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Niagara County 2016-2018 CHA/CHIP Update 1

NYS 2016 Community Health Assessment and Improvement Plan

for the

Niagara County Department of Health

Daniel J. Stapleton, MBA

Public Health Director


5467 Upper Mountain Road

Lockport, NY 14094

[email protected]

Hospital Partners

Niagara Falls

Memorial Medical

Center

Mt. St. Mary’s Hospital Eastern Niagara

Hospital

DeGraff Memorial Hospital

Patrick Bradley Fred Caso Carolyn Moore Kathleen Tompkins

(716) 278-4569 (716) 297-4800 (716) 514-5700 (716) 859-8728 [email protected] [email protected] [email protected] [email protected]

mailto:[email protected]


Executive Summary

Prevention Agenda Priorities and Disparity

The Niagara County Department of Health has partnered with Niagara Falls Memorial Medical

Center, Mt. St. Mary’s Hospital, DeGraff Memorial Hospital and Eastern Niagara Hospital to prepare the

Community Health Assessment and Community Health Improvement Plan/Community Service Plans for

the 2016-2018 period. To support New York State in meeting its Prevention Agenda goals, Niagara

County has chosen New York State Prevention Agenda Priorities 1, Prevent Chronic Disease, and 2,

Promote Mental Health and Prevent Substance Abuse.

2013 Priority Area Update and Changes

For the 2013-2017 CHA/CHIP/CSP, Niagara County chose to work on Priorities 1, Prevent

Chronic Disease, and 2, Promote Healthy and Safe Environments. Under Priority 1, the Niagara County

Department of Health (NCDOH) set a goal to promote the use of evidence-based care to manage chronic

disease, seeking to increase by at least 5% the percentage of adults with chronic diseases who have taken

a course to learn how to manage their condition. Alongside Priority 1 was the targeted disparity of mental

hygiene. In order to reduce this disparity, the NCDOH sought to increase by at least 30, the number of

referrals from the Niagara County Mental Health Department and the Mental Health Association of

Niagara County for individuals with depression to participate in evidence-based workshops. For Priority

2, the goal was set to reduce falls among vulnerable populations in order to reduce hospitalizations in the

population aged 65+ by 10%.

During the data collection phase of the 2016-2018 period, emerging issues were identified and

considered as potential new priorities. The NCDOH met with hospital partners to review the 2013-2017

priority area progress in early 2016. The decision was made to retain ‘Prevent Chronic Disease’ and to

change the second priority from ‘Promote Health and Safe Environments’ to ‘Promote Mental Health and

Prevent Substance Abuse’.


Emerging Issues

Preventing Chronic Disease remains a priority of the Niagara County Department of Health and

its hospital partners. Chronic disease continues to be recognized as a serious burden to quality of life for

Niagara County residents, and the promotion of disease screenings and self-management workshops will

continue for all partners through 2018. In recognition of the current climate surrounding substance abuse

and opioid related hospitalizations and deaths, Promoting Mental Health and Preventing Substance Abuse

was added to the 2016-2018 priorities for all partners in order to develop a comprehensive plan for

Niagara County to begin building a network of supportive services.

Review of Data

According to the 2016 County Health Rankings, Niagara County ranks 55 out of 62 New York

counties for overall health, 51 out of 62 for clinical care/preventative health, and 58 out of 62 for

mortality/premature death. According to 2015 SPARCS data, hospitalization rates for heart attacks and

diabetes have significantly worsened in Niagara County since 2012, in terms of both long and short-term

complications. 64.2% of Niagara County adults are overweight or obese, and 8.1% of the population has

physician-diagnosed diabetes (BRFSS, 2014). The mortality rate due to coronary heart disease is 165.7

per 100,000, and Niagara County has a high rate of emergency room visits due to hypertension and heart

failure. The prevalence of hypertension in the county is 27.1% (55.7% in the Medicare population) and

the prevalence of hyperlipidemia is 30.3% (47.1% in the Medicare population).

In Niagara County, there are 116.6 hospitalizations per 10,000 residents 18+ each year that are

related to mental health (SPARCS, 2016). 16.7% of the Medicare population has physician-diagnosed

depression (BRFSS, 2014). Niagara County has an extreme shortage of mental health providers;

currently, there are 99 providers per 100,000 residents (County Health Rankings, 2016). Substance abuse

data from the Centers for Disease Prevention and Control shows 16.6 deaths per 100,000 residents due to

drug intoxication (CDC, 2014). Opioids are responsible for a surge in both ER and inpatient


hospitalizations: annually there are 177.4 visits per 100,000 residents through the ER, and 350.6 inpatient

admissions per 100,000 residents for opiate related incidents (SPARCS, 2016).

Roles of Partners

NCDOH has engaged with leadership from each of the four local hospitals: Niagara Falls

Memorial Medical Center, Mt. St. Mary’s Hospital, Eastern Niagara Hospital and DeGraff Memorial

Hospital. Each organization has been present at all stages of planning, data collection and analysis.

Membership of the Community Health Assessment workgroup can be found at the end of this document,

in Appendix 1. The selection of the 2016-2018 priorities was a collaborative effort, facilitated by the P2

Collaborative of Western New York. Following the survey and community conversation process, a

community-wide key stakeholder meeting was convened in where information gathered was reviewed.

Broad Community Engagement

The community stakeholder meeting successfully brought together partners from key

organizations working in Niagara County to review current initiatives and programs that support the two

selected priority areas. This meeting engaged a broad spectrum of partners who hold vested interests in

chronic disease prevention or mental health/substance abuse prevention/awareness. A list of participating

partners can be found at the end of this document, in Appendix 2.

During this meeting, community leaders heard from the CHA workgroup and the P2

Collaborative regarding the current climate of population health. Data was shared, and the group was

apprised to the Department’s plans to pursue chronic disease and mental health/substance abuse as 2016-

2018 priorities. Breakout sessions were held, and each organization had the opportunity to share their

experiences and their objectives under these priorities. This information was gathered and has been used

to develop the activities that follow in this report. The NCDOH and partner hospitals plan to continue to

meet with these partners as program implementation begins, utilizing their resources and programs to

support the Prevention Agenda work.


Interventions, Strategies and Activities

For Priority Area #1, Preventing Chronic Disease, the goal of the Niagara County Department of

Health is to promote the use of evidence-based care to manage chronic disease. The objective is to

increase, by at least 5%, the number of adults with chronic disease who have taken a course or class to

learn how to manage their condition. The activities in this plan include data surveillance and education to

all nursing staff, promotion of evidence-based programs at a variety of sites throughout the county,

collaboration with outside agencies to increase referrals, and constructing a working relationship between

our health department and the Department of Mental Health to address the chosen disparity of mental

hygiene. For this priority area, capacity building between the health department and primary care

physicians will be instrumental for the 2017/2018 plan’s success.

For Priority Area #2, Promote Mental Health and Prevent Substance Abuse, the goal will be to

Promote Mental, Emotional and Behavioral Health (MEB). The objective is to increase MEB community

stakeholder involvement by 10% by 12/2018. The activities in this plan include data surveillance and

information sharing, capacity building among mental health partners, becoming involved in mental health

and substance abuse focused coalitions, planning for training department staff in Mental Health First Aid

and Naloxone administration, and promoting a widespread education and media campaign.

Tracking and Impact Evaluation

The Public Health Educator will work closely with the Director of Nursing to monitor progress

on CHIP activities on a monthly basis. Reports from evidence-based workshops will be analyzed on a

quarterly basis to gauge resident participation. Meetings between Department of Health and Department

of Mental Health key staff will occur on a quarterly basis to discuss progress of current interventions and

to facilitate planning for future initiatives. Evaluation of staff time will allow for tracking of personnel

time spent in each priority area at the end of each quarter.


Report

Population

According to the U.S. Census Bureau for Niagara County 2015 American Community Survey,

the estimated population of Niagara County is 212,652, which shows a 1.8% decrease from the previous

2010 Census. The county is considered to be 75% urban and 25% rural. In regard to race alone, or in

combination with one or more other races, 88.1% of residents are Caucasian, 7.2% are Black, 1.1%

American Indian, 1.1% Asian, and 2.4% from two or more races. 2.8% of the population is Hispanic or

Latino of any race. Per capita income is $26,710 and 13.4% of families are living below the Federal

Poverty Line (US Census, 2015). According to Community Health Rankings, 10% of the population of

Niagara County remains uninsured. 32,949 residents received Medicare, (elderly 65+ and disabled), and

36,451 received Medicaid. The ratio of residents to primary care providers is 2,300: 1 (County Health

Rankings, 2016).

New York Counties: Rate of Uninsured Individuals

(County Health Rankings, 2016)


Leading Causes of Death

Life expectancy in Niagara County is lower for both males and females than the national

averages. Life expectancy for females is 79.9 years, and 75.3 years for males (Institute for Health Metrics

and Evaluation, 2015).

According to the Office of Vital Statistics, the leading causes of death in Niagara County are

heart disease, cancer, chronic lower respiratory diseases, stroke and unintentional injuries. Rates of death

from 2014 can be seen below (Vital Statistics, 2016).

Niagara County Health Rankings

The 2016 University of Wisconsin’s Mobilizing Action Toward Community Health

(M.A.T.C.H.) County Health Rankings place Niagara County at 55 out of 62 counties in New York State

based on health outcomes, health factors, clinical care, social and economic factors and physical

environment. The County Health Rankings and Road Map program is collaboration between the Robert

Woods Johnson Foundation and the University of Wisconsin Population Health Institute. The program

shows the rank of nearly every county in the United States and looks at a variety of measures that affect

health.


Chronic Disease

Niagara County continues to have a high incidence and mortality of cardiovascular disease and

diseases of the heart. Cardiovascular disease is the leading cause of death in Niagara County. The

morality rate from cardiovascular disease is 376.1 over per 100,000 residents (Vital Statistics, 2014).

Niagara County is 2nd in the Western New York region for premature death due to cardiovascular illness.

The mortality rate in Niagara County is well above the NYS average.

The age-adjusted rate of heart-attack related hospitalization is also on the rise, per the most

current SPARCS data. The most current rate of 23.4 hospitalizations per 10,000 residents is well above

the threshold of 14.0 set by the NYS Prevention agenda.


Hypertension rates have shown a decline in the last 5 years, however, rates still remain

higher in Niagara County when compared to New York State as a whole. Hypertension is

recognized as a co-morbid condition for cardiovascular disease, cerebrovascular disease and

diabetes, among others.

According to the Prevention Quality Indicators, hospital admission rates for circulatory disease in

the zip codes of the City of Niagara Falls, are among some of the worst in the state. The admission rate

for African Americans regarding all circulatory concerns is 412% of the expected rates, and for

Caucasians the rate is 141% of the expected rate.

According to American Diabetes Association projections, 1 in 3 Americans will develop diabetes

in their lifetime. The risk factors for diabetes include both characteristics that cannot be modified (race,

ethnicity, family history and age) as well as behavioral characteristics that can be modified (physical

activity, nutritional habits and weight management). An estimated 1.5 million adult New Yorkers have

been diagnosed with diabetes. Diabetes is more prevalent in adults who are overweight/obese. As

previously mentioned, 64.2% of Niagara County residents are overweight or obese. Obesity is a serious

health concern for children and adolescents. According to the Centers for Disease Control and Prevention,

obese children and adolescents are more likely to become obese as adults. Obese and overweight youth

are more likely to have risk factors associated with cardiovascular diseases, such as high blood pressure,


high cholesterol, and Type 2 diabetes. Niagara County has one of the highest rates of overweight/obese

adolescent populations in New York State. 42% of Niagara County middle and high school students have

a weight that is considered overweight or obese (Healthy Communities Institute, 2015).

Type 2 diabetes is a significant concern in Niagara County. 8.1% of Niagara County residents

have been diagnosed with Type-2 diabetes (BRFSS, 2014). The age-adjusted death rate due to diabetes

complications is 25.4 death per 100,00 residents, which is in the bottom quartile compared to all NYS

counties. Death rates due to diabetes are higher in males versus females. Despite prevention efforts, these

rates continue to climb across Niagara County.


Chronic disease is of particular concern in the Medicare population; there are high rates of

hospital utilization for cardiovascular disease, diabetes, asthma and COPD in this population.

Hospitalization rates for asthma and COPD in the Medicare population have both risen since 2014,

currently at 6.1% and 14.8% respectively.

BRFSS data indicates that rates of binge drinking, smoking and opiate use are on the rise in

Niagara County. 10.9% of adults in Niagara County reported poor mental health in the past 30 days, with

the greater percentage being females with income levels below $24,000 and between the ages of 45-54.

18.7% of adults report binge drinking; excessive alcohol consumption is a major contributing factor to

cirrhosis and liver disease. 21.7% of the adult population are smokers, contributing to the high incidence

of chronic lower lung disease, asthma and lung cancer.

Data indicating the significance of the opiate crisis in Niagara County is still being analyzed.

Through the end of 2013, the age-adjusted rate of death from opioids was 7.3 per 100,000 residents.


Opioid abuse also accounted for 34.2 ER visits per 10,000 adults, as well as 177.4 hospital admissions per

100,000 residents (SPARCS, 2014). Current events and reporting from local municipalities indicate that

the opiate problem is trending upward in Niagara County, and these figures are anticipated to climb.

There is a recognized shortage of mental health providers in Niagara County, with only 99

providers per 100,000 residents (County Health Rankings, 2016). Rates of inpatient hospitalization for

adults and children in Niagara County are significantly higher than the NY State average. Niagara County

also has the 2nd highest rate of hospitalization due to suicide attempt in the Western Region. Depression is

a concern in the over-65 population, with 16.7% of Niagara County residents currently diagnosed with

depression.


Selected Prevention Agenda Priorities: Results of 2016 Survey

Community Health Assessment surveys were distributed across Niagara County between March

and May 2016. In total, 2,111 surveys were completed by Niagara County residents. The questions were

designed to poll the public about their perceptions of health and health care, and to provide direction to

the CHA workgroup regarding the selection of priority areas. The results are as follows:


In addition to the survey process, focus groups were held throughout Niagara County to further

understand the needs of the population as it pertains to health and healthy communities. Focus groups

were held between May and July 2016, at nine locations including churches, food pantries, hospitals and

community/senior centers. These focus groups were hosted by the Niagara County Department of Health

and the local hospitals, and were facilitated by the P2 Collaborative of WNY. Summaries of the answers

provided follow:


Community Engagement Process

The Niagara County Department of Health partnered with the four local hospitals of the county,

and worked alongside the P2 Collaborative of WNY to develop a brief, yet comprehensive, community

health survey. In addition to the structured questions, an open-ended question was added to the survey to

collect anecdotal information directly from the respondents. The survey was designed in the Survey

Monkey tool, and a QR code was fabricated in order to optimize mobile use. The Public Health Director

composed a press release that was sent to all media outlets once the survey was ready for release to the

public. Survey links were provided on the Facebook pages of the Niagara County Department of Health,

and the partnering hospitals. Emails with the survey link were distributed through a variety of channels.

Division Directors and the Public Health Educator directed staff to take survey flyers to the community as

part of the daily activities such as clinics, home visits and health fairs. Surveys were made available at

congregate meal sites throughout the county, and at some local churches.

The hospitals and the Niagara County Department of Health were in agreement to use community

focus groups as another means of gathering information for the Community Health Improvement Plan.

The Public Health Educator worked closely with facilitators from the P2 Collaborative to execute focus

groups in a variety of settings. The four hospitals also held their own focus groups with coordination

assistance from P2. These focus groups, or community conversations, were strategically planned to

engage residents of Niagara County from varying demographics and geographic areas.

As previously mentioned, key stakeholders from organizations that support the work of the

Niagara County Department of Health and the NYS Prevention agenda were invited to an informational

meeting and discussion on August 4, 2016. At this meeting, these stakeholders were apprised to the

results of the CHA survey from the Public Health Educator and the Population Health Manager of the P2

Collaborative. During breakout sessions, each organization had the opportunity to share their experiences

and their objectives under the selected priorities. This information was gathered and has been used to


develop the activities that were written into the Community Health Improvement Plan. This meeting also

allowed for partners to discuss coalitions that they are a part of, and provided the opportunity for capacity

building to strengthen these existing coalitions.

Priority Area Goals and Objectives

The Community Health Improvement Plan of the Niagara County Department of Health, and the

Community Service Plans of Niagara Falls Memorial Medical Center, Eastern Niagara Hospital, DeGraff

Memorial Hospital and Mt. St. Mary’s Hospital follow this report. For each of the two priority areas,

these plans will detail how each organization intends to address the health issue, and will identify the

resources that will be committed to address the need.

Maintaining Engagement with Stakeholders

In order to maintain engagement with local partners over the next three years, the Niagara County

Department of Health will remain involved in a variety of community-based coalitions and collaboratives

that are addressing health disparities as they relate to the two chosen priority areas. Staff from the

Niagara County Department of Health lead the Diabetes Coalition of Niagara and Orleans Counties, a

coalition that meets monthly and includes leadership from local hospitals, certified diabetes educators, the

P2 Collaborative, pharmaceutical companies (NovoNordisk and Sanofi), Native American Community

Services, pharmacists, the Cornell Cooperative Extension and the American Diabetes Association. The

Public Health Director meets with the Leadership Council of the Creating a Healthier Niagara Falls

Collaborative on a quarterly basis. The Collaborative focuses on addressing social and economic

disparities within the City of Niagara Falls in an effort to promote health equity. Nursing staff attend

monthly meetings of the Community Health Alliance of North Tonawanda and Project Runway,

cooperative groups that meet to discuss substance abuse in Niagara County communities and to plan

initiatives aimed at raising awareness and providing community-wide education. The health department

will maintain a close relationship with the Niagara County Office for the Aging in order to support our


evidence based programs, Diabetes Prevention Program, Chronic Disease Self-Management Program and

Diabetes Self-Management Program.

The Niagara County Department of Health plans to give great priority to capacity building as it

relates to mental health and substance abuse issues. Regular meetings with the Niagara County

Department of Mental Health will take place over the next three years, to allow for communication

between both departments regarding the scope of work in the community. Staff from the Niagara County

Department of Health will engage with mental health providers and school counselors through the

Community Network of Care meetings, which take place quarterly. The Public Health Director will

continue to engage with the Niagara County Legislature as they develop an Opiate Task Force. The

Niagara County Department of Health and all four Niagara County hospitals have committed to meet on a

quarterly basis to maintain collaboration on our prevention agenda priorities.

As the activities of the Community Health Improvement Plan are implemented, the Public Health

Educator and the Director of Nursing will closely monitor the impact of the interventions and make

revisions to the plan as necessary.

Dissemination of Plan

Plans to inform the community of the results of the Community Health Assessment Executive

Summary and the Community Health Improvement Plan will be directed by the Public Health Director in

2017 upon New York State Department of Health approval. A press release will be distributed to local

media outlets, and will be shared on the Department’s social media pages. Copies of the Community

Health Assessment Executive Report and Community Health Improvement Plan will be given to the

members of the Board of Health, and all division directors within the Department of Health. The plan

will also be shared with the leadership of the Niagara County Office for the Aging and the Niagara

County Department of Mental Health. The Community Health Assessment Executive Report and the

Community Health Improvement Plan will be available for public access on the Niagara County


Department of Health website. Local hospitals will be encouraged to provide this information on the

respective websites as well.

Acknowledgement

The Community Health Assessment Report and Community Health Improvement Plan were

written by the Public Health Educator from the Niagara County Department of Health. Many of the data

sources encompass various years and methods of reporting, however, the most current data available at

the time was used. The Niagara County Department of Health would like to acknowledge the P2

Collaborative of WNY for their assistance in the organization and facilitation of the Community Health

Improvement Plan group.



Priority Area #1

Preventing Chronic Disease

Disparity: Mental Hygiene

Focus

Area Goal Objective Activities

Partner

Responsible

Chronic

Disease

Promote

use of

evidence-

based care

to manage

chronic

disease

By December 31, 2018,

increase by 5% the

percentage of adults

with arthritis, asthma,

cardiovascular disease,

or diabetes who have

taken a course or class

to learn how to manage

their condition.

Reduce disparity: By December 31, 2018,

increase, by 5%, the

number of individuals

with depression who

participate in a

CDSMP, DSMP or

DPP program

workshop.

1. Educate nursing staff

regarding recent studies and

data on chronic disease.

2. Increase number of

participants completing

diabetes prevention program

(DPP) by 5% by 12/31/2018.


participants completing the

chronic disease self-

management program

(CDSMP) by 5% by

12/31/2018.


participants completing the

diabetes self-management

program (DSMP) by 5% by

12/31/2018.

5. Conduct outreach to 3

primary care providers and

offices to inform of program

offerings, and to coordinate a

system for referrals into

DPP/CDSMP/DSMP by

12/17.

1. NCDOH -

educates

Nursing Staff

2. NCDOH -

promotes and

schedules

classes

3. NCDOH -

promotes and

schedules

classes

4. NCDOH -

promotes and

schedules

classes

5. NCDOH-

provides

academic

detailing for

DSMP &

CDSMP

American

Diabetes

Assoc.-provides

academic

detailing for the

DPP.


6. Conduct outreach to 3

additional primary care

providers and offices to

inform of program offerings,

and to coordinate a system

for referrals into

DPP/CDSMP/DSMP by

12/18.

7. Conduct CDSMP/DSMP

outreach and provision to

four community / senior

centers each year.

8. Continuously revise and

implement promotional plan.

9. Reconvene with Niagara

County Hospital’s Discharge

Coordinators to remind them

of NCDOH evidence-based

programs and to encourage

referrals to prevent re-

hospitalizations by 3/17.

10. Continue using depression

educational materials and a

depression screening tool to

use at Health Assessment

Clinics (HAC) to identify

patients with depression

through 12/18.

6. NCDOH -

provides

academic

detailing for

DSMP &

CDSMP.

American

Diabetes

Assoc.-provides

academic

detailing for the

DPP

7. NCDOH-

provides

workshops

NC Office for

the Aging-

provides

financial

support for

administering

programs,

printing of

promotional

materials,

scheduling

individuals into

classes.

8. NCDOH-

creates plan

9. NCDOH-

initiate meeting.

Hospitals-

provide

brochures to

patients upon

hospital

discharge.

10. NCDOH -

distributes

educational

materials and

screening tool.

Refer patients as

needed.

Niagara County

Dept. of Mental


11. Reconvene with Niagara

County Mental Health,

Mental Health Association of

Niagara County, and other

local mental health offices to

re-educate and encourage

referrals to NCDOH

evidence-based programs for

individuals with depression

by 3/17.

12. Re-educate Nursing Division

staff to refer all individuals

that screen positive for

depression to the appropriate

mental health professional by

3/17

13. Offer depression screening

as part of a health assessment

at 6 senior nutrition sites by

12/17.

14. Offer depression screening

as part of a health assessment

at 6 senior nutrition sites by

12/18.

15. Offer provision of one

CDSMP, DSMP or DPP

program at each NC hospital

by 12/17.

Health &

Substance

Abuse

(NCDMH) -

recommend and

provide

educational

materials.

11. NCDOH -

re-educate

nursing staff.

NCDMH - refer

patients to

evidence based

programs.

The Mental

Health

Association

(MHANC) -

refer patients to

evidence based

programs.

12. NCDOH -

provide

education.

13. NCDOH -

provide

screening.

14. NCDOH -

provide

screening.

15. NCDOH-

provide

workshop

Hospitals - host

and promote

program at their

facility.



Priority Area #2

Promote Mental Health and Prevent Substance Abuse

Focus

Area

Goal Objective Activities/Interventions Partner

Responsible

Promote

Mental

Health and

Prevent

Substance

Abuse

Promote

Mental,

Emotional and

Behavioral

Health (MEB)

Increase the percent

of employees

trained in trauma-

informed approach

by 35% by

December 2018

Offer information

on and referral to

available Mental

Health services to

100% of individuals

who have positive

depression screens.

1. Train 100% of Nursing

Division Staff in Mental

Health First Aid certification

by 12/17

2. Train 10% of remaining

Health Department staff in

Mental Health First Aid

certification by 12/18

3. Complete depression

screenings on 80% of

patients attending Health

Assessment Clinics

throughout Niagara County

through 12/2018

4. Train Nursing Division staff

on available mental health

services in Niagara County

to allow for facilitation of

patient referrals by 6/2017.

1. NCDOH -

coordinate

training.

The Mental

Health

Association in

Niagara County

(MHANC) -

provide

training.

2. NCDOH -

coordinate

training.

MHANC -

provide

training.

3. NCDOH -

provide

screening, refer

as needed to

appropriate

services.

4. NCDOH -

coordinate

training.

Niagara County

Dept. of Mental

Health &

Substance

Abuse

(NCDMH) -

provide

training.

MHANC -

provide

training.


Prevent

Substance

Abuse

Promote harm

reduction and

increase the number

of Nursing Division

professionals

participating in

Narcan training.

Increase the number

of public awareness,

outreach and

educational efforts

to change attitudes,

beliefs and norms

towards excessive

alcohol and

prescription opiate

use.

1. Offer voluntary harm

reduction training to all

Nursing Division Clinic

Staff in the delivery of

Narcan by 9/17

2. Provide outreach and

education at 6 community

centers or educational

settings regarding the

current climate of the opioid

crisis by 12/18

3. Provide mental health

educational materials and

pamphlets detailing services

available in Niagara County

at 100% of health

assessment clinics and

health fairs in which

NCDOH participates in

through 12/18

4. Create a survey tool to

distribute through social

media regarding the

community’s knowledge and

use of illicit substances by

12/17

5. Use survey to develop

educational materials to

discourage substance abuse;

distribute educational

materials at 100% of health

fairs in which NCDOH

participates through 12/18

1. NCDOH -

coordinate

training.

Evergreen

Health Services

- provide

training.

2. NCDOH -

coordinate and

provide

outreach.

3. NCDOH -

distribute

materials.

NCDMH -

recommend and

provide

materials.

MHANC -

recommend and

provide

materials.

4. NCDOH -

build and

disseminate

tool.

NCDMH -

advise on

content of

survey tool.

5. NCDOH -

distribute

materials.

NCDMH -

advise on

content of

educational

materials and

provide if able.


6. Plan and execute a

educational session of local

television show, Health

Scope, where substance

abuse and mental health

professionals will be guests

by 6/18

NCDOH - Plan

and host MH

professionals as

guests on

NCDOH's

television

program Health

Scope.

NCDMH-

appear as guest

on TV program

LCTV - allow

access to

station and air

taped show.

Strengthen

Infrastructure

Support integration

of MEB health

within chronic

disease prevention

strategies

Increase MEB

stakeholder

involvement across

all initiatives by

10%

1. Make MEB resources and

educational materials

available on the resource

tables at 75% of chronic

disease workshops held in

Niagara County through

12/18

2. Increase MEB community

stakeholder involvement in

public health initiative by

holding quarterly planning

meetings through 12/18.

3. Initiate NCDOH Nursing

staff attendance of

meetings/coalitions related

to Mental Health/Substance

Abuse by 12/18

1. NCDOH -

stock materials

on resource

tables

2. NCDOH -

host meetings

NCDMH -

attend meetings

MHANC -

attend meetings

3. NCDOH –

engage in

coalitions

Community

Organizations

that target

Substance

Abuse -

All above to

engage in

coalitions to

understand

problems and

work toward

solutions.


Eastern Niagara Hospital

Priority/Focus Area #1:

Prevent Chronic Disease/Increase access to high quality chronic disease preventive care and management in clinical and community settings/Promote use of evidence-based care to manage chronic diseases

Goal: Increase cardiovascular screening and education in eastern Niagara County from 2016-2018.

Disparity: Women, including the medically underserved population in Niagara County

DSRIP MCC PPS Project Alignment: Project 3.b.i. – Support implementation of evidence-based best practices for disease management in medical practices for adults with cardiovascular disease.

Outcome/

Objective

Interventions/Strategies/

Activities

Process

Measures

Partner Role &

Resources

Does action

address

disparity

1. Increase the

percentage of

screenings for

cardiovascular disease

at annual physical

exams. Increase the

percentage of women

screened at annual

OBGYN appointment or

primary care visits at

Eastern Niagara Family

Medicine,

Patients presenting for annual

physicals will have the option of

completing cardiovascular self-

assessments.

Upon completion of the self-

assessment, providers will

review the findings and conduct

assessments to determine if the

patient is at risk.

Educational materials will be

provided to patients, in addition

to referrals as needed.

Managers of the participating

facilities will monitor the

initiatives at group meetings and

determine if adjustments need to

be made in the processes to

become more effective.

Implement

cardiovascular

disease

screening

activities at

Eastern Niagara

Family Medicine

clinic and at

participating

OBGYN offices

in order to

increase the

current baseline

of women

screened.

Eastern Niagara

Hospital

Cardiologists and

the Department of

Cardiac Services

will provide

leadership and staff

support.

The Director of

Cardiac Services,

Director of

Education and

Community

Relations Director

will work

collaboratively to

develop and

enhance

educational

materials and

screening

materials.

Yes – The

physician

offices and

clinics

participating

in this

initiative have

a high

percentage of

women who

are covered by

Medicaid

plans.

2. The collaborative

team will implement a

schedule of community

education programs,

featuring topics

presented by

cardiologists and

specialists, as well as

screening events for the

public.

Guest speakers who are experts

on cardiovascular disease and

its risk factors will present at

these events.

Conduct a

minimum of two

events annually

in the ENH

service area of

Niagara County

from 2017-2018.

The ENH

Community

Relations

Department will

provide leadership

and staff support.

Yes – events

are open to

all.


3. Provide outreach and

chronic disease

screening and education

programs targeting the

eastern Niagara County

residents.

Offer chronic disease screening

and education for at risk

populations in eastern Niagara

County communities. Include

chronic disease and mental

health educational materials.

Host Chronic Disease Self-

Management Programs on an

ongoing basis in partnership

with the Niagara County

Department of Health.

Collaborate with affiliate

DeGraff Memorial Hospital –

Kaleida Health to seek

opportunities to jointly sponsor

screening events and

educational programs in the

ENH service area

Educate public

in chronic

disease

identification

and self-

management

through at least

two public events

annually in

2017-2018.

Eastern Niagara

Hospital will

provide leadership

and staff support to

implement

initiatives.

Niagara County

Department of

Health is the

provider of Chronic

Disease Self-

Management

Programs.

Yes- events

are open to

the public.

Niagara

County’s

mental health

disparity is

addressed

through the

distribution of

mental health

educational

materials at

all events.


Eastern Niagara Hospital

Priority/Focus Area #2: Promote Mental Health and Prevent Substance Abuse/Promote Mental, Emotional, and Behavioral Well-Being/Strengthen Infrastructure

Goal: Increase the mental, emotional, and behavioral health, including substance abuse programs and referrals for providers and patients of Eastern Niagara Hospital in Niagara County from 2016 to 2018.

Disparity: Mental health population

DSRIP MCC PPS Project Alignment: Project 4.a.i. – Promote mental, emotional and behavioral well-being in communities.

Outcome

Objective

Interventions/

Strategies/

Activities – ongoing 2016-2018

Process

Measures

Resources –

Eastern

Niagara

Hospital and

Partners

Will action

address

disparity

1.Promote mental,

emotional and

behavioral health

through provider

awareness and

knowledge of

mental health

conditions and

substance abuse;

and available

referral resources.

Promote the available mental health

and substance abuse resources in the

community. Identify additional

sources and create a referral database

for use by ENH ED and discharge

planning staff. Educate staff in its use.

Develop and enhance partnerships

with community mental health

providers, substance abuse agencies

and affiliates at DeGraff Memorial

Hospital – Kaleida Health. Host a

minimum of two educational programs

for ENH staff.

Provide mental health educational

materials at health fairs and

community events in the eastern

Niagara County region.

Expand access to services at ENH’s

alcohol and chemical dependence

treatment program – Reflections

Recovery Center.

Provide substance abuse prevention

and management education materials

at health fairs and community events

in the eastern Niagara County region.

Increase the

awareness and

knowledge of

all ENH staff in

mental health

conditions and

substance

abuse; and

available

referral

resources

during 2016-

2018.

Eastern

Niagara

Hospital will

provide

leadership and

staff support to

implement

initiatives.

ENH will

partner with

its affiliate

DeGraff

Memorial

Hospital and

other

providers in

the region,

including the

Niagara

county

Department of

Health and P2

Collaborative

on initiatives

whenever

possible.

Yes –

addresses

needs of

mental health

population


Degraff Memorial Hospital/Kaleida

Erie County and Niagara County NYS Prevention Agenda Priority/Focus Area/Goal: Prevent Chronic Disease/Increase access to high quality chronic disease preventive care and management in clinical and community settings/Promote use of evidence-based care to manage chronic diseases Kaleida Health Goal: Increase cardiovascular screening and education in Erie and Niagara counties from 2016 to 2018. Disparity: Women including medically underserved; mental health population in Niagara County DSRIP MCC PPS Project Alignment: Project 3.b.i. – Support implementation of evidence-based best practices for disease management in medical practices for adults with cardiovascular disease. Outcome Objective

Interventions/ Strategies/ Activities – ongoing 2016-2018

Process Measures

Resources – Kaleida Health and Partners

Will action address disparity

1. Through evidence-based HeartCaring® and Spirit of Women® program, increase the percentage of women screened for cardiovascular disease at their annual GYN visit at Kaleida Health’s OB-GYN Centers Erie County Buffalo – West Side and East Side locations Hamburg Lancaster Niagara County Lockport

1.a. Patients presenting for annual GYN exam asked to complete Heart Caring cardiovascular self-assessment and give to provider in exam room. 1.b. Providers review self-assessment and based on evidence-based criteria, conduct additional Heart Caring® assessment to determine if patient is at risk or high risk. Provider documents in EMR. Educational materials and referral information provided to at risk and high risk patients. 1.c. Spirit of Women® - All screening participants receive sign-up cards and educational materials available in waiting room. 1.e. Clinic managers assure that providers are certified as HeartCaring® providers. Training module offered to non-certified providers. 1.f. Clinic managers address initiative at team meetings and offer staff incentives to increase patient participation rate.

Implement cardiovascular disease screening activities at five OB-GYN Centers to increase current baseline of 35% of women screened (of estimated 2,900 patients receiving annual GYN exam) to 45% by end of 2017 and 60% by end of 2018.

Women & Children’s Hospital of Buffalo and DeGraff Memorial Hospital - provide leadership and staff support.

HeartCaring® - national evidence-based program focusing on cardiovascular prevention through screening and education to support lifestyle changes.

Spirit of Women® - offers females a support system to nurture a healthy lifestyle through entertaining and interactive educational events.

Yes – In 2015, 73% of patient visits at WCHOB’s OB-GYN clinics were reimbursed by Medicaid


2. Host Heart to Heart public education events at Kaleida Health locations in Erie and Niagara counties

2.a. Recruit guest speakers who are experts on cardiovascular disease and its risk factors and host Heart to Heart public education events. 2.b. Promote events and send invites to HeartCaring® and Spirit of Women® members, and others to recruit attendees.

Conduct 2-3 events annually in Erie and Niagara counties through 2018.

Kaleida Health marketing department will provide leadership and staff support.

Buffalo General Medical Center/Gates Vascular Institute, and physician groups including General Physician, PC will be a resource for physicians and other clinical providers to support the program and participate as guest speakers.

Yes – events are open to all.

3. Provide outreach and chronic disease screening and education programs targeting Niagara County residents.

3.a. Provide chronic disease screening and education targeting at risk populations at Niagara County community and/or business events annually. Include chronic disease and mental health educational materials 3.b. Host Chronic Disease Self-Management Programs annually in partnership with the Niagara County Department of Health. Promote to patients at DeGraff and members of the DeGraff McLaughlin Center for Senior Wellness.

Educate public in chronic disease identification and self-management through 4-5 community/business events annually and 1-2 Chronic Disease Self-Management Programs annually through 2018.

Kaleida Health’s DeGraff Memorial Hospital will provide leadership and staff support to implement initiatives.

Niagara County Department of Health – provides the Chronic Disease Self-Management Program.

Yes- events are open to all. Niagara County’s mental health disparity is addressed through the inclusion of mental health educational materials at events.


Degraff Memorial Hospital/Kaleida

Niagara County NYS Prevention Agenda Priority/Focus Area/Goal: Promote Mental Health and Prevent Substance Abuse/Promote Mental, Emotional, and Behavioral Well-Being/Strengthen Infrastructure Kaleida Health Goal: Increase the mental, emotional, and behavioral health including substance abuse referral resources available for providers and patients at DeGraff Memorial Hospital in Niagara County from 2016 to 2018. Disparity: Mental health population DSRIP MCC PPS Project Alignment: Project 4.a.i. – Promote mental, emotional and behavioral well-being in communities.

Outcome Objective

Interventions/ Strategies/ Activities – ongoing 2016-2018

Process Measures

Resources – Kaleida Health and Partners

Will action address disparity

1.Promote mental, emotional and behavioral health through provider awareness and knowledge of mental health conditions and substance abuse; and available referral resources.

1.a. Identify available community mental health and substance abuse resources and create a referral database for use by DeGraff emergency room and discharge planning staff. Educate staff in its use.

1.b. Develop partnerships with community mental health and substance abuse agencies and host 3-4 agency-specific, interactive mini-workshops annually for DeGraff staff.

1.c Host 2-3 Mental Health First Aid Certification classes annually for staff and others through the P2 Collaborative of WNY.

1.d. Provide mental health educational materials at health fairs and community events in which DeGraff is a participant.

Increase awareness and knowledge of 15% of DeGraff staff in mental health conditions and substance abuse; and available referral resources through 2018.

Kaleida Health’s DeGraff Memorial Hospital will provide leadership and staff support to implement initiatives.

P2 Collaborative of WNY – through a grant, funds the cost of the evidence-based Mental Health First Aid Certification classes.

Yes – addresses needs of mental health population


Mount St. Mary’s Hospital – Niagara County Project 1: Prevent Chronic Disease, Disparity: Mental Hygiene Designated Mount St. Mary’s Project Leaders: Bernadette Franjoine, Mount St. Mary’s Hospital NYS Prevention Agenda Link: Promote use of evidence- based care to manage chronic disease. Goal(s) addressing community need:

Community Health Needs Assessment Focus Groups identified need for mental health first aid

training to help increase awareness and give tools to first line providers, community members,

and to help make mental health first aid training as common as CPR training. This ties in strongly

with the DSRIP initiatives of promoting Mental Emotional and Behavioral Health, and would align

with concerns as identified by Niagara County stakeholder and resident communities.

Project's Target Population

Adults with arthritis, asthma, cardiovascular disease, or diabetes who have taken a course or

class to learn how to manage their condition.

Outcome Objectives:

By December 31, 2018 educate providers/associates and establish programming for adults with

arthritis, asthma, cardiovascular disease, or diabetes in partnership with NCDOH to raise

awareness regarding educational resources for referral and participation.

Reduce Disparity:

By December 31, 2018 include evidence-based care for chronic disease prevention and management programs to 80% of individuals with depression

Project Process Measures:

Year 1 (2016): Develop Implementation Plan.

Year 2 (2017): educate providers/associates and establish programming for adults with arthritis, asthma, cardiovascular disease, or diabetes in partnership with NCDOH to raise awareness regarding educational resources for referral and participation.

Year 3 (2018): educate providers/associates and establish programming for adults with arthritis, asthma, cardiovascular disease, or diabetes in partnership with NCDOH to raise awareness regarding educational resources for referral and participation.

Include evidence-based care for chronic disease prevention and management programs to 80% of individuals with depression.


Project Interventions / Strategic Activities by year and by site:

Year 1 (2016): Educate providers/associates regarding recent studies and data on chronic disease. Reconvene with NCDOH and MSMH Care Management to review NCDOH evidence-based programs and opportunity to reduce re-

hospitalization by 3/17.

Year 2 (2017): Educate providers/associates regarding recent studies and data on chronic disease. Support new Diabetes Educator to establish diabetes education programs, to include gestational diabetic patients. Conduct 2 outreach sessions to community providers and senior centers to inform of program offerings, and to coordinate referral system into Diabetes Education by 12/31/17. Partner with NCDOH, Niagara County hospitals and ADA to host diabetes prevention classes at the Neighborhood Health Center by 12/31/17.

Year 3 (2018): Educate providers/associates regarding recent studies and data on chronic disease. Support new Diabetes Educator to establish diabetes education programs, to include gestational diabetic patients. Partner with NCDOH, Niagara County hospitals and ADA to host diabetes prevention classes at the Neighborhood Health Center. Continue use of depression

screening tool at Article 28

primary care clinics to

identify patients with

depression through

12/31/18. Increase

screening percentage to

80% by 12/31/17 and 90%

by 12/31/18.

CH Resources Necessary:

Year 1 (2016): Support for Diabetes Educator



Collaboration: Who and how each partner will interact to affect the project goal.

Year 1 (2016) Niagara County Department of Health; American Diabetes Association; Neighborhood Health Center.

Year 2 (2017): Niagara County Department of Health; American Diabetes Association; Neighborhood Health Center.

Year 3 (2018): Niagara County Department of Health; American Diabetes Association; Neighborhood Health Center.


Mount St. Mary’s Hospital – Niagara County Project 2: Promote Mental Health and Prevent Substance Abuse Designated Mount St. Mary’s Project Leaders: Bernadette Franjoine, Mount St. Mary’s Hospital; and Karen Hogan, Clearview Treatment Services NYS Prevention Agenda Link: Promote Mental, Emotional and Behavioral Health (MEB). Prevent Substance Abuse Strengthen Infrastructure Goal(s) addressing community need:

Community Health Needs Assessment Focus Groups identified need to advance substance abuse

programs and outreach to the general population.

Project's Target Population

General populations, especially those with mental health needs and identified substance abuse

problems.

Outcome Objectives:

Provide trauma-informed approach education to Niagara County hospital associates and local

community organizations by 12/31/17. Increase number of hospital associates trained to 30%

by 12/31/18; Offer appropriate level of mental health services information to 80% of individuals

who have positive depression screens by 12/31/18; Increase number of public awareness,

outreach and educational efforts to change attitudes, beliefs and norms towards excessive

alcohol and prescription opiate use; Support integration of MEB health within chronic disease

prevention strategies. Establish MEB stakeholder involvement across Niagara County initiatives

by 12/31/17 and increase by 10% by 12/31/18.

Project Process Measures:

Year 1 (2016): Develop Implementation Plan.

Year 2 (2017): Provide trauma-informed approach education to Niagara County hospital associates and local community organizations; Establish MEB stakeholder involvement across Niagara County.

Year 3 (2018): Increase number of hospital associates trained to 30%; Offer appropriate level of mental health services information to 80% of individuals who have positive depression screens; Increase number of public awareness, outreach and educational efforts to change attitudes, beliefs and norms towards excessive alcohol and prescription opiate use; Support integration of MEB health within chronic disease prevention strategies. Increase MEB stakeholder involvement across Niagara County initiatives by 10%.


Project Interventions / Strategic Activities by year and by site:

Year 1 (2016): Begin organization

and planning process Year 2 (2017): Participate in an advisory board with Niagara County Hospitals and evaluate resources. Train associates on available mental health services and facilitate patient referrals Educate providers/associates on alcohol and substance abuse and host community outreach events Provide mental health education materials at 100% of health fairs and events of MSMH Add mental health on-site resources at Neighborhood Health Center

Year 3 (2018): continue 2017 initiatives and provide mental health education materials at 100% of activities and Neighborhood Health Center

CH Resources Necessary:

Year 1 (2016): Staffing and participation



Collaboration: Who and how each partner will interact to affect the project goal.

Year 1 (2016) Niagara County Department of Health; Niagara County hospitals; P2 Collaborative.

Year 2 (2017): Niagara County Department of Health; Niagara County hospitals; P2 Collaborative.

Year 3 (2018): Niagara County Department of Health; Niagara County hospitals; P2 Collaborative.


Niagara Falls Memorial Medical Center

Action Plan

Priority Area #1

Preventing Chronic Disease

Focus Area Goal Objective Activities

Entity

Responsible

Chronic

Disease:

Increase

access to

high quality

chronic

disease

preventive

care and

management

in both

clinical and

community

settings

1.Connect

Niagara

County

residents in

need to high

quality cardiac

catheterization

diagnosis and

treatment

1.By December 31,

2017, provide cardiac

catheterization

services to 669

Niagara County

residents at the new

cardiac

catheterization

laboratory operated at

NFMMC in concert

with its 3 partners:

Catholic Health;

Kaleida Health and

ECMCC

1a. Begin operating a cardiac

catheterization laboratory, the

first and only such facility in

Niagara County, at the

NFMMC campus by April 1,

2017

1b. Work with local EMS

community to ensure timely

and high quality emergency

responses to transport

Niagara County residents to

cardiac catheterization

laboratory

NFMMC

EMS

organizations in

Niagara County

2. Renovate

space and

purchase

equipment to

establish and

operate a

second cardiac

stress lab at

the Heart

Center on

NFMMC’s

campus to

prevent testing

delays

2a. By March 1,

2017, open the second

stress laboratory

2b. By December 31,

2017, provide an

additional 1,000

cardiac stress tests as

a result of improved

access

2a. Employ sufficient staff

to operate the second stress

test lab

2b. Track and monitor

utilization of second stress

laboratory

NFMMC

NFMMC

3. Renovate

NFMMC’s

inpatient

Cardiac-Stroke

Unit

3. By November 1,

2017 begin operating

the new Cardiac-

Stroke unit which will

be located on S-3 to

serve approximately

1,500 cardiac and

stroke patients

annually

3a. Monitor construction to

ensure it is on time and

within budget

3b. Train unit staff on new

software that will facilitate

the patient discharge process

and help connect more

patients to community

resources

NFMMC

NFMMC



Entity

Responsible

Cont…

Chronic

Disease:

Increase

access to

high quality

chronic

disease

preventive

care and

management

in both

clinical and

community

settings

3c. Set-up an on-unit

rehabilitation facility to

enhance physical therapy

programming and facilitate

patient recovery

3d. Re-introduce protocols to

identify patient caretakers,

provide training to them on

medication management and

other care techniques and

emphasize the involvement

of caretakers in a patient’s

recovery

NFMMC

NFMMC

4. Upgrade

Cardiac

Rehabilitation

unit by

replacing

antiquated

exercise

equipment

4a. By February 1,

2017, complete

replacement of

exercise equipment,

including treadmills,

stationary bikes,

elliptical units,

rowing machines and

other equipment

4b. By December 31,

2017 engage an

additional 100

patients in cardiac

rehabilitation

programming

4a. Establish at least one

session per week as a free

introductory exercise class

for NFMMC primary care

patients

4b. Inform NFMMC

primary care providers and

specialty physicians on the

availability of upgraded

cardiac rehabilitation services

so as to increase referrals to

the program

NFMMC

NFMMC

Promote use

of evidence-

based care

to manage

chronic

diseases

5. Establish

and operate a

Million Hearts

program at

NFMMC

primary care

centers in

concert with

the DSRIP

project to

“Improve

Cardiovascular

Health”

5a. Institute Million

Hearts project by

April 1, 2017

5b. By December

31, 2017, identify

4,000 primary care

patients with

hypertension

5c. Provide “Heart

Health” educational

materials and

instruction to at least

90% of identified

hypertensive primary

care patients.

5a. Train primary care

providers on how to

effectively apply the A

(aspirin); B (blood pressure

control); C (manage

cholesterol); S (smoking

cessation) principles to

reduce the risk of heart attack

and stroke

5b. Establish protocols to

refer hypertensive primary

care patients to healthy

lifestyle programs held in the

community

NFMMC

NFMMC and

Community

Partners



Entity

Responsible

Cont…

Promote use

of evidence-

based care

to manage

chronic

diseases

5c. Raise funds to purchase

free blood pressure testing

units at primary care sites

5d. Educate patients on how

to properly take their own

blood pressures

NFMMC

NFMMC

6. Increase

screening rates

for

cardiovascular

disease and

diabetes

among

disparate

populations

6. Establish and

operate a

cardiovascular and

diabetes screening

project for mental

health outpatients

who receive

behavioral health

services at the

NFMMC Wellness

Connection Center

6. By March 30, 2017,

screen 90% of 600 mental

health outpatients who are

diagnosed with bi-polar

disease or schizophrenia

NFMMC


Niagara Falls Memorial Medical Center

Action Plan

Priority Area #2

Promote Mental Health and Prevent Substance Abuse

Focus


Partner

Responsible

Behavioral

Health

Promote

Mental

Health and

Prevent

Substance

Abuse

1. Fully

implement a

second

Integrated

Primary Care/

Behavioral

Health

program at the

Golisano

Center for

Community

Health

1a. Screen 90% of

Golisano Center

primary care

patients for

depression using

the PHQ-9

instrument and

90% of patients for

substance use

using the SBIRT

screen

1b. By December

31, 2017 enroll 250

Golisano primary

care patients in the

Integrated Care

project

1c. Record

improved blood

pressure readings

for at least 50% of

the primary care

patients enrolled in

the Integrated Care

project

1a. Train staff and providers on

the principles of

Integrated/Collaborative Care

1b. Institute work flows to

screen patients for depression

and substance abuse

1c. Implement effective work

flows to connect patients

screening positive for

depression to in-practice

behavioral health therapist

NFMMC

NFMMC

NFMMC

2. Connect

mental health

patients who

are discharged

from the

hospital to

timely

outpatient

therapy

2. By December

31, 2017 achieve a

90% rate of

connection to

outpatient therapy

within 7 days of

hospital discharge

2a. Train inpatient and

outpatient staff on new

workflows to ensure an

outpatient visit within 7 days of

discharge

2b. Provide education to

discharged behavioral health

patients on the importance of

connecting and staying

connected to outpatient

treatment

NFMMC

NFMMC


Focus


Partner

Responsible

Cont…

Promote

mental

health and

prevent

substance

abuse

2c. Establish monitoring and

reporting system to track rate of

connectivity to outpatient

behavioral health treatment

NFMMC

3. Establish

Health and

Recovery

Plans (HARP)

project as part

of the Adult

Health Home

3. By December

31, 2017 enroll 158

adults with

significant

behavioral health

needs in the Adult

Health Home

3a. Provide specialized

training to Health Home care

managers who will manage the

physical health, mental health

and substance use services for

HARP enrollees in an

integrated way

3b. Provide understandable

information to persons with

significant behavioral health

conditions to encourage their

enrollment in HARP

NFMMC

NFMMC

Prevent and

reduce

occurrence

of mental,

emotional

and

behavioral

health

disorders

among

youth

4. Operate a

Children’s

Health Home

to serve at-risk

children in

Niagara

County

4. By December 5,

2016 establish a

Children’s Health

Home to provide

care management

services to at-risk

children who meet

eligibility

requirements

4a. Enroll a minimum of 250

eligible children in Children’s

Health Home by December 31,

2017

4b. As appropriate, connect

enrollees in Children’s Health

Home to child mental health

services

4c. Work with contracted and

community agencies to ensure

seamless and timely

connections of children to the

care and services they require

4d. Monitor and log child

mental health service shortages

so that action can be taken to

expand mental health services

to children

4e. Work with Niagara County

Department of Mental Health

and child mental health service

providers to establish a child

mental health clinic on the first

floor of the Golisano Center

NFMMC

NFMMC

NFMMC

NFMMC

NFMMC


Focus


Partner

Responsible

Promote

mental

health and

prevent

substance

abuse

5. Significantly

reduce the

number of

addicted

newborns in

Niagara

County

5. By January 1,

2018 reduce rate

of addicted

newborns in

Niagara County by

20% from 341.7 to

273.4

5a. Enroll pregnant moms who

are taking drugs during

pregnancy to the Maternal and

Infant Care project

5b. Organize and wage

coordinated effort by Close the

Gaps project to connect

addicted newborns to Early

Intervention services

5c. Effective February 2017,

start-up an evidence-based

Centering Pregnancy project to

provide group prenatal care that

brings women due at the same

time out of the exam room and

into a caring group setting

NFMMC

NFMMC

NFMMC

Millennium

Collaborative

Care PPS

6. Establish

an Integrated

Behavioral

Health/OB-

GYN Center

project

6. By January 1,

2018, integrate

behavioral heath

therapy services

with the operations

of the OB-GYN

Center located on

the 3rd floor of the

Hodge Building

6a. Prepare and file a PAR

application with the Office of

Mental Health to permit this

integrated care program

6b. Provide for SBIRT and

PHQ-9 screening to identify

women with depression and/or

substance abuse

6c. Provide for effective,

warm hand-off referrals of

women who test positive for

drug and/or alcohol abuse

NFMMC

NFMMC

NFMMC


Appendix 1

Niagara County Community Health Assessment Workgroup

Name E-Mail Organization

Patrick Bradley [email protected] NFMMC

Fred Caso [email protected] Mount Saint Mary's Hospital

Kathy Cavagnaro

[email protected] Niagara County DOH

Quintin Dukes [email protected] Catholic Health System

Bernadette

Franjoine [email protected] Mount Saint Mary's Hospital

Phyllis Gentner [email protected] DeGraff Memorial Hospital

Karen Hall [email protected] P2 Collaborative

Laura Kelemen [email protected] Niagara County Department of Mental

Health & Substance Abuse

MaryBeth Kupiec [email protected] DeGraff Memorial Hospital

Jacquelyn

Langdon [email protected] Niagara County DOH

Carolyn Moore [email protected] Eastern Niagara Hospital System

Victoria Pearson [email protected] Niagara County DOH

Marissa Slevar [email protected] P2 Collaborative

Daniel Stapleton [email protected] Niagara County DOH

Jessica Thomas [email protected] Niagara County DOH

Kathleen

Tompkins [email protected] Kaleida Health

Beth Waas [email protected] Eastern Niagara Hospital System


Appendix 2

Participating Partners for August 4, 2016 Community Needs Meeting

Organization Contact

American Diabetes Association Pam Fox, Manager of Community Engagement

American Heart Association Marc Natale, Executive Regional Director

Children and Family Services of Niagara Kelley Swann

Community Health Center of Lockport/Niagara

Lavonne Ansari, CEO/Executive Director

Community Missions, Inc. Kristen Hanley

Cornell Cooperative Jen Regan, Community Educator

Creating a Healthier NF Collab. Shelley Hirshberg, Executive Director

Dale Association Maureen Wendt, President/CEO

Mental Health Association in Niagara County Cheryl Blacklock, Director

Native American Community Svc Star Wheeler

Niagara County Cancer Services Cassandra Jackson

Niagara County Emergency Management Jonathan Schultz, Director

Niagara County Mental Health Laura Kelemen, Director

Niagara County Mental Health Michael White, Deputy Director

Northpointe Council Cheri Kelly

Opportunities Unlimited of Niagara Pete Drew

Russ Hahn

Orleans Niagara Boces Ronald Barstys

Tobacco Free Erie/Niagara Jenna Brinkworth Ezra Scott

University of Buffalo Medical Residents Milind Chaudhari, MD MPH Natdanai Punnanithinont, MD MPH

YMCA Darcee Hughes, Wellness Director

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