a community to lean on each other's strengths to carry forward a message of hope for the many resources and evidence -based practices that can exist within a community. The Collective Impact Framework provides a roadmap for communities to systematically work together to ensure that growing needs are met and that each entity involved owns a piece of the B J.F. Sallis, R.B. Cervero, W. Ascher, K.A. Henderson, M. K. Kraft, and J. Kerr (2006). An Ecological Approach to Creating Active Living Communities. Annual Review of Public Health, 27, 297-322. io Kania, J. and Kramer, M. (2011). Collective Impact. Stanford Social Innovation Review Deschutes County Health Services September 2020 11 work. The five pillars of the Collective Impact Framework include a common agenda, shared measurement, mutually reinforcing activities, continuous communication, and a backbone organization. The 5 Conditions of Collective Impact Kania, J. and Kramer, M. (2011). Collective Impact. Stanford Social Innovation Review The Current Report To date, there has been no comprehensive analysis of deaths by suicide and associated risk factors in Deschutes County. The purpose of this report is to describe the occurrence and risk factors related to suicide in Deschutes County, Oregon from 2000 to 2017. The work of this report has been done to inform the development of actionable recommendations for all members of our community including policy makers, healthcare professionals, social services, educators, and the general public. Despite the focus of this report being on the public health issue of suicide, it is the aim of Deschutes County Health Services that it can serve as a source of hope for those affected by suicide in our community, guidance for those working with those at risk, and awareness of this public health issue for those who may not be familiar with the burden of suicide in our community. We all can help prevent suicide —the information shared in this report can help in this cause. Deschutes County Health Services September 2020 12 METHODS This report is largely exploratory and therefore was not guided by any a priori hypotheses. All variables in the data sources were explored and included in the current study based on several criteria including data quality, relevance, and statistical reliability. Following exploratory analysis, hypotheses were generated and tested when relevant for the creation of actionable recommendations to prevent suicide in Deschutes County. Data related to suicide prevalence and incidence in the U.S., Oregon, and Deschutes County from 2000 to 2017 come from national, state, and county -level vital statistics. Direct age -adjustment was used to calculate all rates using the population weights calculated from the 2000 U.S. Census. When comparing rates, the authors used 95% confidence intervals (95% CI) to estimate variability. The rates associated with 95% Cl's that do not overlap between populations are considered significantly different at the a = 0.05 level. Because suicide is statistically a rare event in an area with the size and population of Deschutes County, many findings reported in this report are meaningful, however may not be statistically significant. The authors chose to report these findings nonetheless when informative to prevention efforts and when they were consistent with statistically reliable state and national findings. Findings related to the characteristics of the decedents and circumstances before the decedent's death come from the Oregon Violent Death Reporting System (OVDRS) 2000 to 2017 data file. The OVDRS is part of the National Violent Death Reporting System (NVDRS) administered by the Centers for Disease Control (CDC). The OVDRS collects incident -based information on all violent deaths that occur in the state including homicides, suicides, deaths of undetermined intent, deaths resulting from legal intervention, and deaths related to unintentional firearm injuries.11 Data is abstracted and coded from a variety of sources including medical examiner and law enforcement reports, death certificates, and child fatality review reports to build this information system. In this report, the OVDRS data are presented primarily in tabular format displaying counts and percentages indicated for each variable. Cells with counts of less than 5 are suppressed or combined with other more generalized variables when necessary in accordance with the "5 and 50" rule for reporting on small numbers in health information.12 This was done in an effort to limit identifiability of the decedents and is noted in each table when applied. This section of analysis is primarily descriptive and therefore no specific statistical tests were used; however general comparisons between sexes and comparisons to state and national data were made. Further information on both the NVDRS and the OVDRS can be found at https:www.cdc.gov/ViolencePrevention/NVDRS/. 11 Centers for Disease Control and Prevention. National Violent Death Reporting System (NVDRS) Coding Manual Revised [Online]2016. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (producer). Available from URL: www.cdc.gov/injury. 12 Wasserman, C., and Ossiander, E. (2018). Department of Health Agency Standards for Reporting Data with Small Numbers (pp. 1-24)(United States, Washington State Department of health, Assessment Operations Group). WA. Deschutes County Health Services September 2020 13 Geo-spatial findings were calculated from the OVDRS 2003-2017 data file. Standardized Mortality Ratios (SMR) were estimated using direct age -adjustment to account for fewer deaths occurring in some age categories in regional communities compared to Deschutes County as a whole. As a result, the age - adjusted rates of death by suicide in this section are not comparable to rates published in the preceding sections using direct age -adjustment. 95% Ci's were calculated and reported as an estimate of variability. The SMR's associated with 95% Ci's that do not overlap between populations are considered statistically significantly different at the a = 0.05 level. Communities outside of Bend and Redmond were combined due to concerns about estimate stability and the identifiability of decedents in smaller communities. Aggregate totals of death by suicide differ in the OVDRS data compared to Vital Statistics Data between 2003 to 2017. This discrepancy is due primarily to the differing inclusion criteria used in both analyses. Vital statistics death counts are based on county of residence while the OVDRS death counts are based on a county in which the death occurred. The authors of the current report chose to use the same inclusion criteria for three reasons: 1) the decedent may have resided in Deschutes County for a significant period of time, but did not officially establish residency, 2) regardless of residency status their death inevitably affects the Deschutes County population and must be considered in terms of public health impact, and 3) the difference represents a total of 9 deaths over the entire report period. Regardless of the data source in this report, death by suicide for all analyses is defined as a death resulting from the intentional use of force against oneself. These deaths were identified according to codes by the International Classification of Diseases, Ninth and Tenth Revision (ICD-9/10) for the underlying cause of death recorded on death certificates. The specific codes used to identify these deaths by suicide include E950-E959 (ICD-9) and X60-84 and y87.0 (ICD-10). People who die by physician assisted suicide (the Death with Dignity Act) are not classified as suicides in the state of Oregon and are therefore excluded from analysis. Several variables were coded manually from the OVDRS data file including the decedent's normal occupation, select mental health diagnoses, and the substances that caused poisoning deaths. This strategy was chosen in favor of computer -guided word -matching due to the extreme variety of entry terms related to these variables in OVDRS. Occupational coding is based on the description of the decedents' normal occupation and field of industry on death certificates and was coded according to the Bureau of Labor Statistics Standard Occupational Categories.13 Mental health diagnoses coded as "other" with a corresponding text entry in the raw OVDRS data file were manually coded and placed into existing categories identified in the OVDRS data file where possible. Categories were created for additional mental health diagnoses that exceeded the reportable threshold identified by the "5 and 50" rule and were known to be associated with suicide i.e. borderline personality disorder. Substances that caused poisoning deaths were classified generally as prescription drugs, over-the-counter drugs, carbon monoxide, street/recreational drugs, or some other poison if they were identified as either the primary, secondary, tertiary, or quaternary cause of death. This categorization was chosen to maintain alignment 13 Standard occupational classification manual. (2018). Washington, DC: Executive Office of the President Office of Management and Budget. Deschutes County Health Services September 2020 14 with the Oregon Health Authority's published materials on suicide deaths caused by poisoning using OVDRS data.14 As a final note of caution, although the OVDRS collects a robust amount of information from multiple sources, that information may be inherently biased or contain omissions. There are numerous points of influence that may cause a lack of standardization. Medical Examiners and Law Enforcement officials do not use a standard set of questionnaires or investigation protocols as unique circumstances may determine the course of any investigation. Witnesses, family members, loved ones, and friends may not know, omit, or provide inaccurate information in their reporting on circumstances related to the death or the characteristics of the decedent. Therefore, this report likely underestimates some circumstances related to each death or decedent characteristics. During the analysis conducted for this report, the authors of the current report compared the findings presented here with state and national findings from the NVDRS, OVDRS, and other data sources when appropriate for consistency with expected values. 14 Shen X, Millet L. Suicides in Oregon: Trends and Associated Factors. 2003-2012. Oregon Health Authority, Portland, Oregon. Deschutes County Health Services September 2020 15 ANALYTICAL FINDINGS Prevalence nd Incidence of Death by Suicide in Deschutes t County 7 Between the years 2000 and 2017, 534 people died by suicide in Deschutes County (Table 1). In any given year, this represents approximately 0.02% of the Deschutes County population. The vast majority of suicide deaths occurred among men —about 76% (N=393). Deaths by men exceeded deaths by women every year of the report period, which is consistent with state and national trends. 15 In 2017, on average, one person died by suicide every week in Deschutes County. Table 1: Suicide Mortality by Sex, Deschutes County, OR 2000 - 2017 Year Females Males Total 2000 * * 13 2001 * * 20 2002 * * 24 2003 5 15 20 2004 7 17 24 2005 * * 23 2006 8 19 27 2007 7 21 28 2008 11 24 35 2009 5 20 25 2010 8 32 40 2011 7 25 32 2012 9 25 34 2013 5 20 25 2014 8 32 40 2015 11 23 34 2016 9 24 33 2017 16 41 57 Total 534 Source: Oregon Public Health Assessment Tool *Suppressed 15 Centers for Disease Control and Prevention. CDC Wonder. http://wonder.cdc.og/. February 2020. Deschutes County Health Services September 2020 16 Graph 1 represents the number of suicides in Deschutes County, categorized by the sex of the individual. While age groups differed significantly, the proportions of deaths were consistent between the ages of 0-64. Proportions were calculated by the total number of deaths for each sex, divided by the number of total deaths per category. In each age category, females ranged between 21% to 29% of the total deaths, whereas males ranged between 71% to 79% of the total deaths. Twenty-seven individuals 17 years of age and younger died by suicide during the reporting period (Graph 1). Thirty-eight young adults between the ages of 18 to 24 died by suicide during the study period. From 2000 to 2017 the majority of suicides (68.5%) occurred among adults ages 25-64 (N=366). The demographic with the highest number of suicide deaths occurred among men between the ages of 45-64, whom accounted for approximately 26% of all suicide deaths during the study period. These findings are consistent with the distribution of suicide among these ages and sex categories in Oregon and the United States.15 Graph 1: Suicide Deaths by Age and Sex, Deschutes County, OR, 2000-2017 25-44 45-64 Age in Years Data Source: Oregon Public Health Assessment Tool Graph 2 compares the national, state and county rates of suicide by year. The United States had a significantly lower rate of suicide than both the state of Oregon and Deschutes County. The national trend increased from 2001 to 2017. Meanwhile, the rate of suicides in Oregon were higher than the national average for the entire report period. Overall, Deschutes County had higher suicide rates than the state of Oregon throughout the report period, with the exception of the years 2003, 2009 and 2013. Most notably, Deschutes County's highest suicide rate occurred 11 in 2017; 29 deaths per 100,000 people. Deschutes County Health Services September 2020 17 r 25 L aJ a w 20 0. 0 a) c 15 0 0 0 10 L a, 0. = 5 co ar 0 Graph 2: Age -Adjusted Suicide Rates in Deschutes County, Oregon, and the United States, 2001-2017 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year Data Source: Oregon Public Health Assessment Tool a Deschutes County Oregon �United States Graph 3 compares Deschutes County's age -adjusted suicide rates by sex and year. Deschutes County males had a significantly higher age -adjusted suicide rate than females during the entire report period. Rates for both sexes in Deschutes County increased from 2000 to 2017. The highest age -adjusted suicide rate for Deschutes County males was 42.1 deaths per 100,000 people in 2017. The highest age -adjusted suicide rate for Deschutes County females was 16.3 deaths per 100,000 people in 2017. The highest age - adjusted suicide rate overall in Deschutes County was 29.0 deaths per 100,000 people in 2017. 50 m a) 40 n a) Q. w 30 a 0 0 0 0 20 Q t 10 Graph 3: Age -Adjusted Suicide Rate by Sex, Deschutes County, OR, 2000-2017 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Years Data Source: Oregon Public Health Assessment Tool Female Male --- Total Deschutes County Health Services September 2020 18 Graph 4 compares the suicide rate by sex and age in Deschutes County. The suicide rate amongst males increased as they aged. The lowest male suicide rate of 7.7 deaths per 100,000 people occurred in those aged 24 years and younger while the highest male suicide rate of 61.9 deaths per 100,000 people occurred in those aged 65 years and older. The suicide rate amongst females increased up to the 45-64 age range-14.1 deaths per 100,000 people. The lowest female suicide rate in Deschutes County occurred in those aged 24 years and younger with 2.4 deaths per 100,000 people. L v T aa) 0. a, a 0 a, 0. 0 0 0 0 0 L d a s m ai C 70 60 50 Graph 4: Suicide Rate by Sex and Age, Deschutes County, OR, 2000-2017 Aee in Years Data Source: Oregon Public Health Assessment Tool 45-64 65+ ® Female Male Total Graph 5 compares the suicide rate by age in 3-year increments in Deschutes County. The suicide rate amongst decedents 24 years of age and younger nearly doubled in the report period; from 6.1 deaths per 100,000 people every three years during the 2000-2002 time period to 11.4 deaths per 100,000 people every three years during the 2015-2017 time period. The suicide rate amongst decedents 45-64 years of age also nearly doubled during the report period; from 14.5 deaths per 100,000 people every three years during the 2000-2002 time period to 29.8 deaths per 100,000 people every three years during the 2015-2017 time period. The suicide rate amongst individuals 25-44 years of age increased from 18.8 deaths per 100,000 people every three years during the 2000-2002 time period to 27.4 deaths per 100,000 people every three years during the 2015-2017 time period. Lastly, the suicide rate amongst decedents 65 years of age and older decreased in the report period; from 37.0 deaths per 100,000 people every three years during the 2000-2002 time period to 30.1 deaths per 100,000 people every three years during the 2015-2017 time period. Deschutes County Health Services September 2020 19 40 L m i 35 M 3� 30 v L 0- 25 LA c 0 y 20 a 0 0 15 0 0 10 a « 5 m d O 0 Graph 5: Suicide Death Rate by Age, Deschutes County, OR, 2000-2017 2000-2002 2003-2005 2006-2008 2009-2011 2012-2014 2015-2017 Years Data Source: Oregon Public Health Assessment Tool <_24 25-44 45-64 65+ Circumstances and Characteristics of Suicide 'in Deschutes County 200 -2017, Oregon VUent Death Reporting System Table 2 displays the demographic characteristics of suicide decedents in Deschutes County. Age, level of education, marital status, veteran status and homelessness status were examined at the time of death. Most individuals that died by suicide were reported to be between the ages of 45-64 (N=190). Overall the characteristics associated with higher number of suicide deaths included those with a Bachelor's Degree or Greater (N=250) and those who were married, in a civil union, or in a domestic partnership (N=174). Decedents with a Veteran status accounted for 103 of the total suicide deaths. Decedents who experienced homelessness at the time of death accounted for 8 suicide deaths. Data for select Deschutes County Health Services September 2020 20 populations, including Veterans and specific age groups, can be found in the Appendix under Tables for Select Populations. Table 2: Demographic Characteristics of Suicide Decedents, Deschutes County, OR 2003-2017 Females Males Total (N=132) (N=393) (N=525) Count % Count % Count % Age <17 * * * * 28 5.3 18-24 12 9.1 31 7.9 43 8.2 25 - 44 43 32.6 129 32.8 172 32.8 45 - 64 56 42.4 134 34.1 190 36.2 > 65 15 11.4 77 20.0 92 17.5 Education Less than High School 6 4.5 52 13.2 58 11.0 High School or GED 0 0 122 31.4 122 23.2 Some College or Associate's Degree 0 0 101 26.0 101 19.2 Bachelor's Degree or Greater 126 95.5 118 30.0 244 46.5 Marital Status Married/Civil Union/Domestic Partnership 47 35.6 127 32.3 174 33.1 Never Married 34 25.6 132 33.6 166 31.6 Widowed 11 8.3 27 6.9 38 7.2 Divorced 39 29.5 101 26.0 140 26.7 Other/i raknown * * * * 7 1.3 Veteran Status * * * * 103 19.7 Homeless * * * * 8 1.5 Data Source: Oregon Violent Death Reporting System *Suppressed Education Status The majority female decedents (N=126, 95.5%) had a Bachelor's Degree or Greater during the report period. Among males, those with a high school diploma or GED had the highest proportion of suicide deaths (N=122, 31%), followed by a Bachelor's Degree or Greater, (N=118, 30%), Some College or Associate's Degree (N=101, 26%), and Less than High School (N=52, 13%). Marital .status Most females who died by suicide were married at the time of death (N=47). Married females accounted for approximately 36% of the total female deaths by suicide. This was followed by divorced (N=39, 30%), never married (N=34, 26%), and widowed (N=11, 8%). Most males in this category were never married, accounting for approximately 34% of the deaths (N=132). This was followed with males who were married (N=127, 32%), divorced (N=101, 26%), and widowed (N=27, 7%). Graph 6 displays marital status by sex for suicide decedents. Deschutes County Health Services September 2020 21 Graph 6: Marital Status of Suicide Decedents by Sex, Deschutes County, OR, 2003-2017 40 35 c 30 v a"i 25 0 20 0 Female .0 H 15 is Male 10 c 0 5 0 0 0 a Married/Civil Never Married Widowed Divorced Union/Domestic Partnership Marital Status Data Source: Oregon Violent Death Reporting System Table 3 describes circumstances related to mental health and substance abuse among suicide decedents in Deschutes County. Approximately 43% (N=228) of all decedents had a mental health problem, meaning they were diagnosed or demonstrated unambiguous evidence of a diagnosable mental illness and/or substance abuse disorder preceding their death, ("Mental Health Problem", Table 3). Disparities between female and male decedents with a mental health problem exist —the proportion of female decedents with that had a mental health problem was 40% greater than male decedents with a mental health problem (62.1% vs 37.2%). It should be noted, however, that this observed disparity may not represent a full picture of reality, as there could certainly be an underdiagnoses and differential expression of mental illness in men.16,1' Approximately 43% (N=228) of all decedents had a depressed mood at the time of death, meaning that the decedent was perceived by self or others to be depressed at the time of death. The proportion of female decedents who had a depressed mood at the time of death was 47.7% (N=63) and the 16 Martin, L. A., Neighbors, H. W., and Griffith, D. M. (2013). The Experience of Symptoms of Depression in Men vs Women. JAMA Psychiatry, 70(10), 1100. 1' Nadeau, M. M., Balsan, M. J., and Rochlen, A. B. (2016). Men's depression: Endorsed experiences and expressions. Psychology of Men and Masculinity, 17(4), 328-335. Deschutes County Health Services September 2020 22 proportion of male decedents was 42% (N=165). As stated before, the proportions may be underreported as there could be underdiagnoses and a differential expression of a depressed mood in men.16,17 Nearly one-third of all suicide decedents were engaged in current mental illness treatment at the time of death (N=179, 34.1%). The proportion of female decedents who were engaged in mental illness treatment at the time of death was 86% greater than males (52.2% vs 28.0%). Decedents with a history of mental illness treatment prior to death were similar to 'Current Mental Illness Treatment' proportions. One-third of all suicide decedents had a problem with any substance at the time of death, (N=175, 33.3%); the proportion of females and males was similar, 34.1% (N=45) and 33.1% (N=130) respectively. Nearly one -quarter of all suicide decedents had a problem with alcohol, meaning the decedent had an alcohol dependence or alcohol problem (N=137, 26.1%); the proportion of females and males was similar, 24.2% (N=32) and 26.7% (N=105) respectively. 16.4% of decedents had a problem with a substance other than alcohol ("Problem with Another Substance"), (N=86). Disparities exist between females and males regarding suicide related behaviors prior to death. The proportion of females with a history of suicide attempt was 99% greater than the proportion of males with a history of suicide attempt (27.3% vs 13.7%). The proportion of females with a history of suicidal thoughts was 71% greater than the proportion of males with a history of suicidal thoughts (17.4%vs 10.2%). Graph 7 displays suicide behaviors of decedents by sex. Table 3: Circumstances Related to Mental Health and Substance Abuse among Suicide Decedents, Deschutes County, OR 2003-2017 Females Males Total (N=132) (N=393) (N=525) Count % Count % Count % Mental Health Status Mental Health Problem 82 62.1 146 37.2 228 43.4 Depressed Mood at Time of Death 63 47.7 165 42.0 228 43.4 Current Mental Illness Treatment 69 52.2 110 28.0 179 34.1 History of Mental Illness Treatment 78 59.1 123 31.3 201 38.3 (including current treatment) Substance Abuse Problem with Any Substance 45 34.1 130 33.1 175 33.3 Problem with Alcohol 32 24.2 105 26.7 137 26.1 Problem with Another Substance 20 15.2 66 16.8 86 16.4 Suicidal Behaviors History of Suicide Attempt(s) 36 27.3 54 13.7 90 17.1 History of Suicidal Thoughts 23 17.4 40 10.2 63 12.0 Disclosed Intent to Die by Suicide 40 30.3 140 35.6 180 34.3 Data Source: Oregon Violent Death Reporting System Deschutes County Health Services September 2020 23 O 40 N a 35 a 30 C 25 �U H 20 0 c 15 0 0 10 a 0 5 a 0 Graph 7: Suicidal Behaviors of Decedents by Sex, Deschutes County, OR, 2003-2017 Disclosed Intent to Die by Suicide Suicidal Behavior Data Source: Oregon Violent Death Reporting System 0 Females Males Mental Health Diagnoses among Decedents with a dental Health Problem Table 4 shows mental health diagnoses among suicide decedents with a known mental health problem (N=228). Among the decedents with a known mental health problem, depression, anxiety, and bipolar dienrriar Xeiarn tha mnet rnmmnn rlinanncac Annrnximately 4 ntit of 5 nennle with n mental health problem were diagnosed with major depression or dysthymia (persistent, mild depression for two years or more) at some time in their life. The proportion of females with a history of depression was 97% greater than the proportion of males with a history of depression (91.5% vs 76%). Both females and males experienced an anxiety disorder at similar proportions, 12.2% and 13.7% respectively. The proportion of females with a history of bipolar disorder was 131% greater than the proportion of males with a history of bipolar disorder (26.8% vs 11.6%). Graph 8 displays mental health diagnoses data among suicide decedents with a known mental health problem. Approximately one-third of decedents with a known mental health problem also experienced a problem with a substance of any kind (N=83, 36.4%). Both females and males experienced a substance problem at similar proportions, 34.1% and 37.7% respectively. Nearly a quarter of all decedents with a known mental health problem had a problem with alcohol, meaning the decedent had an alcohol dependence or alcohol problem (N=61, 26.8%). The proportion of male decedents with a known mental health problem who also had a problem with alcohol was 22% greater than the proportion female decedents with a known mental health problem who also had a problem with alcohol (28.2% vs 23.2%). One out of five decedents with a known mental health problem also experienced a problem with a substance other than alcohol (N=47, 20.6%). Nearly 3 out of 4 decedents with a known mental health problem were engaged in mental illness treatment at the time of death (N=178, 78.1%). A higher proportion of females with a known mental health problem were engaged in treatment when compared to the proportion of males, 84.1% and Deschutes County Health Services September 2020 24 74.7% respectively. A vast majority of decedents with a known mental health problem had a history of mental illness treatment, 86% (N=178). Table 4: Mental Health Diagnoses Among Suicide Decedents with a Known Mental Health Problem", Deschutes County, OR 2003-201 7 Females Males Total (N=82) (N=146) (N=228) Count % Count % Count % Mental Health Diagnosis Depression/Dysthymia 75 91.5 ill 76.0 186 81.6 Anxiety Disorder 10 12.2 20 13.7 30 13.2 Bipolar Disorder 22 26.8 17 11.6 39 17.1 Post -Traumatic Stress Disorder * * * * 11 4.8 Schizophrenia * * * * 21 9.2 Attention Deficit Disorder * * * * 5 2.2 Substance Abuse Problem with Any Substance 28 34.1 55 37.7 83 36.4 Problem with Alcohol 19 23.2 42 28.2 61 26.8 Problem with Another Substance 15 18.3 32 21.9 47 20.6 Mental Health Treatment Current Mental Illness Treatment 69 84.1 109 74.7 178 78.1 History of Mental Illness Treatment 75 91.5 121 82.9 196 86.0 (including current treatment) Data Source: Oroonvr Violent heath Rennrting.S'v.ctem. *Suppressed (**Note: Percentage may exceed 100% because some decedents may have multiple diagnoses) Deschutes County Health Services September 2020 25 Graph 8: Mental Health Diagnosis among Suicide Decedents with a Known Mental Health Problem, Deschutes County, OR, 2003-2017 Depression/Dysthymia H Bipolar Disorder 0 c oc 0 o Anxiety Disorder « M = Schizophrenia 0 PTSD M4.8 Attention Deficit Disorder S 2.2 10 20 30 40 50 60 70 80 Proportion of Suicide Decedents (%) Data Source: Oregon Violent Death Reporting System 90 100 As stated previously in this report —no single thing causes a person to take their life. There are various research -verified circumstances that can contribute to a person dying by suicide; some of which are displayed in Table 5. The interpersonal relationship problem that affected the most Deschutes County suicide decedents was an intimate partner problem (N=161, 30.7%); meaning that problems with a current or former intimate partner appear to have contributed to the death. The proportion of male suicide decedents who experienced an intimate partner problem that contributed to the death is 20% more than the proportion of female decedents (32.3% vs 25.8%). "Other Relationship Problems" contributed to 12.2% of suicide deaths in Deschutes County (N=64); meaning that problems with a friend or associate, other than an intimate partner or family member, appear to have contributed to the death. According to the National Violent Death Reporting System, prior to 2013, this category included family members; therefore, a significant portion of this category should be noted to possibly include family members. The life stressor that affected the most Deschutes County suicide decedents was a financial problem (N=193, 36.8%); meaning financial problems appear to have contributed to the death. The proportion of female suicide decedents who experienced a financial problem that contributed to the death is 21% more than proportion of male decedents (42.4% vs 34.9%). Nearly 1 in 5 decedents (N=102, 19.4%) experienced a physical health problem, meaning a physical health problem appears to have contributed Deschutes County Health Services September 2020 26 to the death. The proportion of female decedents who experienced a physical health problem that contributed to the death was 24% more than the proportion male decedents (22.7% vs 18.3%). Graph 9 and Graph 10 display characteristics related to interpersonal relationship problems and life stressors respectively. Table 5: Interpersonal Problems and Life Stressors among Suicide Decedents, Deschutes County, OR 2003-2017 Females Males Total (N=132) (N=393) (N=525) Count % Count % Count % Interpersonal Relationship Problem Intimate Partner Problem 34 25.8 127 32.3 161 30.7 Other Relationship Problem 15 11.4 49 12.5 64 12.2 Death of Friend or Family Member (within 6 4.5 26 6.6 32 6.1 the past 5 years) Recent Argument 11 8.3 25 6.4 36 6.9 Interpersonal Violence Perpetrator * * * * 21 4.0 Death by Suicide of a Friend or Family 5 3.8 5 1.3 10 1.9 member (within the past 5 years) Life Stressors Financial Problem 56 42.4 137 34.9 193 36.8 Physical Health Problem 30 22.7 72 18.3 102 19.4 Job Problem/Lost Job 18 13.3 62 15.8 80 15.2 Criminal Legal Problem 12 9.1 42 10.7 54 10.3 Other Legal Problem 7 5.3 21 5.3 28 5.3 Eviction or Loss of Home * * * * 22 4.2 School Problem * * * * 11 2.1 Data Source: Oregon Violent Death Reporting System *Suppressed Deschutes County Health Services September 2020 27 Graph 9: Interpersonal Problems among Suicide Decedents by Sex, Deschutes County, OR, 2003-2017 Intimiate Partner Problem 4A 4) Other Relationship Problem 0 a oDeath of Friend or Family Member 0 Males ® Females 0 5 10 15 20 25 30 35 Proportion of Suicide Decedents (%) Data Source: Oregon Violent Death Reporting System Graph 10: Life Stressors among Suicide Decedents by Sex, Deschutes County, OR, 2003-2017 to Males Females 45 50 Deschutes County Health Services September 2020 28 Table 6 shows the mechanism of death decedents used to die by suicide in Deschutes County. Lethal means varied, however over half of all decedents used a firearm to die by suicide (N=298, 56.8%). Disparities in mechanism of death between female and male decedents exist and vary greatly. Male decedents were 66% more likely to die by firearm when compared to female decedents (63.1% vs 37.9%). Further, male decedents were 408% more likely than female decedents to die by fall/jumping (22.9% vs 4.5%). Female decedents were 130% more likely to die by poisoning when compared to male decedents (33.3% vs 14.5%); and female decedents were 31% more likely to die by hanging than male decedents (19.7% vs 15.0%). Graph 11 and Graph 12 display data related to mechanism of death. Table 6: Mechanism of Death among Suicide Decedents, Deschutes County, OR 2003-2017 Females Males Total (N=132) (N=393) (N=525) Count % Count % Count % Mechanism of Death Firearm 50 37.9 248 63.1 298 56.8 Sharp Instrument * * * * 12 2.3 Poisoning (Including Overdose) 44 33.3 57 14.5 101 19.2 Hanging/Strangulation/Suffocation 26 19.7 59 15.0 85 16.2 Fall 6 4.5 9 22.9 15 2.9 Motor Vehicle (including buses, * * * * 5 1.0 motorcycles, cars and trains) Data Source: Oregon Violent Death Reporting System *Suppressed Graph 11: Mechanism of Death among Suicide Decedents by Sex, Deschutes County, OR, 2003-2017 0 70 ® Female Male Data Source: Oregon Violent Death Reporting System Deschutes County Health Services September 2020 29 Graph 12: Mechanism of Death among Suicide Decedents, Deschutes County, OR, 2003-2017 16.2% 19.2% 2.3 % 2.9% 1.0% Data Source: Oregon Violent Death Reporting System ■ Firearm w Sharp Instrument ® Poisoning 56.8% Hanging rm Fall Motor Vehicle SRsiactesnrP.q Cau-iina Poisonina Death There were 101 total deaths by poisoning in Deschutes County between 2003-2017 (Table 7). Poisoning can be in the form of a substance or gas. Among suicide decedents that died by poisoning, prescription drugs were the most -used poison (N=57, 56.4%). This was followed by carbon monoxide poisoning (N=24, 23.8%). Of the decedents that died by poisoning, more males died by carbon monoxide than females while more females died by prescription drugs than males. Table 7. Substance Causing Poisoning Death by Sex** Deschutes County, OR 2003-2017 Females Males Total (N=44) (N=57) (N=101) Count % Count % Count % Substance Carbon Monoxide 7 15.9 17 29.8 24 23.8 Over -the -Counter Drug * * * * 5 5.0 Prescription Drug 32 72.7 25 43.9 57 56.4 Street/Recreational Drug * * * * 5 5.0 Other Poison * * * * 12 11.9 Data Source: Oregon Violent Death Reporting System *Suppressed (**Note: Percentage may exceed 100%because multiple substances may have contributed to death) Deschutes County Health Services September 2020 30 Toxicology information aids in understanding the role of alcohol, illegal drugs, and prescription drugs in suicide deaths. Toxicology results are not available for every decedent in this report as not every decedent is tested for substances in their body at the time of death. Further, when a toxicology test is administered for a decedent, the decedent may only be tested for handful of substances, rather than all substances listed in Table 8. Toxicology testing varies greatly and therefore findings in Table 8 are representative of only those decedents for whom results are available and should not be interpreted as representative of all decedents in the report period. Every decedent in the report period was evaluated for suspected alcohol use, meaning that law enforcement and/or a medical examiner suspect the decedent used alcohol in the hours preceding the death. Of all the suicide decedents, 28.2% (N=148) were suspected of alcohol use in the hours preceding death. Of all the decedents in the report period, 153 decedents were tested for alcohol presence in the body at time of death and 49.7% (N=76) of those individuals tested positive for alcohol. Of all the decedents in the report period, 66 decedents were tested for opiates and 31.8% (N=21) of those individuals tested positive for opiates. Remaining toxicology results are displayed in Table 8. Table 8: Toxicology Results among Suicide Decedents**, Deschutes County, OR 2003-2017 Females Males Total (N=variable (N= variable (N= variable depei = IL) dependent) dcpciidciit) Count % Count % Count % Substance Alcohol Use Suspected (N = 525) 34 25.8 114 29.0 148 28.2 Alcohol Result (N = 153) 18 40.9 58 53.2 76 49.7 Amphetamine (N = 48) * * * * 12 25.0 Antidepressant (N = 70) 17 68.0 16 35.6 33 47.1 Benzodiazepines (N = 32) * * * * 11 34.4 Cannabis (N = 65) * * * * 12 18.5 Muscle Relaxant (N = 30) * * * * 7 23.3 Opiate (N = 66) 10 43.5 11 25.6 21 31.8 Data Source: Oregon Violent Death Reporting System *Suppressed **Toxicology findings are representative of only those decedents for whom results are available and should not be interpreted as representative of all decedents Deschutes County Health Services September 2020 31 It is vital to note that deaths by suicide not only affect family members and other loved ones, but also co-workers and organizations with which decedents were employed. In a study conducted by the Centers for Disease Control and Prevention, researchers found that nationally, persons working in farming, fishing, and forestry had the highest rate of suicide in the United States.18 Occupations of suicide decedents are displayed in Table 9. During the report period, occupations among decedents vary greatly. Nearly a quarter (24.5%, N=129) of all decedents were not actively participating in the workforce at the time of death ("Not Currently in Workforce"); this includes individuals that were retired, unemployed, or a homemaker. The occupation with the highest number of suicide decedents was "Construction" (12.4%, N=65), followed by'Sales and Related' (8.0%, N=42), and "Production" (5.5%, N=29). Meaning that nearly every 1 in 8 decedents worked in the construction industry, every 1 in 12 decedents worked in the sales industry, and every 1 in 18 decedents worked in the production industry. 18 McIntosh WL, Spies E, Stone DM, Lokey CN, Trudeau AT, Bartholow B. Suicide Rates by Occupational Group — 17 States, 2012. MMWR Morbidity and Mortality Weekly. 2016;65:641-645. Deschutes County Health Services September 2020 32 Table 9: Normal Occupations among Suicide Decedents, Deschutes County, 2003-2017 Total (N = 525) Count % Occupation Construction 65 12.4 Sales and Related 42 8.0 Production 29 5.5 Healthcare Practitioners and Technical Support 27 5.1 Food Preparation and Serving Related 23 4.4 Office and Administrative Support 23 4.4 Transportation and Material Moving 23 4.4 Building and Grounds Cleaning and Maintenance 21 4.0 Installation, Maintenance, and Repair 20 3.8 Arts, Design, Entertainment, Sports, and Media 17 3.3 Business and Financial Operations 14 2.3 Personal Care and Service 12 2.3 Computer and Mathematical 11 2.1 Architecture and Engineering 11 2.1 Community and Social Service 10 1.9 Farming, Fishing, and Forestry 10 1.9 Protective Service 7 1.3 Educational Instruction and Library 7 1.3 Life, Physical, and Social Science 6 1.1 Military Specific 6 1.1 Not Currently in Workforce 129 24.5 Other & Unknown 12 2.3 Data Source: Oregon Violent Death Reporting System Table 10 displays the locations with which suicide deaths occurred. A vast majority of suicide deaths during the report period occurred in decedents' homes (68.2%, N=358), demonstrating the critical need for family, friends, and loved ones of those at risk for suicide to be aware of suicide warning signs and how to effectively intervene and refer the person at risk to appropriate resources. Nearly every 1 in 10 suicide deaths occurred in a natural area (9.7%, N=48), which include fields, beaches, rivers, or woods. Roughly every 1 in 17 deaths occurred on a street, road, or highway during the report period. Graph 13 displays place of death data during the report period. Deschutes County Health Services September 2020 33 Table 10: Place of Death, Deschutes County, OR 2003-2017 Females Males Total (N=131) (N= 391) (N= 525) Count % Count % Count % Location Decedent's Home 92 70.2 266 68 358 68.2 Natural Area 15 11.5 33 8.4 48 9.7 Street/Road/Highway 6 4.6 26 6.6 32 6.1 Motel/Hotel 7 5.3 17 4.3 24 4.6 Park/Recreational Area * * * * 18 3.4 Parking Lot/Public Parking Garage * * * * 9 1.7 Motor Vehicle * * * * 7 1.3 Other/Unknown 7 5.3 19 4.9 26 5.0 Data Source: Oregon Violent Death Reporting System *Suppressed Graph 13: Place of Death, Deschutes County, OR, 2003-2017 1.7% 1.3% 5.0% 4. 6.1% 9.7 % ® Decedent's Home ■ Natural Area m� Street/Road/Highway ■ Motel/Hotel Park/Recreational Area Parking Lot/Public Parking 13 2% Garage Motor Vehicle Other/Unknown Data Source: Oregon Violent Death Reporting System Deschutes County Health Services September 2020 34 Research conducted by the Centers for Disease Control and Prevention suggest that rates of death by suicide are greater in nonmetropolitan areas throughout the United States compared to metropolitan areas.19 Within in Deschutes County, deaths by suicide varied greatly by region from 2003-2017 (Table 11). Due to the relative rarity of death by suicide in small communities in Deschutes County, it is impossible to create stable estimates and comparability metrics for many populations areas —however, it is possible for some areas such as Bend and Redmond. "All other Deschutes Counties Areas Combined" includes La Pine, Sisters, Sunriver, and Terrebonne. Please note that the analytical method, indirect age adjustment, used to calculate standardized mortality ratios in this section are different from those to calculate previously reviewed rates of death in this report, which was direct age -adjustment. As a result, the rates in Table 11 should not be compared to previous rates and may reflect a different estimate.20 Table 11 includes Standardized Mortality Ratios (SMR). When a SMR is equal to 1.0, this means the number of observed deaths equals that of expected cases. When a SMR is higher than 1.0, there is a higher number of deaths than is expected when compared to the referent. Conversely, when a SMR is lower than 1.0, there is a lower number of deaths than is expected when compared to the referent. Bend saw 1.4 (95% CI=1.3-1.6) times the suicide mortality compared to the county average and Redmond saw 1.2 (95% CI= 0.9-1.4) times the suicide mortality compared to the county average. All other Deschutes County Areas Combined however, saw 0.7 (95% CI = 0.6-0.9) times less mortality compared to the county average. Nearly 61% of suicide deaths during the study period occurred in Bend (iv=318). The indirect age - adjusted rate of suicide in Bend was higher than the rate for Deschutes County as a whole with 32.1 deaths (SMR: 1.4; 95% CI=1.3-1.6) per 100,000 people. Redmond's indirect age -adjusted suicide rate was 26 deaths (SMR: 1.2; 95% CI=0.9-1.4) per 100,000 people. All other Deschutes County Areas Combined includes more rural areas, which had a lower indirect age -adjusted suicide rate than the suburban and urban areas in Deschutes County-15.9 deaths (SMR 0.7; 95% CI=0.6-0.9) per 100,000 people. 19 Ivey -Stephenson AZ, Crosby AE, Jack SP, Haileyesus T, Kresnow-Sedacca M. Suicide Trends Among and Within Urbanization Levels by Sex, Race/Ethnicity, Age Group, and Mechanism of Death — United States, 2001-2015. MMWR Surveillance Summary 2017;66(No. SS-18):1-16. For further information on methods of age adjustment please see: Curtin, LR, Klein, RJ. Direct Standardization (Age -Adjusted Death Rates). Healthy People Statistical Notes, no. 6. Hyattsville, Maryland: National Center for Health Statistics. March 1995. 21 For further information on methods of age adjustment please see: Curtin, LR, Klein, RJ. Direct Standardization (Age -Adjusted Death Rates). Healthy People Statistical Notes, no. 6. Hyattsville, Maryland: National Center for Health Statistics. March 1995. Deschutes County Health Services September 2020 35 Table 11: Suicide Rates and Standardized Mortality Ratios for Regions within Deschutes County, OR 2003-2017* Region Observed Crude Age -Adjusted Standardized 95% Deaths Suicide Rate Suicide Rate Mortality Confidence Ratio Interval Deschutes County 525 22.2 25.3 Referent Bend 318 27.6 32.1 1.4 1.3 —1.6 Redmond 85 21.6 26.0 1.2 0.9 —1.4 All other Deschutes 66 14.7 15.9 0.7 0.6 — 0.9 County Areas Combined Data Source: Oregon Violent Death Reporting System *Note: 56 deaths are not included in the calculations as those decedents' residences were outside of Deschutes County Deschutes County Health Services September 2020 36 DISCUSSION AND RECOMMENDATIONS The current report discusses suicide -related trends, contributors, and risk factors for Deschutes County. Analysis for this report has been limited to the exclusive use of mortality surveillance data and therefore it is necessary to incorporate findings with other relevant data sources to establish a comprehensive basis for addressing suicide as a public health issue in Deschutes County. The following discussion and recommendations are based on the analytical findings of this report as well as evidence -based constructs for developing a comprehensive approach to suicide prevention. It is important to note that a successful suicide prevention approach requires consistent leadership and coordination. The Deschutes County Suicide Prevention Program includes a braided funding model, which shows strong collaboration across the Deschutes County Health Services agency. Moreover, the braided funding model leaves staff responding to multiple funder requirements and focused on resource development and maintenance at the expense of program implementation. Adequate financial support to maintain program staff is imperative for decreasing the rate of suicide attempts and deaths in Deschutes County. Preventing suicide is not the responsibility of a single entity, rather it takes a community to prevent suicide. Therefore, it is vital to implement a comprehensive approach with sustainable, population -level impact. Stigma in regards to mental health and suicide can contribute to a code of silence around suicide, which in turn can hinder help -seeking behavior. In order to combat stigma, it is vital for the general public to discuss suicide as a public health issue. The community conversation should be guided using principles of suicide safe messaging in order to prevent the increase of risk for vulnerable individuals in Deschutes County.21 Further, community conversations should also include messaging around mental health being just as important as physical health, such as community -wide messages from the Mind Your Mind Central Oregon Campaign." The current report showed that most suicides occurred in the home and that over one-third of all suicide decedents disclosed an intent to die by suicide. Suicide prevention training and education being made available to the general public is of the utmost importance to help prevent suicide in Deschutes County. The general public needs important knowledge, training, and skills on how to recognize suicide warning signs, how to ask someone about suicidal intent, and how to connect someone to appropriate, professional help. Therefore, it is recommended for continual maintenance of funding and capacity to offer evidence -based trainings in Deschutes County, such as Question Persuade Refer, Mental Health First Aid, and Applied Suicide Intervention Skills Training. In addition to increasing knowledge and skills for suicide prevention in the general public, it is important to increase general awareness around suicide zl Chambers DA, Pearson JL, Lubell K, Brandon S, O'Brien K, Zinn J. The science of public messages for suicide prevention: a workshop summary. Suicide Life Threat Behay. 2005;35(2):134-145 22 Mind Your Mind Central Oregon Website: www.mindyourmindco.org Deschutes County Health Services September 2020 37 prevention resources in Deschutes County. Knowing what is available and how to access resources can increase the likelihood that community members will refer loved ones to appropriate, professional help. It is important to promote and educate the general public on safe storage of lethal means. The majority of suicide deaths in Deschutes County occur in the home, and over 50% of suicides are completed by firearm and 20% by poisoning. Suicidal impulses are relatively brief, approximately half of all individuals that attempt suicide report that the time between suicidal thoughts and acting on those thoughts was 10 minutes or less.23 Suicide can be avoided if someone does not have an easy way to act on suicidal impulses during their most vulnerable moments —safe storage, such as prescription lock boxes or gun safes, is key to helping prevent suicide. Suicide not only affects an individual's loved ones, but can also have deleterious effects on the workplace. Therefore local businesses in industries with higher prevalence of death by suicide are encouraged to implement comprehensive suicide prevention policies and protocols to support employees and save lives. The occupation with the highest number of suicide decedents in Deschutes County is the construction industry. Efforts should be made to engage with local construction companies to implement suicide prevention policies and protocols as it relates to occupational health and safety. Given that nearly a quarter (24.5%, N=129) of decedents were not engaged in the workforce, efforts should be made to engage with unemployment agencies to implement suicide prevention policies and protocols. All businesses in Deschutes County are encouraged to follow the U.S. Surgeon General's National Strategy for Suicide Prevention, specifically, the goals and objectives outlined for workplaces as well as implementing appropriate suicide prevention protocols when employees are fired, laid -off, and when employees resign. The U.S. Surgeon General's National Strategy for Suicide Prevention includes goals and objectives for all workplaces.24 Some recommendations to note include: • Implement organizational changes to promote mental and emotional health of employees; • Ensure that mental health services are included as a benefit in health plans and encourage employees to use these services as needed; • Screen for mental health needs, including suicidal thoughts and behaviors, and make referrals to appropriate resources as needed; • Train employees and supervisors to recognize coworkers in distress and respond appropriately; • Disseminate information about the National Suicide Prevention Lifeline as well as other local and regional resources. 23 Deisenhammer EA, Ing C, Strauss R, Kemmler G, Hinterhuber H, Weiss EM. The duration of the suicidal process: How much time left for intervention between consideration and accomplishment of a suicide attempt? J Clin Pysch iatry. 2009; 70 (1) : 19-24 21 Office of the Surgeon General (US); National Action Alliance for Suicide Prevention (US). 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. Washington (DC): US Department of Health & Human Services (US); 2012 Sep. Available from: https://www.ncbi.nim.nih.gov/books/NBK109917/ Deschutes County Health Services September 2020 38 The media can play an important role in preventing suicide when using evidence -based media reporting practices; conversely, irresponsible reporting on suicide in the media can increase suicide risk in a community.25 Further, multiple entities, including the Office of the Surgeon General, the World Health Organization, the National Action Alliance for Suicide Prevention, and the Poynter Institute urge the media to adhere to Suicide Safe Messaging Guidelines when reporting on suicide.25,26,27,28 Engagement with local media entities in Deschutes County is highly recommended in order to implement suicide prevention best practices, policies, and protocols. For example, onboarding training for all new employees in regards to suicide reporting best practices is highly recommended. Moreover, media agencies should consider posting suicide prevention resources at the beginning and end of publications and articles that cover suicide. Collaboration between local media agencies and the Central Oregon Suicide Prevention Alliance is also recommended in order to foster mutually beneficial partnerships and ultimately prevent suicide in Deschutes County as well as Central Oregon. Research shows that a majority of suicide decedents have visited a primary care physician within one year, and one -fifth of decedents within one month, preceding death.29 There is ample opportunity for suicide prevention and intervention in the primary care setting. A comprehensive approach to preventing suicide in clinical settings will help prevent suicide —and one approach alone is not enough. It is recommended that primary care clinics consider adopting Zero Suicide, which is a model that guides health care organizations through systems -wide transformations change toward safer suicide care.30 The Zero Suicide model includes seven essential elements geared toward organizational culture shifts as well as quality improvement mechanisms. The seven essential elements include leadership development, staff training, patient screening and assessment, care protocols, treatment, program evaluation, and quality improvement.30 Zero Suicide prioritizes suicide prevention as a core organizational value. Another comprehensive model to consider adopting is the Primary Care Toolkit developed by a team of experts from the Central Oregon Suicide Prevention Alliance.31 The Primary Care Toolkit is designed to 21 Stack, S. (2000). Media impacts on suicide: A quantitative review of 293 findings. Social Science Quarterly, 81(4), 957-971. 26 World Health Organization. (2017). Preventing suicide: A resource guide for media professionals. Retrieved from: http://apps.who.int/iris/bitstream/10665/258814/l/W HO-MSD-MER-17.5-eng.pdf?ua=1 27 National Action Alliance for Suicide Prevention, Media Messaging: https://theactionalliance.org/news 21 Poynter. 2020. Reporting On Suicide? Consider These Common Problems And Their Solutions - Poynter. [online] Available at: https://www.poynter.org/reporting-editing/2019/reporting-on-suicide-consider-these-common- problems-and-their-solutions/ 21 Ahmedani, B.K., Simon, G.E., Stewart, C. et al. Health Care Contacts in the Year Before Suicide Death. J GEN INTERN MED 29, 870-877 (2014). https://doi.org/10.1007/sll6O6-014-2767-3 31 Zero Suicide Institute, About Us: http://zerosuicideinstitute.com/about-us 31 Suicide Prevention in Primary Care Settings: https://www.oregonsuicideprevention.org/deschutes-county- toolkit/ Deschutes County Health Services September 2020 39 help primary care practices support at -risk patients and includes various components such as guidelines, workflows, screenings, and how to discuss firearms in a culturally responsive approach with patients. Further, it is also recommended that collaboration between primary care and specialty behavioral health care continue to be strengthened in the Central Oregon region through the Advancing Integrated Care (AIC) project, which is a project of the Regional Health Improvement Plan and the Central Oregon Health Counci1.32 The goal of AIC is to identify and engage 100% of individuals in Central Oregon that have a behavioral health need and ensure an effectively and timely response. There are five key components to the AIC project: identification, integration, referrals, coordination, and care team expansion. Research shows that people who die by suicide are more likely to engage with a primary care physician than any other medical provider preceding their death.29 In order to support comprehensive approaches to preventing suicide in primary care settings, it is also recommended that clinicians participate in suicide prevention and intervention training, such as Kognito and Applied Suicide Intervention Skills Training (ASIST). Primary care providers can play a vital role in preventing suicide in Deschutes County. A vast majority of suicide decedents in Deschutes County who had a mental health problem-75%-- were engaged in mental illness treatment at the time of death, however that when an individual dies by suicide, it is no one's fault, including a behavioral health provider. It is recommended that behavioral health providers and other social service providers, who have not already done so, engage in training around screening and managing suicide care. Multiple suicide screening tools exist, however many entities in Deschutes County have already implemented the Columbia Suicide Severity Risk Scale (C-SSRS); a tool that is also supported by the Substance Abuse and Mental Health Services Administration (SAMHSA).33 Training in using the C-SSRS is available at no cost online and personalized trainings can also be requested. Individuals trained in clinical behavioral health practice should be treating and managing patients at risk of suicide using evidence -based training models. Clinical behavioral health clinicians are encouraged to engage in various suicide -care trainings, such as Collaborative Assessment and Management of Suicidality (CAMS) or Assessing and Managing Suicide Risk (AMSR). Further, it is recommended that providers use effective, strengths -based safety planning with people at risk for suicide, such as the Stanley and Brown Safety Planning Intervention (SPI).34 All behavioral health and social service providers 32 Central Oregon Health Council Behavioral Health: Identification and Awareness Workgroup: https:Hcohealthcouncil.org/workgroups/id-and-awareness/ 33 The Columbia Lighthouse Project: https://cssrs.columbia.edu/ 34 Stanley, B., and Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264. Deschutes County Health Services September 2020 40 are urged to refrain from using "no -suicide contracts" as this type of intervention is not supported by evidence and could potentially be deleterious in reducing suicide risk.35,36 It is also recommended, as with primary care settings, that behavioral health and other social services settings consider implementing the comprehensive, evidenced -based Zero Suicide model. The description of this model can be found in the aforementioned section of this report. Further, in order to increase access to specialty behavioral health care, it is recommended that clinicians engage in the AIC project described in the primary care section of this report. Although data from this report shows the majority of suicide deaths in Deschutes County occur among middle-aged adults, it should be noted that the youth suicide rate during this report period nearly doubled. Further, according to the Oregon Public Health Assessment Tool and the Oregon Health Authority, Deschutes County has the sixth -highest youth suicide death burden in the state. Adolescents are more vulnerable to suicide contagion than adults, as adolescents are developing a sense of self that makes them more susceptible to peer influences.37,38 Adolescents are also less future -oriented than adults, and are often more concerned with rewards reaped from their peers rather than adults."," Further, exposure to a suicide attempt or death of an important other can lead to an increased risk of suicidality and distress .41 Specific youth -focused suicide prevention efforts should continue to be prioritized in Deschutes County. Schools play an integral role in helping prevent youth suicide. Because suicide is a complex public health issue, it is not schools' responsibility alone to prevent youth suicide. It is recommended that Deschutes County School Districts continue to strengthen their comprehensive approach to youth suicide prevention that includes collaboration with, and connection to, community -wide suicide prevention efforts. A comprehensive approach should include suicide prevention, intervention, and postvention strategies that not only targets students, but also parents, staff, and administrators. Further, a comprehensive approach should include strategies that span beyond knowledge attainment and awareness raising. In other words, suicide prevention curricula or mental health awareness days alone are not sufficient. Skill- 11 Edwards, S., & Sachmann, M. (2010). No -suicide contracts, no -suicide agreements, and no -suicide assurances. Crisis, 31(6), 290-302. doi: 10.1027/0227-5910/a000048 31 Rudd, M., Mandrusiak, M., & Joiner Jr., T. (2006). The case against no -suicide contracts: The commitment to treatment statement as a practice alternative. Journal Of Clinical Psychology, 62(2), 243-251. doi: 10.1002/jclp.20227 37 Cheng 4, Li H, Silenzio V, Caine ED (2014) Suicide contagion: A systematic review of definitions and research utility. PLoS ONE 9(9): e108724. doi:10.1371/journal.pone.0108724 38 Giordano, Peggy C. Relationships in adolescence. Annual Review of Sociology. 2003; 29:252-81. 39 Steinberg, Laurence; Graham, Sandra; O'Brien, Lia; Woolard, Jennifer; Cauff man, Elizabeth; Banich, Marie. Age differences in future orientation and delay discounting. Child Development. 2009; 80(1):28-44. [PubMed: 19236391) 40 Crosnoe, Robert. Fitting in, standing out: Navigating the social challenges of high school to get an education. Cambridge University Press; 2011. 41 Liu, Ruth X. Vulnerability to friends' suicide influence: The moderating effects of gender and adolescent depression. Journal of Youth and Adolescence. 2006; 35(3):479-89. Deschutes County Health Services September 2020 41 building, care coordination, and policy, systems, and environmental change strategies should also be incorporated into a compressive approach to prevent youth suicide. Not only is a compressive approach to preventing youth suicide evidence -based, but it also mandated by the Oregon law. It is recommended that Deschutes County school districts collaborate with one another as well as Deschutes County Health Services in order to comply with Senate Bill 485, Senate Bill 52, as well as the Student Success Act. A comprehensive approach is also one that includes strategies for shifting school culture towards positive attitudes around mental health and help -seeking among students. Currently, four schools within Deschutes County have Youth Action Councils that are geared toward promoting positive school culture and promoting school -based health center resources. It is recommended that more schools within Deschutes County adopt a Youth Action Council in order to promote youth resiliency. One-third of suicide decedents in Deschutes County had a substance abuse problem and over one - quarter of all suicide decedents had a problem with alcohol. Given that increased substance use is a warning sign for suicide, it is imperative that behavioral health professionals that treat individuals experiencing substance use disorders be trained in screening and treating suicidality in clients. This is particularly important for people at risk of relapse or those who have relapsed after a period of sobriety.42 Recommended suicide prevention trainings for substance use disorder clinicians include: Applied Suicide Intervention Skills Training, Assessing and Managing for Suicide Risk, Kognito, and Counseling on Access to Lethal Means. Multiple suicide screening tools exist, and many entities in Deschutes County have already implemented the Columbia Suicide Severity Risk Scale (C-SSRS); a tool that is also supported by the Substance Abuse and Mental Health Services Administration. Training in using the C-SSRS is available at no cost online and personalized trainings can also be requested. Men Similar to national and statewide findings, the majority of suicide deaths occur among men in Deschutes County. Half of all suicide deaths in Deschutes County occurred among men between the ages of 25 to 64 in the report period. There is no single cause to this disparity, however research has shown that various risk factors are more prevalent among men, such as substance use disorders, access to firearms, and reduced engagement in behavioral health care .4s,44 The report showed similar findings in Deschutes County decedents —males were 68% more likely to die by firearm than females and females were 86% 42 Wilcox, H., Conner, K., & Caine, E. (2004). Association of alcohol and drug use disorders and completed suicide: An empirical review of cohort studies. Drug And Alcohol Dependence, 76, S11-S19. doi: 10.1016/j.d rugs Icdep.2004.08.003 43 Cibis, A., Mergl, R., Bramesfeld, A., Althaus, D., Niklewski, G., Schmidtke, A., and Hegerl, U. (2012). Preference of lethal methods is not the only cause for higher suicide rates in males. Journal of Affective Disorders, 136(1-2), 9-16. 44 Schrijvers, D. L., Bollen, J., and Sabbe, B. G. (2012). The gender paradox in suicidal behavior and its impact on the suicidal process. Journal of Affective Disorders, 138(1-2), 19-26. Deschutes County Health Services September 2020 42 more likely to be engaged in mental illness treatment than males. Substance use problem prevalence was similar between male and female decedents. A notable characteristic among male suicide decedents is that one-third experienced an intimate partner problem that contributed to the death. As stated earlier, the occupation with the largest proportion of suicide decedents was the construction occupation, which is a male -dominated industry. It is recommended that behavioral health professionals find culturally relevant ways to engage men in services through targeted outreach and partnerships with industries that primarily employ men. Further, because the report shows that males are more likely to use firearms than females for dying by suicide, it is recommended that mental health promotion and suicide prevention professionals in Deschutes County engage with local firearm retailers in order to promote and normalize mental health resources in culturally relevant ways that resonate with males in Deschutes County. Veterans Veteran suicide decedents accounted for one -fifth of all suicides during the reporting period. Given that veterans are engaged in a wide variety of sectors in Deschutes County, it is recommended that all suicide prevention efforts include culturally responsive components to reach veterans. Further, because there is a wide variety of veteran -serving organizations in Deschutes County, it is also recommended that a unified veteran suicide prevention taskforce emerge in order to coordinate efforts and provide resources mapping in order to ensure equitable access to resources for all veterans in Deschutes County. American indian/Aiaskan Native Due to concerns regarding statistical reliability and decedent identifiability, the current report did not analyze suicide among racial and ethnic subpopulations. In the United States, people who identify as American Indian/Alaskan Native (AI/NA) have the highest suicide rate compared to the general population and other racial and ethnic subpopulations.45 Medical, behavioral health, and other social service providers are encouraged to develop and adopt culturally responsive, evidence -based and tribal practices to support people who identify as AI/NA at risk for suicide 46 LGBTQ+ Youth While not analyzed it the current study, national research shows that young people who identify as LGBTQ+ have higher rates of suicide ideation and attempts that the general population.47 This disparity also exists in the state of Oregon; young people who identify as LGBTQ+ have reported significantly higher rates of contemplating suicide in the last 12 months than students who identified as straight.48 Further, Oregon students who identify as straight meet positive youth development benchmarks at significantly higher proportions than students who identify as LGBTQ+.so 45 Racial and Ethnic Disparities. (2020). Retrieved from http://www.sprc.org/scope/racial-ethnic-disparities 46 U.S. Department of Health and Human Services. To Live To See the Great Day That Dawns: Preventing Suicide by American Indian and Alaska Native Youth and Young Adults. DHHS Publication SMA (10)-4480, CMHS-NSPL-0196, Printed 2010. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2010. 47 Kann L, Olsen EO, McManus T, et al. Sexual Identity, Sex of Sexual Contacts, and Health -Related Behaviors Among Students in Grades 9-12 — United States and Selected Sites, 2015. MMWR Surveillance Summary 2016;65(No. SS-9):1-202. 48 2017 Oregon Healthy Teens Survey, Oregon Health Authority. https://www.oregon.gov/oha/PH/BIRTHDEATHCERTIFICATES/SURVEYS/0REGON HEALTHYTEENS/Pages/2017.aspx Deschutes County Health Services September 2020 43 Medical, behavioral health, and other social services providers should be aware of these disparities and also integrate culturally responsive practices to meet the needs of LGBTQ+ youth at risk for suicide. Further, youth -serving organizations, including schools, should ensure that safe environments are being fostered for students of all identities, especially those that identify as LGBTQ+, to feel safe, welcomed and supported. Over half of all suicide decedents in Deschutes County during the report period died by firearm, followed by one -fifth of suicide decedents dying by poisoning, which includes intentional overdose. Research over the last few decades indicates that when lethal means are less accessible or less deadly, suicide rates by that method tend to decline, which can in turn reduce the overall suicide rate for a community.49 A pervasive myth that exists not only in Deschutes County, but nationally, involves the belief that the act of suicide is one that is careful, deliberate, and thought-out. However, research shows that the vast majority of suicides are quickly decided upon and involve little -to -no planning, meaning that the time between the thought and the action is brief.50 A majority of suicides are decided upon in 10 minutes or less.12, 51, s2A majority of suicide deaths can be avoided if people do not have an easy way to act on suicidal impulses during their most vulnerable moments. It is recommended that safe storage efforts be implemented and expanded widely in Deschutes County. This should include a combination of evidence -based approaches, including community awareness campaigns around safe storage, engaging with firearm retailers on training, and increasing access to safe storage means. Safe storage efforts should include approaches for firearms as well as prescription medications, as these are the most widely used methods to die by suicide in Deschutes County. Further, it is recommended that there be increased collaboration between suicide prevention and substance abuse prevention efforts to ensure continuity of efforts and cross promotion. Efforts should also target firearm owners in a culturally responsive manner. Engaging with firearm owners on effective approaches for safe storage is imperative to mitigating risks of suicide by firearm. Further, because a large proportion of suicide decedents engage with primary care providers, it is recommended that clinicians be trained in specific trainings around lethal means and suicide, such as the Counseling on Access to Lethal Means (CALM) training. 49 Means Reduction Saves Lives. (2020), from https://www.hsph.harvard.edu/means-matter/means-matter/saves- lives/ so Hawton, K. (2007). Restricting access to methods of suicide: Rationale and evaluation of this approach to suicide prevention. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 28(Suppl 1), 4- 9. https:Hdoi.org/10.1027/0227-5910.28.S1.4 51 Simon, T., Swann, A., Powell, K., Potter, L., Kresnow, M., & O'Carroll, P. (2002). Characteristics of impulsive suicide attempts and attempters. Suicide And Life -Threatening Behavior, 32, 49-59. doi: 10.1521/s u I i.32.1.5.49.24212 52 Deisenhammer EA, Ing CM, Strauss R, et al. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry. 2009;70(1):19-24. Deschutes County Health Services September 2020 44 During the report period, 61% of all suicides in Deschutes County occurred among Bend residents, 16% occurred among Redmond residents, and 13% occurred among residences in all other Deschutes County cities. Most national trends show that the burden of suicide disproportionally affects rural communities more than suburban or urban areas, however Deschutes County is not consistent with this national trend. Bend, being the most populated city in Deschutes County has the highest age -adjusted suicide rate than any other Deschutes County city and the rate is higher than the overall Deschutes County age - adjusted suicide rate. It is important to remember that each city in Deschutes County is unique and therefore a one -size -fits -all approach to suicide prevention in Deschutes County will be ineffective. In order to appropriately and effectively prevent suicide in Deschutes County, it is imperative to target specific suicide prevention approaches culturally relevant to the Bend area as well as additional culturally relevant approaches for Redmond and the other rural areas of Deschutes County. Authentic engagement in community organizations and residents from throughout Deschutes County is vital. It is recommended that Deschutes County staff work to engage more community partners and organizations in the Central Oregon Suicide Prevention Alliance. Deschutes County Health Services September 2020 45 SUICIDE PREVENTION RESOURCES Crisis and Call lines • Deschutes County's 24-hour Crisis Line: 541-322-7500 x9 • National Suicide Prevention Lifeline: 1-800-273-8255 or text "273Talk" to 839863 o For Veterans press #1 o For Spanish Language call 1-888-628-9454 or text "MIL1" to 839863 • YouthLine: 1-877-968-8491 or text "teen2teen" to 83983 • Trans Lifeline: 1-877-565-8860 • Trevor Project (LBGTQ+ Youth): 1-866-4881386 Counseling In Deschutes County • Deschutes County Behavioral Health: 541-322-7500 • St. Charles Behavioral Health Services: 541-706-2768 • Lutheran Community Services Northwest: 541-323-5332 • OSU-Cascades Counseling Clinic: https:Hosucascades.edu/counseling-clinic o Offers free counseling to community to individuals 14 years of age and older • Central Oregon Mental Health Provider Directory: www.preventsuicideco.org/provider-directory/ o A list of private mental health providers in Central Oregon Support for Survivors o Sulclde loss • Bend Area Suicide Bereavement Group: meets the second Monday of the month, 7:00-8:30pm n Located at Partners in Care (2075 NE Wyatt Ct.) o Email Alison Sorenson at alison@alisonsorensoncounseling.com • The Compassionate Friends: meets the first Tuesday of the month at 7:00pm (except December) o Located at Partners in Care (2075 NE Wyatt Ct.) o Contact Carol Palmer at carolpalmerrn@icloud.com or 541-480-0667 • Individual Grief Support from Partners in Care: 541-382-5882 o Short-term individual support counseling sessions to those who have experienced death of a loved one • American Foundation for Suicide Prevention, Health Conversations Program: https:Hafsp.org/healing-conversations o Outreach support from bereaved individuals to newly bereaved individuals Suicide Prevention Information • Deschutes County Suicide Prevention Program: www.deschutes.org/suicideprevention • Central Oregon Suicide Prevention Alliance: www.preventsuicideco.org • Suicide Prevention Lifeline: www.suicidepreventionlifeline.org • National Alliance on Mental Illness (NAM[) Central Oregon: www.namicentraloregon.org • Suicide Prevention Resource Center: www.sprc.org Youth, Teens, & Young Adults • First Step Oregon app: www.firststeporegon or download the app wherever you get your apps • The Trevor Project: www.thetrevorpro*ect.org • YouthLine: www.oregonyouthline.org Deschutes County Health Services September 2020 46 APPENDIX Table 12: Veteran Suicide Decedents by Age, Deschutes County, OR 2003-2017 Total (N=103) Count % Age 18-24 25 — 44 20 19.4 45 — 64 35 34.0 65+ 46 44.7 Data Source: Oregon Violent Death Reporting System *Suppressed Table 13: Circumstances Related to Mental Health and Substance Abuse among Veteran Suicide Decedents, Deschutes County, OR 2003-2017 Total (N=103) Count % Mental Health Status Mental Health Problem 36 35.0 Depressed Mood at Time of Death 51 49.5 History of Mental illness Treatment 29 28.2 (including current) Current Mental Illness Treatment 28 27.2 Substance Abuse Problem with Any Substance 32 31.1 Problem with Alcohol 28 27.2 Problem with Another Substance 10 9.7 Suicidal Behaviors History of Suicide Attempts 15 14.6 History of Suicidal Thoughts 11 10.7 Data Source: Oregon Violent Death Reporting System Deschutes County Health Services September 2020 47 Table 14: Mental Health Diagnosis among Veteran Suicide Decedents with a Known Mental Health Problem*, Deschutes County, OR 2003-2017 Total (N=36) Count % Mental Health Diagnosis Depression/Dysthymia 28 77.8 Anxiety 6 16.7 Post -Traumatic Stress Disorder 6 16.7 Mental Health Treatment Current Mental Illness Treatment 28 77.8 History of Mental Illness Treatment 29 80.6 (including current treatment) Data Source: Oregon Violent Death Reporting System (*Note: Percentage may exceed 100% because some decedents may have multiple diagnoses) Table 15: Interpersonal Problems and Life Stressors among Veteran Suicide Decedents, Deschutes County, OR 2003-2017 Total (N=103) Count % Interpersonal Problem Intimate Partner Problem 30 29.1 Other Relationship Problem 8 7.8 RPeent Ara iment 6 5.8 Life Stressors Job Problem/Lost Job 10 9.7 Financial Problem 38 36.9 Criminal/Legal Problem 11 10.7 Other Legal Problem 8 7.8 Physical Health Problem 39 37.9 Data Source: Oregon Violent Death Reporting System Table 16: Mechanism of Death among Veteran Suicide Decedents, Deschutes County, OR 2003- 2017 Total (N=103) Count % Mechanism of Death Firearm 74 71.8 Poisoning 16 15.5 Hanging, Strangulation, Suffocation 9 8.7 Data Source: Oregon Violent Death Reporting System Deschutes County Health Services September 2020 48 Table 17. Place of Death among Veteran Suicide Decedents, Deschutes County, OR 2003-2017 Total (N=103) Count % Location Decedent's Home 71 69.6 Street/Road/Highway 9 8.8 Natural Area 8 7.8 Motel/Hotel 8 7.8 Data Source: Oregon Violent Death Reporting System Deschutes County Health Services September 2020 49 Table 18: Circumstances Related to Mental Health and Substance Abuse among Adolescent & Young Adult Decedents (< 24), Deschutes County, OR 2003-2017 Total (N=71) Count % Mental Health Status Mental Health Problem 37 52.1 Depressed Mood at Time of Death 32 45.1 History of Mental Illness Treatment 31 43.6 (including current) Current Mental Illness Treatment 25 35.2 Substance Abuse Problem with Any Substance 24 33.8 Problem with Alcohol 20 28.2 Problem with Another Substance 19 26.8 Suicidal Behaviors History of Suicide Attempts 14 19.7 Disclosed Intent to Die by Suicide 22 31.0 Data Source: Oregon Violent Death Reporting System Table 19: Interpersonal Problems and Life Stressors among Adolescent & Young Adult Decedents (<_ 24), Deschutes County, OR 2003-2017 Total (N=71) Count % Interpersonal Problem Intimate Partner Problem 14 19.7 Other Relationship Problem 19 26.8 Recent Argument 5 7.0 Life Stressors _ School Problem 10 14.1 Financial Problem 17 23.9 Criminal/Legal Problem 11 15.5 Data Source: Oregon Violent Death Reporting System Deschutes County Health Services September 2020 50 Table 20: Mental Health Diagnosis among Adolescent & Young Adult Decedents (<_ 24) with a Known Mental Health Problem*, Deschutes County, OR 2003-2017 Total (N=37) Count % Mental Health Diagnosis Depression/Dysthymia 27 73.0 Bipolar Disorder 6 16.2 Schizophrenia 5 13.5 Mental Health Treatment Current Mental Illness Treatment 25 67.6 History of Mental Illness Treatment 31 83.8 (including current treatment) Data Source: Oregon Violent Death Reporting System (*Note: Percentage may exceed 100% because some decedents may have multiple diagnoses) Table 21: Mechanism of Death among Adolescent & Young Adult Decedents (<_ 24), Deschutes County, OR 2003-2017 Total (N=71) Count % Mechanism of Death FirPnrm 40 56.3 Poisoning 6 8.5 Hanging, Strangulation, Suffocation 18 25.4 Other 7 9.8 Data Source: Oregon Violent Death Reporting System Deschutes County Health Services September 2020 51 Table 22: Circumstances Related to Mental health and Substance Abuse among Adult Suicide Decedents (25 - 44), Deschutes County, OR 2003-2017 Females Males Total (N=43) (N=129) (N=172) Count % Count % Count % Mental Health Status Mental Health Problem 29 67.4 50 38.8 79 46.0 Depressed Mood at Time of Death 25 58.1 54 41.9 79 45.9 Current Mental Illness Treatment 26 60.5 37 28.7 63 36.6 History of Mental Illness Treatment 27 62.8 46 35.7 73 42.4 (including current treatment) Substance Abuse Problem with Any Substance 17 39.5 50 38.8 67 39.0 Problem with Alcohol 11 25.6 36 27.9 47 27.3 Problem with Another Substance 9 21.0 28 21.8 37 21.5 Suicidal Behaviors History of Suicide Attempt(s) 21 48.8 22 17.1 43 25.0 History of Suicidal Thoughts 11 25.6 11 8.5 22 12.8 Disclosed Intent to Die by Suicide 15 34.9 44 34.1 59 34.3 Data Source: Oregon Violent Death Reporting System Table 23: Mental Health Diagnoses Among Adult Suicide Decedents (25 - 44) with a Known Mental Health Problem", Deschutes County, OR 2003-2017 Females Males Total (N=29) (N=50) (N=79) Count % Count % Count % Mental Health Diagnosis_ Depression/Dysthymia 26 90.0 34 68.0 60 76.0 Anxiety Disorder * * * * 9 11.4 Bipolar Disorder 11 37.9 8 16.0 19 24.1 Schizophrenia * * * * 13 16.5 Mental Health Treatment Current Mental Illness Treatment 26 90.0 34 68.0 60 78.5 History of Mental Illness Treatment 26 90.0 44 88.0 70 88.6 (includine current treatment) Data Source: Oregon Violent Death Reporting System *Suppressed (**Note: Percentage may exceed 100% because some decedents may have multiple diagnoses) Deschutes County Health Services September 2020 52 Table 24: Interpersonal Problems and Life Stressors among Adult Suicide Decedents (25 — 44), Deschutes County, OR 2003-2017 Females Males Total (N=43) (N=129) (N=172) Count % Count % Count % Interpersonal Relationship Problem Intimate Partner Problem 13 30.2 64 49.6 77 44.8 Other Relationship Problem * * * * 16 9.3 Interpersonal Violence Perpetrator * * * * 9 5.2 Life Stressors Financial Problem 18 41.9 43 33.3 61 35.5 Physical Health Problem 8 18.6 8 6.2 16 9.3 Job Problem/Lost Job 7 16.3 30 23.3 37 21.5 Criminal Legal Problem 6 14.0 14 10.9 20 11.6 Other Legal Problem * * * * 12 7.0 Eviction or Loss of Home * * * * 17 9.9 Data Source: Oregon Violent Death Reporting System *Suppressed Table 25: Mechanism of Death among Adult Suicide Decedents (25 — 44), Deschutes County, OR 2003-2017 _ Females Males Total (N=43) (N=129) (N=172) Count % Count % Count % Mechanism of Death Firearm 17 39.5 68 52.7 85 49.4 Sharp Instrument * * * * 5 2.9 Poisoning (Including Overdose) 13 30.2 20 15.5 33 19.2 Hanging/Strangulation/Suffocation 10 23.3 29 22.5 39 22.7 Fall * * * * 5 2.9 Data Source: Oregon Violent Death Reporting System *Suppressed Deschutes County Health Services September 2020 53 Table 26: Circumstances Related to Mental health and Substance Abuse among Middle Aged Adult Suicide Decedents (45 - 64), Deschutes County, OR 2003-2017 Females Males Total (N=56) (N=134) (N=190) Count % Count % Count % Mental Health Status Mental Health Problem 38 67.9 51 38.1 89 46.8 Depressed Mood at Time of Death 27 48.2 52 28.8 79 41.6 Current Mental Illness Treatment 33 58.9 40 29.9 73 38.4 History of Mental Illness Treatment 35 62.5 42 31.3 77 40.5 (including current treatment) Substance Abuse Problem with Any Substance 19 33.9 48 35.8 67 35.3 Problem with Alcohol 14 25.0 42 31.3 56 29.5 Problem with Another Substance 6 10.7 18 13.4 24 12.6 Suicidal Behaviors History of Suicide Attempt(s) 11 19.6 19 14.2 30 15.8 History of Suicidal Thoughts 9 16.1 16 12.0 25 13.2 Disclosed Intent to Die by Suicide 21 37.5 47 35.1 68 35.8 Data Source: Oregon Violent Death Reporting System Table 27. Mental Health Diagnoses Among Middle Aged Adult Suicide Decedents (45 - 64) with a Known Mental Health Problem** Deschutes County, OR 2003-2017 Females Males Total (N=38) (N=51) (N=89) Count % Count % Count % Mental Health Diagnosis Depression/Dysthymia 36 94.7 42 82.4 78 87.6 Anxiety Disorder 6 15.8 6 11.8 12 13.5 Bipolar Disorder 7 18.4 6 11.8 13 14.6 Post -Traumatic Stress Disorder * * * * 6 6.7 Mental Health Treatment Current Mental Illness Treatment 34 89.5 42 82.4 76 85.3 History of Mental Illness Treatment 33 86.8 40 78.4 73 82.0 (including current treatment Data Source: Oregon Violent Death Reporting System *Suppressed (**Note: Percentage may exceed 100% because some decedents may have multiple diagnoses) Deschutes County Health Services September 2020 54 Table 28: Interpersonal Problems and Life Stressors among Middle Aged Adult Suicide Decedents (45 - 64), Deschutes County, OR 2003-2017 Females Males Total (N=56) (N=134) (N=190) Count % Count % Count % Interpersonal Relationship Problem Intimate Partner Problem 16 28.6 41 30.6 57 30.0 Other Relationship Problem 10 17.9 15 11.1 25 13.1 Death of a Family Member or Friend 5 8.9 9 6.7 14 7.4 (within past 5 years) Death by Suicide of Friend or Family * * * * 6 3.2 Member (within past 5 years) Life Stressors Financial Problem 26 46.6 49 36.6 75 39.5 Recent Argument * * * * 10 5.3 Physical Health Problem 14 25.0 20 15.0 34 17.9 Job Problem/Lost Job 10 17.9 31 23.1 41 21.6 Criminal Legal Problem 5 8.9 12 9.0 17 8.9 Other Legal Problem 5 8.9 8 6.0 13 6.8 Eviction or Loss of Home * * * * 12 7.5 Data Source: Oregon Violent Death Reporting System *Suppressed Table 29: Mechanism of Death among Middle Aged Adult Suicide Decedents (45 - 64), Deschutes County, OR 2003-2017 Females Males Total (N=56) (N=134) (N=190) Count % Count % Count % Mechanism of Death Firearm 24 42.9 82 61.2 106 55.8 Sharp Instrument * * * * 5 2.6 Poisoning (Including Overdose) 23 41.1 26 19.4 49 25.8 Hanging/Strangulation/Suffocation * * * * 21 11.1 Fall * * * * 5 2.6 Data Source: Oregon Violent Death Reporting System *Suppressed Deschutes County Health Services September 2020 55 Table 30: Circumstances Related to Mental health and Substance Abuse among Older Adult Suicide Decedents (65+), Deschutes County, OR 2003-2017 Females Males Total (N=15) (N=77) (N=92) Count % Count % Count % Mental Health Status Mental Health Problem 5 33.3 18 23.3 23 25.0 Depressed Mood at Time of Death * * * * 38 41.3 Current Mental Illness Treatment * * * * 18 19.6 History of Mental Illness Treatment 6 40.0 14 18.2 20 21.7 (including current treatment) Substance Abuse Problem with Any Substance * * * * 17 18.5 Problem with Alcohol * * * * 14 15.2 Problem with Another Substance * * * * 6 6.5 Suicidal Behaviors History of Suicidal Thoughts * * * * 9 9.8 Disclosed Intent to Die by Suicide * * * * 18 19.6 Data Source: Oregon Violent Death Reporting System Table 31: Mental Health Diagnoses Among Older Adult Suicide Decedents (65+) with a Known Mental Health Problem", Deschutes County, OR 2003-2017 Females Males Total (N=5) (N=18) (N=23) Count % Count % Count % Mental Health Diagnosis _ Depression/Dysthymia 5 100 16 88.9 21 91.3 Anxiety Disorder * * * * 5 21.7 Mental Health Treatment Current Mental Illness Treatment * * * * 18 78.2 History of Mental Illness Treatment * * * * 19 82.6 (including current treatment Data Source: Oregon Violent Death Reporting System *Suppressed (**Note: Percentage may exceed 100% because some decedents may have multiple diagnoses) Deschutes County Health Services September 2020 56 Table 32: Interpersonal Problems and Life Stressors Older Adult Suicide Decedents (65+), Deschutes County, OR 2003-2017 Females Males Total (N=15) (N=77) (N=92) Count % Count % Count % Interpersonal Relationship Problem Intimate Partner Problem * * * * 13 14.1 Death of a Family Member or Friend * * * * 11 12.0 (within past 5 years) Life Stressors Financial Problem 9 60.0 31 40.3 40 43.5 Physical Health Problem * * * * 49 53.3 Data Source: Oregon Violent Death Reporting System *Suppressed Table 33: Mechanism of Death among Older Adult Suicide Decedents (65+), Deschutes County, OR 2003-2017 Females Males Total (N=15) (N=77) (N=92) Count % Count % Count % Mechanism of Death Firearm * * * * 67 72.8 Poisoning (Including Overdose) 5 33.3 8 10.4 13 14.1 Hanging/Strangulation/Suffocation * * * 7 7.o Data Source: Oregon Violent Death Reporting System *Suppressed Deschutes County Health Services September 2020 57 E S CO �� GZ o Deschutes County Board of Commissioners 1300 NW Wall St, Bend, OR 97703 (541) 388-6570 - Fax (541) 385-3202 - https://www.deschutes.org/ AGENDA REQUEST & STAFF REPORT For Board of Commissioners BOCC Wednesday Meeting of September 9, 2020 DATE: September 3, 2020 FROM: Greg Munn, Finance, 541-388-6559 TITLE OF AGENDA ITEM: PRESENTATION: Government Finance Officers Association Popular Annual Financial Report Award RECOMMENDATION & ACTION REQUESTED: Recommend that the Board of County Commissioners recognize James Wood, Cam Sparks, Whitney Hale and David Givans for their award winning efforts in developing the County's first Popular Annual Financial Report. BACKGROUND AND POLICY IMPLICATIONS: Historically, the County has participated in two best practice fiscal reporting programs sponsored by the Government Finance Officers Association (GFOA) - the Certificate of Excellence in Financial Reporting and the Distinguished Budget Presentation Award. The County has been recognized for excellence in both programs by receiving awards annually for several years. The Popular Annual Financial Report award was established to encourage local governments to extract information from their Comprehensive Annual Financial Report to produce a specifically designed, accessible and easily understandable report to the general public and other interested parties without a background in public finance. James Wood led the effort with help from Cam Sparks, Whitney Hale and David Givans to develop and submit the County's first report for review and consideration which received the GFOA's Award for Outstanding Achievement in Popular Annual Financial Reporting. FISCAL IMPLICATIONS: Participation in best practice programs enhances the County's financial reporting practices, improves transparency and aids in the maintenance of the County's bond rating. ATTENDANCE: Greg Munn and James Wood. Government Finance Officers Association 20.3 North LaSalle Street, Suite 2700 Chicago, Illinois 60601-1210 312.977.9700 J x: 312,977.4806 August 19, 2020 Gregg Munn Chief Financial Officer Deschutes County 1300 NW Wall Street, Suite 203 Bend, Oregon 97703 Dear Mr. Munn: A panel of independent reviewers has completed its examination of your Popular Annual Financial Report (PAFR) submitted to Government Finance Officers Association (GFOA). We are pleased to notify you that your PAFR for the fiscal year ended June 30, 2019, has substantially met the requirements of the PAFR Program. In the absence of authoritative standards governing the presentation, these requirements are based on an evaluation of information presented, reader appeal, understandability, distribution, and other elements (such as whether the PAFR is a notable achievement for the government given the government's type and size, and the PAFR's creativity and usefulness). The report received a weighted average score of 75.00 percent or above from three of the four highest individual reviews. Each entity submitting a report to the PAFR Program is provided with confidential comments and suggestions for possible improvements in the subsequent year's presentation. Your comments and suggestions, as well as a "Summary of Grading" form, are enclosed. We urge you to carefully consider the suggestions offered by our reviewers as you prepare your next PAFR. Continuing participants will find a Certificate and brass medallion enclosed with these results. The brass medallion may be mounted on your ten-year plaque. First-time recipients will find a Certificate enclosed with these results and will receive a plaque in approximately 10 weeks. We hope that appropriate publicity will be given to this notable achievement. A sample news release has been enclosed. A current holder of a PAFR Award may include a reproduction of the Certificate in its immediately subsequent PAFR. A camera-ready copy of your Certificate is enclosed for that purpose. If you reproduce your Certificate in your next report, please refer to the enclosed instructions. Washington, DC Office Federal Liaison Center, 660 North Capitol Street, NW, Suite 410 • Washington, DC 20001 • 202.393.8020 fax: 202,393.0780 wwxv.gfoa.org Gregg Munn August 19, 2020 Page 2 The PAFR Award is valid for one year. To continue your participation in the program, it will be necessary for you to submit your next PAFR to GFOA within six months of the end of your entity's fiscal year. A Popular Annual Financial Reporting Award Program Application is posted on GFOA's website at www.gfoa.org. Over the course of the year, we are anticipating some changes to our application process. We will still be asking governments for the same documents we asked for in the past, but we are encouraging electronic submissions to pafr@gfoa.org and expect to be making other changes going forward. We will keep members informed of any changes via email, and application instructions will be updated on our website. We appreciate your participation in this program, and we sincerely hope that your example will encourage others in their efforts to achieve and maintain a well -presented PAFR. If we can be of further assistance, please do not hesitate to contact the PAFR Program staff in the Technical Services Center at (312) 977- 9700. Sincerely, Michele Mark Levine Director, Technical Services Center Enclosures E * k Government Finance Officers Association Award for Outstanding Achievement in Popular Annual Financial Reporting Presented to Deschutes County Oregon For its Annual Financial Report for the Fiscal Year Ended June 30, 2019 04t .,. P° ; of� Executive Director/CEO .; I • 11 �� Page Introduction (see below).................................................................................. 1 WhereDo Your Taxes Go?.............................................................................. 2 NetPosition....................................................................................................... 3 Assets& Liabilities............................................................................................ 4 Revenues & Expenses —Fiscal Year 2019...................................................... 5 Revenues & Expenses-10 Year History ........................................................ 6 Debt..................................................................................................................... 7 PropertyTaxes................................................................................................... 8 Demographics & Staffing Ratio....................................................................... 9 AdditionalInformation..................................................................................... 10 Residents of Deschutes County, The Deschutes County Finance Department has recently released its 200+ page annual financial report for Fiscal Year ended June 30, 2019; however, in an attempt to provide residents with a relatively quick -read of the annual financial report, the Deschutes County Finance Department has also prepared this Popular Annual Financial Report (PAFR). As encouraged by the Government Financial Officer Association (GFOA), this inaugural PAFR will provide insight into long-term trends of the County's largest financial indicators found in the Comprehensive Annual Financial Report (CAFR). All financial information included in this report is from the independently -audited Comprehensive Annual Financial Report (CAFR). The CAFR was audited by Eide Bailly, an independent auditing firm and received an unmodified (clean) opinion. The CAFR is available online at: www.deschutes.orgICAFR oow Greg Munn, Chief Financial Officer Jam Wood, Accounting Manager Where do your taxes Although Deschutes County is the tax collector for Deschutes County, overall only 17 tents of each dollar paid in taxes is kept by the County. The remaining 83 cents is passed through to other government agencies to provide for schools, police & fire departments, parks, libraries, and more. *The allocation below is for a City of Bend taxpayer. All other city/rural allocations are similar. r- L 48G ,>> < Ls<t �D u Bend Parker �� a LIBRARY Recreation RES a.y EM M Deschutes County uses its taxes to fund Public Safety, Health & Welfare, and General Government. 1 G 2C 3C Public Safety includes the Sheriffs Office, Deschutes 9-1-1, and Community Justice. Health & Welfare includes Deschutes County Health Services and Veterans' Services. General overn ent includes a variety of departments, such as the Assessor's Office, Clerk's Office, District Attorney's Office (including Victims' Assistance), and Justice Court. NOTE: Tax allocations based on the City of Bend Taxing District (Tax Code 1001). 2 DESCHUTES COUNTY, OREGON Ntet Position $200 Deschutes Countys net position as of June 30, 2019 was approximately $208 million. Net Position is broken into two types: Capital Assets and Other Assets. r_ represents the current value of County infrastructure, offset for amounts owed. County infrastructure includes the County's investment in: • Roads • Vehicles & equipment • Buildings for providing services The net position of capital assets could be viewed in a similar manner as home -equity (i.e. in 2019, capital assets ' 1 0 are worth $151 million more than what we still owe). Net position —Other assets represents the current value of all other assets, offset for amounts we owe. • Cash reserves • Inventory • Loans (businesses or people owing the County money) ` 513 The current value in net position of all other assets could be viewed in a similar manner to that of a checking account. (i.e. other assets are worth $57 million more than what is owed). (in millions) Net position - otheras.sets Tota( Net Position $ 191 $ 195 $ 196 $ 192 $ 166 $ 191 $ 183 $ 176 $ 187 $ 208 $1,400 $ J rl01 per capita $114}� � 0 g, Ez F'W r- 00 { 6�+.,99 CD CD CDC) f3 C ) D y yQ1 4 Y 7 'tl M1 v ' 4 1 �+1. 5 Y ., � kN 1 �1 3 DESCHUTES COUNTY, OREGON Current year breakout of assets held as of June 30, 2019 is represented with the graphic below. Total assets held by Deschutes County as of June 30, 2019 was $439 million. Assets represent items of value owned by Deschutes County. Approximately 44% of asset value is related to capital assets (roads, vehicles & equipment, and buildings), 43% of asset value is held as cash and investments, and the remaining 13% is made up of receivables and inventory. Teal Assets $ 330 $ 327 $ 324 $ 317 $ 294 $ 345 $ 355 404 $ 407 $ 439 Current year breakout of li11JOHIties held as of June 30, 2v^19 is represented with the graphic below. Total liabilities incurred by Deschutes County as of June 30, 2019 was $231 million. Liabilities represent amounts owed by Deschutes County. Approximately 59% of our liabilities is in relation to future pension and other post -employment benefits (OPEB) obligations, 22% of our liabilities is related to long-term debt, 12% is related to vendor amounts payable, and the final 7% is for insurance claims and closing the Knott landfill. (in millions) Pension $ - $ - $ - $ $ - $ - $ 46 $ 96 $ 87 $ 102 Debt 102 94 88 79 79 72 66 59 55 52 OPEB 6 8 10 14 17 46 20 33 34 35 Payables 17 16 is 16 18 19 21 22 30 27 Claims & closure 14 14 is 16 14 17 19 18 14 15 Total Liabilities 139 $ 132 128 $ 125 128 154 $ 172 $ 228 $ 220 $ 231 4 DESCHUTES COUNTY, OREGON Deschutes County revenues for Fiscal Year 2019, were $202.8 million (a 3.0% increase over the prior year). Deschutes County's revenue makeup consists of 3 different sources: • Taxes: include both property tax revenue and room -tax revenue. Total tax revenue for the year was $82 million (a 6.5% increase over the prior year). • Charges for Services: include payments made by residents for a specific service provided to the resident (e.g. building permit application). Total charges for services for the year was $61 million (a 3.4% increase over the prior year). • Grants and Contributions: include payments made for services by the Federal, State, and other local governments. Total grants and contributions for the year was $54 million (a -1.8% decrease from the prior year). "' -risCa, Charges for Services 30% Grants and contributions 27% Taxes 40'[ fter]�ioi Deschutes County expenses for Fiscal _�Mft Health & Welfare Genera[ Government Year 2019, were $182.1 million 25% 'bf'`` 18% (a -2.2% decrease from the prior year). interest and Public Safety fiscal charges 38% 1% Change from the prior year: Public Safety: + 9.3% Health & Welfare: — 9.9% General Government: — 9.9% County Roads: ® 2.6% Solid Waste / Fair & Expo: ® 3.4% Interest and fiscal charges: - 3.8% Public Safety includes the Sheriff's Office, Deschutes 9-1-1, and Community Justice. Health & Welfare includes Deschutes County Health Services and Veterans' Services. General Government includes a variety of departments, such as the Assessor's Office, Clerk's Office, District Attorney's Office (including Victims' Assistance), and Justice Court. 5 DESCHUTES COUNTY, OREGON -Nevenues 10 Year Historr� on (in millions) Taxes Chargesfor services Grants and contributions other " ill !!1 9 k Taxes $ 66 $ 66 $ 66 $ 67 $ 69 66 $ 72 $ 75 $ 77 $ 82 Charges for services 42 44 43 46 49 51 57 57 59 61 Grants and contributions 38 33 34 31 41 41 50 42 55 54 Other 2 1 1 (21 1 1 2 1 5 5 Total Revenues $ 148 $ 144 $ 144 $ 143 $ 160 $ 160 $ 181 S 176 $ 197 $ 203 A 9% VA ff I 1 0 — volatility from changes in accounting rules. txpenses 'I U Tear n isA. L U F Stabilized after afew years. $100 Public safety Health and welfare General $50 government County roads S.W. & Fair interest and fiscal charges (in millions) MEIMMIMMIT-W MIZOM Public safety $ SO $ 54 $ 57 $ 58 $ 73 $ 46 $ 75 $ 69 $ 64 $ 70 Health and welfare 24 29 30 32 44 32 44 45 50 45 General government 26 24 26 26 33 25 35 32 36 33 County roads is 19 16 16 19 17 18 19 18 18 S.W. & Fair 11 12 12 12 13 12 14 16 15 15 Interest and fiscal charges 3 3 3 2 3 2 2 2 2 2 Total Expenses $ 129 $ 140 $ 144 $ 146 $ 185 $ 135 $ 189 $ 183 $ 186 $ 182 DESCHUTES COUNTY, OREGON Over the last 10 years, Deschutes County has reduced its debt from $102.4 million down to $50.2 million (a 51% reduction). On June 30, 2019, Deschutes County owed: $9.8 million for the buildings and equipment at the Knott landfill and the Fair & Expo center. $31.3 million on general government buildings and equipment used in County operations • $9.1 on pension bonds that were issued during 2002 and 2004 to offset the long-term costs of the pension liability. Genera`? Government On February 19th, 2019, Moody's© announced an upgrade to the County's debt rating. The rating was increased from Aa2 to Aa1. Moody's© credited Deschutes County's "large and growing tax base", "healthy reserve levels and liquidity", and its "modest debt burden and manageable pension liabilities" for its increase in credit worthiness. Moody's rating of Aa1 represents that Deschutes County is a "High Grade" investment to municipal investors. The chart below presents the amount of debt outstanding each year, as well as the amount attributable to each resident in Deschutes County. The debt per capita metric illustrates the County's debt burden in relation to an individual resident. �S ��, a1 PER C,API-P' History10 Year 120 700 CAP 40 200 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 7 DESCHUTES COUNTY, OREGON Property Taxes In Oregon, property taxes are billed based on the assessed value of a property Assessed Value X multiplied by the approved (levied) = Ta X B ill Deschutes County is funded, in part, by 5 separate tax levies. General Deschutes County Levy: District Attorney, Assessor, Community Justice, and more, for all residents. Countywide Law Enforcement Levy: County Jail, Civil Unit, and Search and Rescue for all residents. Rural Law Enforcement Levy: Detectives, Patrol, and Records for residents outside of city limits. • 9-1-1 Levy: Traditional 9-1-1 services for all residents. Extension and 4-H Levy: Extension and 4-H services for all residents. The cumulative total of __ .; r -u' � levied and the assessed value for the past 10 years are shown below. 10 Year History of thle'Tax Rates* Rate per $1,000 of assessed value (excludes expired local option levies) 2010 2011 2012 2013 2014.2015 2016 2017 2018 2019 * % Change in Assessed Value from prior year 8 DESCHUTES COUNTY, OREGON growth rate of 2.07%. 150 Assuming this growth rate continues, Deschutes County's population should eclipse the 200,000 mark within 3 years. Source: Portland State University Median Age for Deschutes County has been stable at around 40 years old over the last 10 years. The median age for the United States over that same period hovered around 38 years old. At the end of Fiscal Year 2019, 50% of County residents were older than 41.50 years and 50% were younger. Source: Portland State University Unemployment Rate for Deschutes County has been at or below 5.0% for the last 4 years, with Fiscal Year 2019 ending at 4.5%. Deschutes County started the 10 year period shown with an unemployment rate of 14.8%. Source: Oregon Employment Department Population per FTE (or # residents per County employee) for Deschutes County has remained stable over the last 10 years. At the end of Fiscal Year 2019, there were 183 residents per County employee. This data point provides insight into the size of government versus the population governed. Source: Deschutes County no 2010 20131 C1 (# residents per County employee) �iL 180 00 0 00 0 0 160 010 2013 201601 9 DESCHUTES COUNTY, OREGON Additional Information Disclosures: • Intended audience: Residents seeking high-level financial information concerning the County. • Measurement focus: The financial data presented in the Popular Annual Financial Report (PAFR) uses the same measurement focus and basis of accounting as the County's Comprehensive Annual Financial Report (CAFR). • Financial information: Financial information from the Comprehensive Annual Financial Report (CAFR) government -wide financials have been reproduced (full -accrual). Fund -level information has not been provided, but is available in the CAFR. All financial entities (including component units), as presented in the CAFR, have been consolidated in the PAFR. • Departures from accounting terminology: In preparing the PAFR, minor departures were made from standard generally accepted accounting principal (GAAP) prescribed terminology. Such departures were made in an attempt to avoid confusion concerning the materials presented. Highlighted departures from GAAP are: "Assets" as used in this report, at times, include both Assets and Deferred Outflows. • 'Liabilities" as used in this report, at times, include both Liabilities and Deferred inflows. "Net Position —Other Assets" includes both Restricted & Unrestricted Net Position. • "Net Position -Capital Assets" is Net Investment in Capital Assets. Volatility due to changes in accounting measurement: Over the course of the 10 years presented, the Government Accounting Standards Board (GASB) has made modification to how certain items are presented (e.g. pensions and other post -employment benefits). Such changes in recognition practices introduced volatility to the 10 year trend information, as presented. Contact Information: Deschutes County Finance Department 1300 NW Wall Street, Suite 203 Bend, Oregon 97703 finance@deschutes.org Special thanks to Finance Department staff and their commitment to the underlying debits/credits. 10 DESCHUTES COUNTY, OREGON °t FINANCE OT E S C0141 GZ q.� Deschutes County Board of Commissioners 1300 NW Wall St, Bend, OR 97703 (541) 388-6570 - Fax (541) 385-3202 - https://www.deschutes.org/ AGENDA REQUEST & STAFF REPORT For Board of Commissioners BOCC Wednesday Meeting of September 9, 2020 DATE: September 3, 2020 FROM: Erik Kropp, Administrative Services, 541-388-6584 TITLE OF AGENDA ITEM: Continued Discussion of Vacant Position List RECOMMENDATION & ACTION REQUESTED: Discuss vacant position list and direct staff as appropriate. BACKGROUND AND POLICY IMPLICATIONS: See attached staff report and vacant position list. FISCAL IMPLICATIONS: ATTENDANCE: Deputy County Administrator Erik Kropp and HR Director Kathleen Hinman �X\ ES as K `f Date: September 3, 2020 To: Board of County Commissioners From: Erik Kropp, Deputy County Administrator LE 4 Re: Vacant Position List On August 5, 2020, the Board last discussed the list of vacant positons. At that meeting, the Board directed staff to return in September to continue the discussion after the State Legislature's Special Session. In preparation for the vacant position discussion scheduled for your September 9, 2020 Board meeting, attached is a vacancy report divided into three sections: • List of the 10.75 positions already eliminated — these positions are highlighted in green (page 1 of 10). List of 14 positions that have not requested a recruitment — positions from an office of an elected official are shaded in blue, the other positions are shaded in pink/salmon (pages 2-3). List of 112.60 positions that are 100% grant funded, are in the recruitment process, or are in the Sheriff's Office (pages 4-10). None of the positions in this section are shaded. In addition, the Board asked about the number of positions that have been added since the adoption of the FY 20-21 Budget, which occurred on June 24, 2020. The table on the next page shows the positions added and eliminated since the adoption of the budget. Date Action June 24, 2020 FY 20-21 Budget Approved June 24, 2020 Round 1 of Vacant Position Elimination included July 8, 2020 Round 2 of Vacant Position Elimination July 22, 2020 Health Services - SAMHSA Grant Limited duration staff to serve children with serious emotional disturbances July 22, 2020 Health Services - IMPACTS Grant Limited duration positions at Crisis Stabliz. Center July 22, 2020 Health Services - COVID related Limited Duration Auirust 12, 2020 DA/SO Grant - Management Analyst Limited duration August 19, 2020 August 26, 2020 Health Services - COVID related Limited Duration FTEs Board Resolution # 1,071.7 -5.75 -5.0 2020-054 8.0 2020-049 7.8 2020-050 4.0 2020-045 2n2n-n52 0.1 ---- --- 1.0 Sheriffs Office - Behavioral Health - reduce recidivism 3.0 Eliminate BH Program Manager -0.5 Total: 1,084.4 Difference: 12.65 300 N1W VvIII Street Bend C r eegu n 97703 Q� 388 6584 @ (giI<,I<er w,,esC�n�C<-s.pl"g 2020-053 2020-047 \{ \\\ \ \ \ \ \\ (!{ BE k \ azA O � f s � _ 0 i a E g E Ism: „ g s E g o n E n E d V o in lot a Z E m E E 2 PIES F 12 O a o o o o 0 0 K E o F - c a =^f 2a 3- !� \� o F E E E E E E E _ E 'u E 'u E E- n £ A c _ u E Q z -—— a 3 tR ? E 3 0 o 43 _'o - - A E rc Z � O E i u v 8 a u E „ E p O E W _ 's 0 � S E ts E E 0 E L ills E G E E A s E E c '1° A _ $ -� 3 o c `nu o f `o u All o o '8 0 _ I_33 3' Eo 3 A o i n 3 E o 3 04 '" _ _ Q_ E6X�a„ A L tmumga v E c zo9E _ r E L 'n - o 0 3 a n o E a _ u v E 3$ _ ' 0 8 o g' = E OZ if - G A o E o E o f i m S E c i A o 3 .. .El! E o E fill llljj;l- G - - - E Z - i i _ ...E d - HIM a uEA EIZ.m HUM $E -A oIamo%='-oa_m Em°vE v_ co 3> E V n g g o ` E u 9 x p Ero 2 1 r r r r r r r r r o _ _ f £ LL - LL - LL a a a a a a a x O z � 8 8 E E E E c E s ti o 'E- a E A a -- a L - '�„' r E A c - - 5 E n- i- _ E E- m _ 3 21 m G c N E g E g E g L P - d ni 5 E a E E m O G x x x x O o S o a o S a E 0 E 0 E E o E E V E 8 E E E c E E E c E - C E E E E E E n E E E E E E $ E E E E E E E E E E E $& o a `o - oY Ei Ei E� Bv�E mB E Ei = �E � o N r - Z f E f f f E E f a a d c'E E d d d E 72 E - - _ x x x x x x x x x x x x x a x a x a x a a x E E E E E E E E _ E E 3 Y m 3 C is — O E- E c . > & _ 2 E u o E � E -- a E o 0 - E ., c 9 v"; v u A c o cf E E a o - i $ ', v - ° to E u E- � EE E i W p x G d \ i Q E bo E E E E _ 'Git a f F f i' c x a x a = a x = x a = a a a a a � \ { { \ \ } \\\cl \ \ \\ \\\ \\\ OK i - - \� ! \ \ cl / C E E E E E E E E x x rr 0 C E - R 2 3 E _ d 2 O E 00 d sW �o 3 S r � E - - S - Z O O E W E f r m A A A A .. .• � u - a r a u 3 a 0 o 0 0 0 0 0 0 0 0 0 0 o o N 9 0