NYS 2016 Community Health Assessment and Improvement Plan

Transcription

1 NYS 2016 Community Health Assessment and Improvement Plan for the Niagara County Department of Health 1 Daniel J. Stapleton, MBA Public Health Director Niagara County Department of Health 5467 Upper Mountain Road Lockport, NY Dan.Stapleton@niagaracounty.com 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) (716) (716) (716) pat.bradley@nfmmc.org fred.caso@chsbuffalo.org cmoore@enhs.org KTompkins@KaleidaHealth.Org

2 2 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 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 Priority Area Update and Changes For the 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 period, emerging issues were identified and considered as potential new priorities. The NCDOH met with hospital partners to review the priority area progress in early 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.

3 3 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 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 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 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 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

4 4 hospitalizations: annually there are visits per 100,000 residents through the ER, and 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 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 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.

5 5 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.

6 6 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)

7 7 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.

8 8 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 over per 100,000 residents (Vital Statistics, 2014). Niagara County is 2 nd 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.

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10 10 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,

11 11 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.

12 12 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 % 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.

13 13 Opioid abuse also accounted for 34.2 ER visits per 10,000 adults, as well as 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 2 nd 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.

14 14 Selected Prevention Agenda Priorities: Results of 2016 Survey Community Health Assessment surveys were distributed across Niagara County between March and May 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:

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16 16 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:

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18 18 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. s 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, 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

19 19 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

20 20 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

21 21 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.

22 22 Niagara County Department of Health Priority Area #1 Preventing Chronic Disease Disparity: Mental Hygiene Focus Area Goal Objective Activities Partner Responsible Chronic Disease Promote use of evidencebased 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/ Increase number of participants completing the chronic disease selfmanagement program (CDSMP) by 5% by 12/31/ Increase number of participants completing the diabetes self-management program (DSMP) by 5% by 12/31/ NCDOH - educates Nursing Staff 2. NCDOH - promotes and schedules classes 3. NCDOH - promotes and schedules classes 4. NCDOH - promotes and schedules classes 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/ NCDOHprovides academic detailing for DSMP & CDSMP American Diabetes Assoc.-provides academic detailing for the DPP.

23 23 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/ 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 rehospitalizations by 3/ Continue using depression educational materials and a depression screening tool to use at Health Assessment Clinics (HAC) to identify patients with depression through 12/ NCDOH - provides academic detailing for DSMP & CDSMP. American Diabetes Assoc.-provides academic detailing for the DPP 7. NCDOHprovides workshops NC Office for the Agingprovides financial support for administering programs, printing of promotional materials, scheduling individuals into classes. 8. NCDOHcreates plan 9. NCDOHinitiate meeting. Hospitalsprovide brochures to patients upon hospital discharge. 10. NCDOH - distributes educational materials and screening tool. Refer patients as needed. Niagara County Dept. of Mental

24 24 Health & Substance Abuse (NCDMH) - recommend and provide educational materials. 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/ Re-educate Nursing Division staff to refer all individuals that screen positive for depression to the appropriate mental health professional by 3/ Offer depression screening as part of a health assessment at 6 senior nutrition sites by 12/ Offer depression screening as part of a health assessment at 6 senior nutrition sites by 12/ Offer provision of one CDSMP, DSMP or DPP program at each NC hospital by 12/ 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. NCDOHprovide workshop Hospitals - host and promote program at their facility.

25 25 Niagara County Department of Health Priority Area #2 Promote Mental Health and Prevent Substance Abuse Focus Area Promote Mental Health and Prevent Substance Abuse Goal Objective Activities/Interventions Partner Responsible Promote Increase the percent 1. Train 100% of Nursing 1. NCDOH - Mental, of employees Division Staff in Mental coordinate Emotional and trained in traumainformed Health First Aid certification training. Behavioral approach by 12/17 The Mental Health (MEB) by 35% by Health December 2018 Association in Niagara County (MHANC) - provide training. Offer information on and referral to available Mental Health services to 100% of individuals who have positive depression screens. 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/ Train Nursing Division staff on available mental health services in Niagara County to allow for facilitation of patient referrals by 6/ 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.

26 26 Prevent Substance Abuse Promote harm reduction and increase the number of Nursing Division professionals participating in Narcan training. 1. Offer voluntary harm reduction training to all Nursing Division Clinic Staff in the delivery of Narcan by 9/17 1. NCDOH - coordinate training. Evergreen Health Services - provide training. Increase the number of public awareness, outreach and educational efforts to change attitudes, beliefs and norms towards excessive alcohol and prescription opiate use. 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 2. NCDOH - coordinate and provide outreach. 3. NCDOH - distribute materials. NCDMH - recommend and provide materials. MHANC - recommend and provide materials. 4. Create a survey tool to distribute through social media regarding the community s knowledge and use of illicit substances by 12/17 4. NCDOH - build and disseminate tool. NCDMH - advise on content of survey tool. 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 5. NCDOH - distribute materials. NCDMH - advise on content of educational materials and provide if able.

27 27 Strengthen Infrastructure Support integration of MEB health within chronic disease prevention strategies 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 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 NCDOH - Plan and host MH professionals as guests on NCDOH's television program Health Scope. NCDMHappear as guest on TV program LCTV - allow access to station and air taped show. 1. NCDOH - stock materials on resource tables Increase MEB stakeholder involvement across all initiatives by 10% 2. Increase MEB community stakeholder involvement in public health initiative by holding quarterly planning meetings through 12/ NCDOH - host meetings NCDMH - attend meetings MHANC - attend meetings 3. Initiate NCDOH Nursing staff attendance of meetings/coalitions related to Mental Health/Substance Abuse by 12/18 3. NCDOH engage in coalitions Community Organizations that target Substance Abuse - All above to engage in coalitions to understand problems and work toward solutions.

28 28 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 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 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, Interventions/Strategies/ Activities Patients presenting for annual physicals will have the option of completing cardiovascular selfassessments. Upon completion of the selfassessment, 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. Process Measures 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. Partner Role & Resources 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. Does action address disparity 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 The ENH Community Relations Department will provide leadership and staff support. Yes events are open to all.

29 29 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 selfmanagement through at least two public events annually in 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.

30 30 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 Disparity: Mental health population DSRIP MCC PPS Project Alignment: Project 4.a.i. Promote mental, emotional and behavioral wellbeing in communities. Outcome Objective Interventions/ Strategies/ Activities ongoing 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 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

31 31 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 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 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 Interventions/ Strategies/ Activities ongoing 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. Process Measures 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 Resources Kaleida Health and Partners Women & Children s Hospital of Buffalo and DeGraff Memorial Hospital - provide leadership and staff support. HeartCaring - national evidencebased 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. Will action address disparity Yes In 2015, 73% of patient visits at WCHOB s OB-GYN clinics were reimbursed by Medicaid

32 32 2. Host Heart to Heart public education events at Kaleida Health locations in Erie and Niagara counties 3. Provide outreach and chronic disease screening and education programs targeting Niagara County residents. 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. 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. Conduct 2-3 events annually in Erie and Niagara counties through Educate public in chronic disease identification and selfmanagement through 4-5 community/bus iness events annually and 1-2 Chronic Disease Self- Management Programs annually through 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. 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. Yes- events are open to all. Niagara County s mental health disparity is addressed through the inclusion of mental health educationa l materials at events.

33 33 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 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 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 miniworkshops 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 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 evidencebased Mental Health First Aid Certification classes. Yes addresses needs of mental health population

34 34 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.

35 35 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 rehospitalization 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. 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. Partner with NCDOH, Niagara County hospitals and ADA to host diabetes prevention classes at the Neighborhood Health Center by 12/31/17. 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 Year 2 (2017): Support for Diabetes Educator Year 3 (2018): 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.

36 36 Mount St. Mary s Hospital Niagara County Project 2: Promote Mental Health and Prevent Substance Abuse Designated Mount St. Mary s Project Leaders: Clearview Treatment Services Bernadette Franjoine, Mount St. Mary s Hospital; and Karen Hogan, 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 Outcome Objectives: General populations, especially those with mental health needs and identified substance abuse problems. 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%.