rensselaer county community health improvement plan 2016 … · 2017. 3. 20. · 1 rensselaer...

Rensselaer County

Community Health Improvement Plan

2016-2018

0

Rensselaer County Department of Health

1600 7th Avenue

Troy, NY 12180

Phone: 518-270-2655

Fax: 518-270-2973

Mary Fran Wachunas, Director

1 Rensselaer County Community Health Improvement Plan 2016-2018

Summary The New York State Department of Health (NYSDOH) has required that each county develop a health assessment and improvement plan. A regional process was lead by the Healthy Capital District Initiative (HCDI) which includes Albany, Rensselaer, Saratoga, Schenectady, Columbia and Greene counties, in addition to input from Albany Medical Center, St. Peter’s Health Partners, Columbia Memorial Hospital, Ellis Medicine and Saratoga Hospital. Representatives from each county health department and each hospital worked collaboratively with HCDI to discuss health issues facing the Capital District, and commit to providing resources to achieve the goals of each identified health priority. The Rensselaer County Wellness Committee (RCWC) was formed in 2012 when the 2013-2018 Community Health Assessment and Community Health Improvement Plan were being developed. This committee continues to meet on the first Monday of each month to discuss emerging health issues in the community, in addition to highlighting the achievements of each participating organization to improve the health of Rensselaer County residents. The membership of the committee is continually reviewed to identify partners in Rensselaer County who could contribute to the goals of the RCWC. A positive consequence of our committee is increased awareness among agencies already working to address identified concerns. The formation of multiagency collaborations has given us the opportunity to build trust, cooperation and mutual respect among agencies. As a result, many new partnerships were borne, and continue to grow and develop. One of the accomplishments of the Rensselaer County Wellness Committee for 2016 was that the membership created a directory of sexual health resources that is now available to the RCWC member so that they may share that information with their clients. At each RCWC meeting, the larger group breaks into smaller groups to focus on the areas of need identified in the Community Health Improvement Plan, and other priorities that are of concern in Rensselaer County. Two new members of the RCWC for 2016 are Mom Starts Here and Capital District Physicians Health Plan, a large health insurance provider in the Capital District. Appendix B is a list of the Rensselaer County Wellness Committee Members.

The priorities for the 2013-2017 Rensselaer County Community Health Improvement Plan were mental health, obesity, tobacco use, teen pregnancy and sexually transmitted diseases. The priorities for the 2016-2018 Community Health Improvement Plan were narrowed to two priorities from a long list of potential health problems facing the Capital District. Although mental health, teen pregnancy and sexually transmitted diseases were not chosen as focus areas for this Community Health Improvement Plan, they remain in the forefront as health problems in Rensselaer County, and as a community, the Rensselaer County Department of Health and its partners in the Rensselaer County Wellness Committee will continue to address these health challenges to improve the health of Rensselaer County residents. The two priority areas that were identified by the Capital District partners are Chronic Disease (obesity, asthma) and Behavioral Health (substance abuse and other mental emotional behavioral disorders).


MISSION STATEMENT: To enhance the health and well-being of Rensselaer County residents by

providing integrated health programs through the formation of partnerships and unified goals

among organizations in the community. We will collaboratively build awareness through

traditional and nontraditional promotion of wellness.

VISION

Rensselaer County, a healthy place to live.

Rensselaer County

Sociodemographic

Rensselaer County has a population of 159,565 and is the 3rd most rural county in the

Capital Region (245.0 pop. /sq. mile);

Rensselaer County has the 2nd lowest median age (39.9 years) in the Capital Region;

About 17% of Rensselaer County’s population was 14 years of age or younger, while

14% was 65+ years of age;

Approximately 12.3% of Rensselaer County’s population was non-White, and 4.0% was

Hispanic;

Troy/Lansingburgh neighborhood has the largest non-White population (21.3%) as well

as the largest Hispanic population (6.6%);

Rensselaer County’s poverty rate of 12.3% was lower than that of NYS (15.3%);

Troy/Lansingburgh neighborhood has the highest neighborhood poverty rate (21.6%).

Chronic Disease

Rensselaer County’s adult current asthma prevalence (13.5%), and asthma emergency

department visit rate (61.2/10,000), were higher or significantly higher than Rest of State

(10.5%, and 47.6); The Rensselaer County’s asthma ED visit rate decreased 4%, and asthma hospitalization rate

40% between 2009 and 2013;

Troy/Lansingburgh had 2.3 times the asthma ED visit rate and 1.5 times the asthma

hospitalization rate as Rest of State;

Troy/Lansingburgh had 2.6 times the chronic lower respiratory disease (CLRD) ED visit rate, and

1.7 times the CLRD hospitalization rate compared to Rest of State;

Rensselaer County’s adult diabetes prevalence rate of 10.0% was higher than Rest of State

(8.2%);

Rensselaer County’s diabetes hospitalization rate of 15.4/10,000 and mortality rate of

19.8/100,000 were higher or significantly higher than Rest of State (14.2, and 15.6);


Rensselaer County’s diabetes short-term complication hospitalization rate (6.6/10,000) was

significantly higher than Rest of State (5.8) and increased 14% from 2009 to 2013;

Troy/Lansingburgh neighborhood had 2 times the diabetes ED rates, and 1.7 times the diabetes

hospitalization rates compared to Rest of State;

Rensselaer County’s colorectal screening rate of 68.8% was lower than Rest of State (70.0%),

while the county’s colorectal cancer incidence rate (45.0/100,000) and mortality rate

(14.5/100,000) were both higher than Rest of State (41.2 and 13.9);

Rensselaer County’s childhood obesity rate of 18.0% was higher than Rest of State (17.3%).

Mental Health and Substance Abuse

The National Survey of Drug Use and Health estimated 19% of Rensselaer residents with a

mental illness and 4% with a serious mental illness;

The National Survey of Drug Use and Health estimated 3% of Rensselaer residents with drug

dependence/abuse, and 2% needing, but not receiving, drug treatment;

While Rensselaer County’s residents had lower substance abuse (any diagnosis) ED visit rates

(194.7/10,000) than Rest of State (349.5), Rensselaer’s rate increased 25% from 2009 to 2014;

Similarly, Rensselaer County residents had a lower substance abuse mortality rate (4.8/100,000)

than Rest of State (9.3), but the rate increased 113% from 2009-11 to 2011-13;

Rensselaer County had an opiate-poisoning related ED visit rate (any diagnosis) of 13.4/10,000

that was slightly lower than the Rest of State (15.2), but showed a 26% increase from 2008-10 to

2011-13

Troy/Lansingburgh neighborhood had 2 times the substance abuse (any diagnosis) ED visit rate,

2 times the substance abuse hospitalization rate, 1.8 times the opiate-related ED visit rate and 2

times the opiate-related hospitalization rate than Rest of the State


Profile of

Rensselaer County

Rensselaer County is located in the

Hudson-Mohawk Heritage area of

Upstate New York’s Capital Region.

The County has a total area of 665

square miles. The cities of Rensselaer

and Troy, which are comprised of

fourteen square miles, house

approximately forty percent of the

county’s population.

Rensselaer County is also bordered by

five counties which include Albany,

Columbia, Greene, Saratoga and

Washington, and the states of

Massachusetts and Vermont.

The Prevention Agenda Workgroup

(PAWG) is comprised of six county

health departments, (Albany,

Rensselaer, Schenectady, Saratoga,

Columbia and Greene Counties) as well as the local hospitals for each county. The partners

worked with Healthy Capital District Initiative (HCDI) in developing the scope and content for a

Capital Region Community Health Needs Assessment.

Data Sources and Indicator Selection

The health indicators selected for this report were based on a review of available public

health data and New York State priorities promulgated through the Prevention Agenda

for a Healthier New York. Upon examination of these key resources, identification of

additional indicators of importance with data available, and discussion with public

health as well as health care professionals in the Capital Region, it was decided that

building upon the 2013-2017 Prevention Agenda would provide the most

comprehensive analysis of available public health needs and behaviors for the Region.

The collection and management of this data has been supported by the state for an


extended period, and are very likely to continue to be supported. This provides reliable

and comparable data over time and across the state. These measures, when

complemented by the recent Expanded Behavioral Risk Factor Surveillance System and

Prevention Quality Indicators, provide health indicators that can be potentially impacted

in the short-term. This is a distinct step forward from mortality data leading public

health efforts in the past.

HCDI has completed previous Capital District Community Health Assessments in the

past. HCDI was contracted to complete the 2016 CHNA and prevention agenda

indicators.

The Finger Lakes Health Systems Agency provided SPARCS (hospitalizations and ED

visits) and Vital Statistics Data Portals that were utilized to generate county and ZIP code

level analyses of mortality, hospitalizations, and emergency room utilization, for all

residents, by gender, race and ethnicity. The time frames used for the Zip code analyses

were 2009-2013 Vital Statistics and 2010-2014 Statewide Planning and Research

Cooperative System (SPARCS) data. The 5-year period establishes more reliable rates

when looking at small geographic areas or minority populations.

The Healthy Capital District Initiative had access to the Finger Lakes Health System

Agency portals and developed the 2016 Capital Region Community Health Needs

Assessment which enabled a comprehensive set of population health indicators for the

6 Capital Region counties.

Additional data was examined from a wide variety of sources:

• Prevention Agenda 2013-18 indicators

• Community Health Indicator Reports (2011-2013)

• County Health Assessment Indicators (2011-2013)

• County Health Indicators by Race/Ethnicity (2011-2013)

• County Perinatal Profiles (2011-2013)

• Behavioral Risk Factor Surveillance System (BRFSS) and Expanded BRFSS (2013-

14)

• Cancer Registry, New York State (2010-2012)

• Prevention Quality Indicators (2011-2013)

• Communicable Disease Annual Reports (2011-2013)

• The Pediatric Nutrition Surveillance System (PedNSS) (2010-2012)

• Student Weight Status Category Reporting System (2010-2014)


• New York State Office of Alcoholism and Substance Abuse Services Data

Warehouse (2007-2014)

• New York State Conference of Local Mental Hygiene Directors Behavioral Health

Information Portal (2013)

• Hospital-Acquired Infection Reporting System (2010-2013)

• NYS Child Health Lead Poisoning Prevention Program ( 2010 birth cohort; 2011-

2013)

• NYS Kids’ Well-being Indicator Clearinghouse (KWIC) (2011, 2014)

• County Health Rankings (2016)

• American Fact Finder (factfinder2.census.gov) (2009-2013)

• Bureau of Census, American Community Survey (2009-2013)

These data sources were supplemented by a Siena College Research Institute

Community Health Survey. The 2016 Community Health Survey was conducted from

February to March 2016 by the Siena College Research Institute. The survey was a

random digit dial telephone survey of adult (18+ years) residents for each of the six

counties (n= 400 per county; 2,400 for Capital Region). Cell phones and landlines were

utilized for the survey. This consumer survey was conducted to learn about the health

needs and concerns of residents in the Capital Region. The Appendix B (2016 Capital

Region Community Health Survey) contains a detailed summary of the findings and the

questionnaire used.

Local data were compiled from these data sources and draft reports were prepared by

health condition for inclusion in this community health needs assessment. Drafts were

reviewed for accuracy and thoroughness by two staff with specialized health

knowledge: Kevin Jobin-Davis, Ph.D. who has over 15 years of public health data analysis

experience in the Capital Region; and Michael Medvesky, M.P.H. who has over 35 years

of experience working with public health data in the New York State Department of

Health in many roles including Director of the Public Health Information Group. Drafts of

the sections were sent to local subject matter experts for review in the health

departments of Albany, Rensselaer, Schenectady, Saratoga, Columbia and Greene

Counties and in St. Peter’s Health Partners, Albany Medical Center, Ellis Hospital,

Saratoga Hospital and Columbia Memorial Hospital. Comments were addressed and

changes were incorporated into the final document.

The 2016 Rensselaer County Community Health Needs Assessment, prepared by the

Healthy Capital District Initiative of which the Rensselaer County Department of Health

is a member, provides more detailed information and data regarding health issues of


concern in Rensselaer County. The Rensselaer County Community Health Improvement

Plan and the Capital District Community Health Assessment Plan can be found at the

Rensselaer County web site: www.rensco.com.

SELECTION OF PREVENTION AGENDA PRIORITIES

Selection of the top health priorities for Rensselaer County were based on a multi-year

process building on existing knowledge from present Community Health Improvement

Plan/Community Service Plan implementation efforts, as well as the 2015 Medicaid

Delivery System Reform Incentive Payment (DSRIP) Needs Assessment. A Capital Region

Prevention Agenda Steering Committee was formed to guide the 2016 Public Health

Prioritization process and Plan development. Meetings were held during Fall/Winter

2015-2016 with participation from local health departments of Albany, Columbia,

Greene, Rensselaer, Saratoga and Schenectady counties, St. Peter’s Health Partners, Ellis

Medicine, Albany Medical Center, Saratoga Hospital, Columbia Memorial Hospital and

Healthy Capital District Initiative, to ensure that health needs analysis, prioritization, and

community health plans were timely, and of high quality. Members of these

organizations worked to identify individuals to participate in the Capital Region Public

Health Prioritization Workgroups.

The Capital Region Public Health Prioritization Workgroups were formed to review data

analyses prepared by HCDI and to select the top priorities with one health disparity to

be addressed. Data presentations were given at the meetings to provide summarized

available data on the leading problems in each of the Workgroup’s service areas. Health

indicators were included in the Prioritization data presentations if:

At least one of the county rates were significantly higher than the New York

State, excluding New York City data; or

At least one of the county rates were in the highest risk quartile in the

state; or

Rates for the health condition worsened over the past decade for one of the

counties; or

The health condition was a leading cause of death in one of the counties; or

Disparity between rates was clearly evident in sub-populations; or

There were a high absolute number of cases in the counties.

Health indicators that met the criteria were included in the data presentations for each

of the five Prevention Agenda Priority Areas: Prevent Chronic Diseases, Promote a

http://www.rensco.com/


Healthy and Safe Environment, Promote Healthy Women, Infants, and Children,

Promote Mental Health and Prevent Substance Abuse, and Prevent HIV/STDs, Vaccine

Preventable Diseases and Healthcare-Associated Infections.

Ninety (90) health indicators across the five Prevention Agenda Priority Areas were

presented. Available data on prevalence, emergency department visits, hospitalizations,

mortality and trends were included for each indicator. Equity data for gender, age,

race/ethnicity, and neighborhood groupings were presented as available. Each topic

was presented in summary form in a Power Point presentation using graphs and maps

to visually depict the information.

After the presentation of each set of health indicators, a discussion was held to answer

any questions, or for individuals to share their experiences with the health condition in

the population. Participants did a preliminary vote on the importance of the condition in

the community based on three qualitative dimensions: the impact of the condition on

quality of life and cost of health care; if there was community awareness and concern

about the condition; and the opportunity to prevent or reduce the burden of this health

issue on the community. Participants were provided with a Prioritization Tracking Tool

to record their own comments and measure their thoughts on the severity, community

values, and opportunity regarding each health indicator.

Upon completion of the data summaries, Capital Region Public Health Prioritization

Workgroup members were given an opportunity to advocate for the priority they

believed was most meritorious, and the group voted on the top two Prevention Agenda

categories. Behavioral health and chronic disease categories received the greatest

amount of votes by far, because they impacted the largest number of people in the

most significant ways, both directly and indirectly, through their influence on other

health conditions. They also contributed most significantly to the cost of health care. A

summary of the Albany-Rensselaer Public Health Priority Workgroup follows.

Albany-Rensselaer Public Health Priority Workgroup

The Albany Rensselaer Public Health Priority Workgroup was spearheaded by the Albany

County Department of Health, the Rensselaer County Department of Health, Albany Medical

Center, and St. Peters Health Partners. Because the hospitals catchment areas covered both

counties, it was felt a joint-county Albany-Rensselaer Public Health Priority Workgroup was

appropriate. Three meetings were held on February 10, February 24, and March 18, 2016.

During these meetings, HCDI presented heath indicators for each of the 5 Prevention agenda

Priority Areas, and facilitated Albany-Rensselaer Public Health Priority Workgroup discussions.

The Power Point data presentations used during these meetings were made available to the


Albany-Rensselaer Public Health Priority Workgroup members and the public on the HCDI

Website:

http://www.hcdiny.org/index.php?module=Tiles&controller=index&action=display&id=663866

80430034968

The Albany-Rensselaer Public Health Priority Workgroup chose their priorities at the

last Workgroup meeting. Organizations participating in the Albany-Rensselaer Public

Health Priority Workgroup include:

- Albany County Department of Health

- Albany County Department of Mental Health

- Albany County Department of Social Services

- Albany Medical Center

- Albany Medical Center: DSRIP

- Albany Rensselaer Cancer Program

- Alzheimer’s Association

- Belvedere Health Services, LLC

- Berkshire Farm Center & Youth Services

- Capital District Childcare Coordinating Council

- Capital District Physicans’ Health Plan (CDPHP)

- Capital District Psychiatric Center- Office of Mental Health

- Capital District Tobacco-Free Coalition

- Capital District Transportation Committee

- Capital District YMCA

- Capitol Region BOCES

- Care Coordination Services

- Catholic Charities

- Catholic Charities: Commuity Maternity Services

- Center for Disability Services

- City of Albany Police Department

- Colonie Senior Services Centers

- Commission for Economic Opportunity

- Community Care Behavioral Health Organization

- Conifer Park

- Fidelis Care Network

- Hometown Health Centers

- Hospitatlity House

- Independent Living Center of the Hudson Valley

- Interfaith Partnership

- Jewish Family Services of Northeastern NY

- LaSalle School


- Mental Health Empowerment Project

- National Association of Social Workers

- National Grid

- Next Wave

- Rehabilitation Support Services

- Rensselaer County Department of Health

- Rensselaer County Department of Mental Health

- Rensselaer Park Elementary school

- Samaritan Radiation Oncology

- Senator Neil Breslin

- Senior Hope

- Senior Servics of Albany and Cohoes Multi-Service Senior Citizen Center, Inc.

- St. Catherine’s Center for Children

- St. Mary’s Hospital

- St. Peter’s Health Partenrs

- The Community Hospice

- The Food Pantries for the Capital District

- The Sage Colleges

- United Way of the Greater Capital Region

- Unity House

- University at Albany School of Public Health

- Upper Hudson Planned Parenthood

- Van Rensselaer Manor

- Village of Colonie Outreach

- Visiting Nurses Association of Albany

- Xerox State Healthcare

Albany and Rensselaer counties completed the Community Health Prioritization

Meetings together between February and March 2016. Attendance during these

meetings ranged between 40-60 participants representing many health care,

community based, and public service providers. Participants were engaged in the data

presentations, raised many questions, and provided what services look like day to day.

The two priority areas being focused on in Rensselaer County are Chronic Disease

(obesity, asthma) and Behavioral Health (substance abuse and other mental emotional

behavioral disorders).

Focus areas were chosen based on statistical data gathered for the Community Health

Needs Assessment. Rensselaer County’s adult diabetes prevalence rate of 10% was

higher than the rest of the state (8.2%). Rensselaer County’s diabetes hospitalization

rate of 15.4/10,000 and mortality rate of 19.8/100,000 was higher and significantly


higher than the rest of the state (14.2 and 15.6). Rensselaer County’s diabetes short-

term complication hospitalization rate (6.6/100,000) was significantly higher than the

rest of the state (5.8) and increased 14% from 2009-2013. The Troy/Lansingburgh

neighborhood had 2 times the diabetes emergency department visit rates, and 1.7 times

the diabetes hospitalization rates compared to the rest of the state.

Rensselaer County’s adult current asthma prevalence (13.5%) and asthma emergency

department visit rate (61.2/100,000) were higher or significantly higher than the rest of

the state (10.5% and 47.6). The Troy/Lansingburgh area had 2.3 times the asthma

emergency department visit rate and 1.5 times the asthma hospitalization rate as the

rest of the state. There is a disparity among Troy/Lansingburgh area residents with

regard to asthma related hospitalizations and ED visits.

The Troy/Lansingburgh area of Rensselaer County has the largest non-white population

(21.3%) as well as the largest Hispanic population (6.6%). The Troy/Lansingburgh

neighborhood has the highest neighborhood poverty rate in Rensselaer County (21.6%).

Health disparities are often seen in poor and non white populations. Higher asthma

emergency department visits and asthma hospitalization rates in the Troy/Lansingburgh

area are most likely linked to the socioeconomic status of it’s’ residents.

Behavioral health was chosen as a focus area from the results of the National Survey of

Drug Use and Health, which estimated 19% of Rensselaer County residents with a

mental illness, 4% with a serious mental illness. This same survey estimated that 3% of

Rensselaer County residents with drug dependence/abuse, and 2% needing, but not

receiving drug treatment. It is estimated that 7% of Rensselaer County residents live

with alcohol dependence/abuse, and 7% of that population needs, but does not receive

alcohol treatment. While Rensselaer County residents had a lower substance abuse

(any diagnosis) ED visit rate (194.7/100,000) than the Rest of State (349.5), Rensselaer

County’s rate increased 25% from 2009-2014. Similarly, Rensselaer County residents

had a lower substance abuse mortality rate (4.8/100,000) than the Rest of State (9.3),

but the rate increased 113% from 2009-2011 to 2011-2013. Rensselaer County had an

opiate poising related ED visit rate (any diagnosis) of 13.4/10,000 that was slightly lower

than the Rest of the State, (15.2), but this rate increased 26% from 2008-2010 to 2011-

2013. Of the autopsy reports completed for 2015 as of this date, the Rensselaer County

Medical Examiner has confirmed that there have been 21 deaths due to heroin/opioid

abuse. As in many parts of the country, Rensselaer County has not been immune to the

opioid epidemic that is affecting many areas across the state and the country.

Rensselaer County established a heroin coalition in March of 2016 to address the

growing heroin abuse and heroin deaths in Rensselaer County. The goal of the coalition

is to take back our community from the affliction of opioid addiction by educating and

raising public awareness through multiple means and venues, forming a multi-layers


shield for the purpose of prevention, treatment and recovery. The coalition is

comprised of four subgroups: Community Education, Harm Reduction, Law

Enforcement and Medical interventions. The Rensselaer County Heroin Coalition aims

to reach out to educate the public and enhance communication between our

community members and partners. The Rensselaer County Heroin Coalition is

comprised of over 200 community organizations. It is co-chaired by the Rensselaer

County Department of Health Director and the Rensselaer County Sheriff.

Summary of Rensselaer County Accomplishments in 2016:

Continued to be an associate member of the Food Pantries of the Capital Region

Continued to distribute Diabetes Resource Guides to school nurses, Wellness

Committee members, and consumers in our county.

Continued to distribute the Breastfeeding Resource Guide to professionals and

consumers.

Continued to distribute Asthma Action Plans to the school nurses to disseminate to

their asthmatic students.

Promoted two “Take Back Drug Initiatives”

Continued collaborating with Upper Hudson Planned Parenthood and the Alliance

for Positive Health on shared communication and information points for consistent

messaging.

Created and printed 500 packets of low literacy nutrition information on proper

portion size showing each food group.

Engaged children in physical activity with the The Schaghticoke Fair.

Became a registered NYSDOH Opioid Overdose Prevention Program Trainer,

completing trainings throughout the community.

Continued to hold monthly Rensselaer County Wellness Committee meetings,

adding two new members in 2016.

Trained a Public Health Educator to conduct NDPP trainings.


Prevent Chronic Diseases Action Plan

Focus Area 1- Reduce Obesity in Children and Adults

Goal Outcome Objective Intervention/

Strategies, Activities

Partner Resources Partner roles Process Measures By When Will Action

Address

Disparity?

Prevention Agenda

Goal 1.1

Create Community environments that

promote and support

healthy food and

beverage choices and

physical activity.

Prevention Agenda

Overarching Objective

1.0.1: Reduce the percentage

of youth and adults who

are obese from 28.5% in

2013-14 to 27.1% in

2018 (adults) and 18.0% in 2012-14 to 17.1% in

2018 (children).

Implement nutrition

and beverage standards

in public institutions, worksites, school

districts, and childcare

centers.

Rensselaer County

Department of Health Serves residents in Rensselaer County through physical health

and mental health activities.

Albany Medical Center

Adopted a robust, multi-

faceted wellness program, which includes health and

wellness policies that

positively impact patients, visitors and employees.

Healthy Capital District

Initiative Provides access to coverage and care, health planning

expertise and supports health

prevention programs across the Capital Region. Facilitates the

Albany-Rensselaer Diabetes

Task Force.

St. Peter’s Health Partners:

Adopted a Health and Wellness policy that impacts patients and

employees. SPHP was awarded

Rensselaer County

Department of Health Provide technical assistance to area worksites implementing

healthy workplace strategies.

Albany Medical Center Promote healthy living and

wellness through Albany Med’s “Wellness: Healthy Choices,

Healthy You” program; Sodium

Reduction in Communities grant.


Initiative

Promote worksite wellness, and

health and wellness policies.

Review policies, and evidenced based practices.

St. Peter’s Health Partners

Encourage healthy living through St. Peter’s Wellness

Committee.

Number of organizations

that adopt and implement

nutrition and beverage standards (e.g. healthy

meeting and events policies,

healthy vending policies,

applicable worksite wellness

programs) including number of persons impacted by

standards.

Number of participants

involved in Move, Learn,

Heal and Eat initiatives.

Number of schools that

adopt and implement comprehensive and strong

Local School Wellness

December 31, 2018


the Creating Healthy Places

contract from the NYS Department of Health that

seeks to: increase opportunities

for physical activity, and improve access to nutritious

foods both in the community

and in schools.

Creating Healthy Schools:

Provides technical assistance in

developing implementing strategies for health and wellness

policies within school districts.

Polices.

Promote Physical

Activity in childcare

centers, school

districts, community

venues, and worksites.

Rensselaer County

Department of Health: Serves residents in Rensselaer County through physical health



Adopted a robust, multi-

faceted wellness program,

which includes health and

wellness policies that

positively impact patients,

visitors and employees.


Initiative Provides access to coverage and care, health planning



Albany-Rensselaer Diabetes

Task Force.


Awarded the Creating Healthy Places contract from the NYS

Department of Health that

seeks to: increase opportunities

Rensselaer County

Promote physical activity and

wellness through Community Outreach.

Albany Medical Center Promote healthy living as part of

Albany Med’s Wellness

Program’s “Move, Learn, Heal and Eat” initiatives – Fitness

Center, Fitness Classes, and

Fitness App, walking groups, etc.; exercise prescriptions given

to patient populations.


Initiative

Promote and provide support to

outreach activities throughout

both counties.


Encourage healthy living

through Wellness Committee,

evidenced based Community Soccer Program, and Creating

Number of plans adopted or

opportunities available

promoting physical activity (e.g. Complete Streets

policies, joint use

agreements, applicable

worksite wellness

initiatives).

Number of school districts that implement

Comprehensive School

Physical Activity Programs(CSPAP)


for physical activity, and

improve access to nutritious foods both in the community

and in schools.

Healthy Schools and

Communities grant program.

Number of children

participating in the evidenced based Soccer for

Success program that

promotes healthy lifestyle through: physical activity,

nutrition, mentorship and

family engagement.

Focus Area 2- Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings.

Goal Outcome Objective Intervention

Strategies, Activities

Partner Resources Partner roles Process Measures By When Will Action

Address

Disparity?

Prevention Agenda

Goal 1.1

Promote asthma activities in the

community by

providing in home support to adults and

children who have

asthma.

Reduce age adjusted

asthma hospitalizations

age 5-64 years of age per 10,000 from

6.5/10,000 (2012-2014)

by 10% to 5.9/10,000.

Reduce age-adjusted

asthma Emergency Department visits per

10,000 from

Implement evidenced

based asthma

management guidelines between

primary care

practitioners, specialists and

community based

asthma programs to ensure regional

population-based

Rensselaer County Health

Department

In collaboration with community based

organizations Rensselaer

County provides the Healthy Neighborhoods Program.

Trained Healthy

Neighborhoods Program educators schedule a home

visit and identify

Rensselaer County Health

Department

Provide, coordinate, or link clients to resources for

evidenced based trigger

reduction home-based interventions (i.e. change indoor

environment to reduce exposure

to asthma triggers such as pests, mold, and second hand smoke)

via Healthy Neighborhood

Number of Healthy

Neighborhood home visits

conducted.

Number of certified asthma

educator follow up home visits conducted.

Number of homes with appropriate modifications.

December 31, 2018 Yes

Reduce asthma

related hospitalizations

and ED visits in

the Troy/Lansingbu

rgh

neighborhood by 5%


26.4/10,000 (2012-

2014) by 10% to 23.8/10,000. (Data

Source: NYS BRFSS)

approach to asthma

management by supporting DSRIP

Project 3.d.ii.

DSRIP Project 3.d.i.i.

Description: Ensure

implementation of asthma self-

management skills

including home environmental trigger

reduction, self-

monitoring,

medication use and

medical follow-up to

reduce avoidable emergency department

and hospital care. A

special focus will be on children for whom

asthma is a major driver of avoidable

hospital use.

environmental hazards by

asking residents questions from a standardized assessment

form. Residents are educated

about these concerns and provided referrals and follow

up resources. Free cleaning,

safety, and health products are also distributed to improve the

home living environment.


Initiative (HCDI)

Provides access to coverage

and care, health planning



Asthma Coalition that

encompasses asthma providers from within the capital region.

HCDI reviews and provides evidenced based practices and

professional development

opportunities for this workforce.

Alliance for Better

Healthcare

(St. Peter’s Health Partners)

The Alliance for Better Health

Care is governed by a five

member Board. The Alliance Members are: Ellis Medicine;

Samaritan Hospital, which

Program.

For residents identified at risk for uncontrolled asthma, provide

in-home certified asthma

educator services. Rensselaer County is a member of the

Capital Region Asthma

Coalition.


Initiative Asthma Coalition:

Promote bi-directional referral to

regional Healthy Neighborhood

Programs and smoking cessation

programs.

Provide continuing education

and asthma training opportunities to Certified

Asthma Educators (AE-C) and medical professionals.

Provide financial assistance to AE-C examination candidates.

Provide durable medical goods, environmental remediation

products, and educational

materials to home-based service providers.

Alliance for Better Healthcare

(St. Peter’s Health Partners)

Development of a Home Based Asthma program that will

arrange for patient visits in their

homes by a Respiratory Therapist, Registered Nurse and

Community Health Worker to

Track utilization of the

Home Based Asthma Program.

Track hospital and ED visits by diagnosis


represents St. Peter’s Health

Partners; St. Mary’s Healthcare Amsterdam; Hometown

Health; and Whitney M.

Young, Jr. Health Center. The Alliance was formed in

response to a New York State

Department of Health initiative called the Delivery System

Reform Incentive Payment.

provide appropriate asthma

education. . Home-based self-management programs to

include home environmental

trigger reduction, self-monitoring, medication use and

medication follow up.

Educate health care providers about the Home Based Asthma

program

Prevention Agenda Goal 3.1

Increase screening rates

for cardiovascular

disease, diabetes and

breast, cervical and

colorectal cancers, economically among

disparate populations

Prevention Agenda overarching objective

3.1.4:

Increase the percentage

of adults 18 years and

older who had a test for

high blood sugar or diabetes within the past

three years by 17% from

58.8% (2011) to 61.7%. (Data Source: NYS

BRFSS)

Promote prediabetes screenings and

education through the

use of evidence based

tools.

Rensselaer County

Department of Health:

Serves residents in Rensselaer

County through physical health


St. Peter’s Health Partners Primary Care, Urgent Care,

Behavioral Health,

Endocrinology, Outpatient Nutrition Counseling, CDE

Services and Hospital

Providers

Burdett Care Center

Birthing Center located in Rensselaer County. Provides

labor and birthing care;

prenatal and childbirth education classes and

breastfeeding education classes

and support groups.

Rensselaer County

Department of Health

Educating and providing

technical assistance to primary

care offices (Public Health

Detailing). Outreach within the

community, and producing marketing material that will

include, but not limited to

referral resources for nutrition counseling, and dietitian.

St. Peter’s Health Partners Provide access to St. Peter's

Hospital professionals to

become trained on the Prediabetes Screening and

resources available within the

Rensselaer County community.

Burdett Care Center

Pre-natal providers will provide information/refer patients as

appropriate. All patients with

gestational diabetes are referred to nutritional counseling.

Promote NDPP programs to

appropriate patients. Implementing Baby Friendly

Initiative; Strongly encourage all

new mothers to breastfeed; Provide breastfeeding education

Number of Healthcare Professionals educated on

the Evidenced Based

Screening tool.

{http://www.cdc.gov/diabet

es/prevention/pdf/prediabete

stest.pdf}

Number of primary care

offices receiving visits, materials.

Number of community members educated on

prediabetes through

outreach activities.

Number of marketing

materials developed and

distributed and locations.

Number of gestational diabetes referrals and

receivers of nutritional

counseling.

December 31, 2018



Initiative

Provides access to coverage and care, health planning



Asthma Coalition that

encompasses asthma providers

from within the capital region.

HCDI reviews and provides

evidenced based practices and professional development

opportunities for this

workforce.

Albany Medical Center Hospital which includes

primary care, and

comprehensive endocrinology services, serving Albany and

Rensselaer Counties.

Affiliation with Northeastern Diabetes Educators

Association.

and support groups. Attend

community outreach events to encourage breast feeding.


Initiative

The Diabetes/Obesity Task Force will assist in the

development of the marketing

materials and provide support for outreach programming.

Albany Medical Center:

Provide professional diabetes

education summit; provide

assistance in development of educational materials; educate

Albany Med primary care

physicians.

Number of participants who attend the annual Diabetes

Educators Summit.

Number of Albany Medical

Center primary care

physicians educated on Prediabetes.

Prevention Agenda

Goal #3.3: Promote culturally

relevant chronic disease

self-management education.

Prevention Agenda

overarching objective 3.3.1: Reduce use of

hospital for short-term

complications of diabetes 18+ years by

3% {7.7/10,000 (2012-

14) to 7.4/10,000 (2018)}.

Participation of adults

in self-management programs.

Rensselaer County

Department of Health:

Has certified National Diabetes

Prevention Program (NDPP)

Lifestyle coaches who will provide training in Rensselaer

County.


Primary Care, Urgent Care,

Behavioral Health, Endocrinology, Outpatient

Rensselaer County

Promote and provide NDPP Training. Strengthen Referral

Systems to NDPP and other

Evidenced Based Self-Management Programs.

St Peter’s Health Partners

Provide funding for two

professionals to be trained in NDPP to expand existing NDPP

Number of new sites

providing Prediabetes NDPP and YDPP.

Number of participants enrolled in the NDPP and

YDPP.

Number of participants in

other (i.e. non-YDPP/NDPP

chronic disease self-management programs that

December 31, 2018


Nutrition Counseling, CDE

Services and Hospital Providers.


Initiative Provides access to

coverage and care, health

planning expertise and supports health prevention programs

across the Capital Region.

Facilitates the Diabetes Task

Force.

Albany Medical Center Hospital which includes

primary care, and

comprehensive endocrinology services, serving Albany and

Rensselaer Counties. Affiliation with Northeastern

Diabetes Educators

Association.

programs within Rensselaer

County. Offer NDPP to employees, encourage patients to

participate in NDPP.


Initiative

Promote NDPP, Review and

update Diabetes Resource Guide, Review Alternative

Lifestyle Change programs.


Promote lifestyle changes and

prediabetes education; diabetes

prevention and education sessions and brochures; increase

# of CDEs.

support Lifestyle Change,

nutrition, exercise counseling).

Number of Resource Guides circulated.


Promote Mental Health and Prevent Substance Abuse Action Plan

Focus Area 2- Substance Abuse and other Mental Emotional Behavioral Disorders

Goal Outcome Objective Intervention/

Strategies,

Activities

Partner Resources Partner Role Process Measures By When Will Action

Address

Disparity? Prevention Agenda

Goal #2.1: Prevent underage

drinking, excessive

alcohol consumption by youth and adults, and

reduce non-medical use

of prescription pain medication, by youth

and adults.

Reduce ED Visits by

10% from 2013-15 to

2018.

23.3% to

21.0/100,000.

Reduce Number of

Overdose Deaths by

20% from 2016 to

2018.

Rensselaer County

from 25 deaths in

2015 to 20 deaths in

2018 (Data Source:

Rensselaer County

Medical Examiner)

Provider Education of

Addiction & Pain Management

Prescribing Guidelines

Community Resources

(Prevention, Addiction Treatment & Recovery

Support)

Information to provide

to patients regarding risk of harm and

misuse.

Rensselaer County

Department of Health: Serves residents in Rensselaer



Albany Medical Center Hospital with primary care behavioral health, pain

management and physician

education services


Primary Care, Urgent Care, Behavioral Health,

Endocrinology, Outpatient

Nutrition Counseling, CDE Services and Hospital

Providers.


Initiative Provides access to coverage and care, health

planning expertise and supports

health prevention programs across the Capital Region.

Facilitates the Behavioral

Health Task Force.

Rensselaer County


Promote prescriber training

opportunities.

Albany Medical Center Educate physicians regarding prescribing guidelines;

participate in prescription drug

monitoring program; host provider addiction/pain medicine

conference.


Educate both St. Peter’s Health Partners, and community

prescribers regarding prescribing

consistent with State & Federal guidelines.


Initiative Behavioral Health Task Force

will develop community

resource materials.

Number of prescriber

trainings offered.

Number of prescribers

trained.

Number of prescribing

guidelines developed and distributed.

Number of community

resource materials developed.

December 31,

2018

Promote safe storage

& proper disposal of

unused prescription

Rensselaer County


Serves residents in Rensselaer

Rensselaer County


Promote Drug Take Backs and

Number of proper disposal education activities.

December 31, 2018


medications.

Community

Education

Increase Disposal

opportunities





education services.


Primary Care, Urgent Care,

Behavioral Health, Endocrinology, Outpatient

Nutrition Counseling, CDE

Services and Hospital

Providers.


Initiative Brings community

based organizations together

serving the behavioral health community. Facilitators of the

Behavioral Health Task Force.

Proper Storage.


Provide community with a mechanism for proper disposal

of unused medications; promote

proper storage.


Promote Drug Take Backs and

proper storage materials.


Initiative

Behavioral Health Task Force

will promote Drug Take Backs and Proper Storage

Number of new permanent

and temporary sites for Rx collection.

Total pounds of prescriptions collected.

New York State Opioid Overdose Prevention

Training

Rensselaer County


In collaboration with both the

health department and mental health department. Educators

from both departments are

certified to facilitate NYS

Opioid Overdose Prevention

Training.

Rensselaer County

Department of Mental Health

Maintain responsibility and a commitment to the mental

hygiene needs of our residents

by monitoring and continuously improving the

system of behavioral healthcare

services delivered in the county.

Rensselaer County

Department of Health and

Mental Health

Host, and provide Narcan Training.

Number of trainings provided.

Number of persons participating in Naloxone

trainings.

Number of Narcan

administrations by provider.

December 31, 2018




education services


Primary Care, Urgent Care, Behavioral Health,

Endocrinology, Outpatient

Nutrition Counseling, CDE Services and Hospital

Providers.


Initiative Health planning expertise and supports health prevention

programs across the Capital

Region. Facilitates the Behavioral Health Task Force.


Educate and train law enforcement and emergency

medical professionals on Narcan

distribution.


Host and Publicize community Narcan Trainings.


Initiative Behavioral Health Task Force will design patient education

materials about community

resources.

Number of patient education materials developed.

Promote DSRIP

Project 3aiv.

Project Description:

Development of Withdrawal

Management (e.g.

ambulatory

detoxification,

ancillary withdrawal

services) capabilities and appropriate

enhanced abstinence

services within community-based

addiction treatment

programs.

Establish Ambulatory Detox Programs

Rensselaer County


Maintain responsibility and a

commitment to the mental

hygiene needs of our residents by monitoring and

continuously improving the

system of behavioral healthcare

services delivered in the count.


The Alliance for Better Health

Care is governed by a five

member Board. The Alliance Members are: Ellis Medicine;

Samaritan Hospital, which

represents St. Peter’s Health Partners; St. Mary’s

Healthcare Amsterdam;

Hometown Health; and Whitney M. Young, Jr. Health

Rensselaer County


Refer patients and promote

programs.


Establish four ambulatory

withdrawal programs. Increase

the number of X licensed primary care physicians.

Number of programs

established.

Number of additional physicians with X license

Number of patients served by new programs.

December 31,

2018


Center. The Alliance was

formed in response to a New York State Department of

Health initiative called the

Delivery System Reform Incentive Payment Program

(DSRIP).

St. Peter’s Health Partners,

St. Peter’s Medical

Associates, Catholic

Charities, Whitney Young Will develop withdrawal

management services for

substance use disorders (SUD)

within community-based

addiction treatment programs that provide medical

supervision and allow

simultaneous or rapid transfer of stabilized patients into the

associated SUD services and provide/link with care

management services that will

assist the stabilizing patient to address the life disruption

related to the prior substance

use.

St. Peter’s Health Partners, St.

Peter’s Medical Associates,

and Whitney Young Expand medication assisted

treatment in primary care

practices.

St. Peter’s Health Partners,

Project Safe Point, Catholic

Charities, and Project Lead

Develop care coordination

services for patients receiving ancillary withdrawal services.


COMMUNITY HEALTH IMPROVEMENT PLAN ENGAGEMENT AND EVALUATION

Engaging the community in the health needs assessment process was a priority of Rensselaer

County Department of Health, HCDI and stakeholders. Broad community engagement began

with participation in the community health survey. The surveys offered multiple choice and

open-ended questions to learn about residents’ health needs, health behaviors and barriers to

care. Demographic information collected by the survey allowed review of information by age,

gender, race/ethnicity and income.

Survey results were incorporated into the examination of health needs by the members of the

four Capital Region Public Health Prioritization Workgroups (Albany-Rensselaer, Columbia-

Greene, Saratoga and Schenectady). The Workgroups included community voices through

representatives from consumers, community based organizations that serve low-income

residents, the homeless, those with HIV/AIDS, advocacy groups, employers, public health

departments, providers and health insurers. Participants were encouraged to share data of

their own and to advocate for the needs of their constituents. While all health institutions serve

high need individuals, the two federally qualified health centers, Food Pantries of the Capital

District, United Way of the Capital Region, Interfaith Partnership for the Homeless, and our

consumer community representatives have unique access to medically underserved residents.

The Rensselaer County Wellness Committee will continue to meet on a monthly basis, in a

continuing effort to engage community partners.

COMMUNICATIONS STRATEGY

Strategies for disseminating and educating professional organizations, governmental agencies,

stakeholders and the community on the Community Health Improvement Plan as outlined

below:

A press release announcing publication of the 2016-2018 Community Health

improvement Plan will be provided to local print media including a link to the Rensselaer

County Department of Health website.

Printed hard copies of the document(s) will be provided to (CHIP) stakeholders

County, town, and village governments will be provided with both hard and

electronic copies.

New York State senators and assemblypersons representing Rensselaer County will

be send a letter and link to access the document(s) on the Rensselaer County

Department of Health website.


APPENDIX A

PROFILE OF COMMUNITY RESOURCES

AVAILABLE TO MEET HEALTH-RELATED NEEDS OF

RENSSELAER COUNTY

Rensselaer County Wellness Committee Member Organizations • 15 Love Program • AIDS Council of Northeastern New York • American Cancer Society • Asthma Coalition of the Capital Region • Burdett Care Center • Cancer Services Program • Capital District Community Gardens • Capital District Physicians Health Plan • Capital District Tobacco-Free Coalition • Capital District YMCA • Center for Smoking Cessation • City of Troy • City of Troy Mayor's Office • Commission on Economic Opportunities (CEO) • CONSERNS-U • Cornell Cooperative Extension • Empowerment Exchange • Grace United Methodist Church • Hannaford Supermarkets • Health Homes • Healthy Capital District Initiative • Healthy Families Rensselaer County • Healthy School NY • Heroes At Home, services to veterans • Hillside North Neighborhood Group • Hoosick Area Church Association • Hope 7 Community Center • Hudson Valley Community College (HVCC) • HVCC Counseling Center • HVCC Health Services • Independent Living Center of the Hudson Valley • Lansingburgh Boys and Girls Club • Literacy Volunteers of Rensselaer County • Mom Starts Here • NYS Department of Health


• Pediatric Obesity Prevention • Questar III • Reality Check • Rensselaer Adult Rehabilitation Center (ARC) • Rensselaer Boys and Girls Club • Rensselaer Cares Prescription Assistance Program • Rensselaer County Aging Department • Rensselaer County Department of Health • Rensselaer County Department of Health Board Members • Rensselaer County Department of Mental Health • Rensselaer County Department of Social Services • Rensselaer County Department of Youth • Rensselaer County Executive's Office • Rensselaer County Legislature • Rensselaer County Probation • Rensselaer Polytechnic Institute (RPI) • RPI-Gallagher Student Health Center • Sexual Assault and Crime Victim Assistance Program • St. John's/St. Joseph's • St. Jude's-Troy • St. Jude's-Wynantskill • St. Peter’s Health Partners/Samaritan Hospital/Northeast Health • St. Peter’s Health Partners/Seton Health/St. Mary’s Hospital • St. Peter's Health Partners • St. Peters Health Partners MOMS Program • St. Peter's Partners Faith Community Nurse Program • St. Timothy's Lutheran • The Arc of Rensselaer County • The Sage Colleges • Transfiguration Parish • Troy Area United Ministries • Troy Boys and Girls Club • Troy City Council • Troy Housing Authority • United Way of the Greater Capital Region • Upper Hudson Planned Parenthood • Uptown Initiative • Van Rensselaer Manor • Whitney Young Jr. Health Services Troy • YMCA-Greenbush Center • YMCA – Troy


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Appendix B - 2016 Capital Region Community Health Survey


Appendix C Capital District Task Force Members

Asthma Coalition Albany College of Pharmacy Albany County Department of Health Albany Medical Center Alliance for Better Health Care Ballston Spa School District Bassett Healthcare Network Capital District Child Care Coordination Capital District Community Garden Capital District Tobacco-Free Communities Catholic Charities of Fulton & Montgomery Counties Capital District Physicians Health Plan- CDPHP Cornell Cooperative Extension Ellis Medicine Emblem Health Fidelis Care Future of Education in Mayfield Healthy Capital District Initiative Healthy Policy Matters Hometown Health Center Hudson Valley Community College- HVCC Montgomery County Nathan Littauer Hospital & Nursing Home Next Wave NYS Department of Health Price Chopper Rensselaer County Rensselaer County Public Health Department Schenectady County Public Health Services Scotia Glenville City School District Seton Health St. Mary's Healthcare St. Peters Hospital Unity House Visiting Nurses Association Visiting Nurses Association Whitney M Young Health Center


Obesity-Diabetes Task Force

Albany County Department of Health Albany Medical Center American Diabetes Association Capital District Physicians' Health Plan, Inc. Capital District YMCA Capital Region Diabetes and Endocrine Care Capital Roots Childcare Coordinating Council Cornell Cooperative Extension Creating Healthy Schools and Communities/SPHP Golub Corp- Price Chopper Healthy Capital District Initiative Healthy Capital District Initiative Healthy Schools NY/ SPHP Northeast NY Diabetes Educators Rensselaer County Health Department Samaritan Hospital Shoprite St. Peter’s Health Partners St. Peter's Health Partners, Center for Health Programs and Promotion Stratton VAMC/AADE/ Northeastern NY Diabetes Educators (NENYDE) University at Albany Behavioral Health Task Force

Albany County Department of Health Albany County Department of Mental Health Albany Medical Center Camino Nuevo Catholic Charities Care Coordination Services Capital District Physicians Health Plan (CDPHP) Albany Medical Center - Center for Health Systems Transformation Northeast Health Catholic Charities- Project Safe Point Rensselaer County Health Department Rensselaer Department of Mental Health St. Peter’ Hospital (Samaritan & St. Mary’s) St. Peter’s Health Partners The Addictions Care Center

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