2016 Community Health Needs Assessment

Transcription

1 Nathan Littauer Hospital and Fulton County 2016 Community Health Needs Assessment - 1 -

2 Table of Contents Introduction... 3 The Adirondack Rural Health Network... 3 New York State s Prevention Agenda New York State's Health Care Transformation... 5 Community Health Assessment Process and Measures... 6 Geography... 7 Infrastructure and Services... 8 Health Care Facilities... 8 Population and Demographics... 9 Health Indicators Health Care Challenges by Prevention Agenda Priority Area Community Input Priority Selection Appendices: Appendix A - Methodology and Data Sources 36 Appendix B - NYS Prevention Agenda Appendix C - Demographic Profile 44 Appendix D- Educational Profile Appendix E - Health System Profile.. 48 Appendix F - Data Consultants and Data Sources Appendix G - ARHN Community Health Assessment Committee an & Schedule

3 Introduction: The purpose of this Community Health Needs Assessment (CHNA) is to identify and prioritize the healthcare challenges currently faced by the residents of Nathan Littauer Hospital s service area which includes Fulton and Montgomery counties. The hospital also serves residents residing in southern Hamilton County. The findings in this CHNA result from a year-long process of collecting and analyzing data and consulting with stakeholders throughout the community and the region. The results of this CHNA will assist members of the community, especially healthcare providers, work together to provide programs and services targeted to improve the overall health and well-being of all residents of Fulton County. Working within the framework provided by New York State s Prevention Agenda , Nathan Littauer Hospital and Fulton County Public Health collaborated in the development of this CHNA. Additionally, Nathan Littauer Hospital and Fulton County Public Health participated in regional health assessment and planning efforts conducted by the Adirondack Rural Health Network. The Adirondack Rural Health Network: The Adirondack Rural Health Network (ARHN) is a program of the Adirondack Health Institute, Inc. (AHI). AHI is a 501c3 not-for-profit organization that is licensed as an Article 28 Central Service Facility. AHI is a joint venture of Adirondack Health (Adirondack Medical Center), University of Vermont Health Network Champlain Valley Physicians Hospital, Glens Falls Hospital and Hudson Headwaters Health Network. The mission of AHI is to promote, sponsor, and coordinate initiatives and programs that improve health care quality, access, and service delivery in the Adirondack region. Established in 1992 through a New York State Department of Health, Rural Health Development Grant, the Adirondack Rural Health Network (ARHN) provides a forum for local public health services, community health centers, hospitals, community mental health programs, emergency medical services, and other community-based organizations to address rural health care delivery barriers, identify regional health needs and support the NYS Prevention Agenda to improve health care in the region. ARHN includes organizations from New York s Clinton, Essex, Franklin, Fulton, Hamilton, Warren, and Washington counties. Since 2002, ARHN has been recognized as the leading sponsor of formal community health planning in the region. The Community Health Assessment (CHA) Committee, facilitated by ARHN, is comprised of hospitals and county health departments working together utilizing a systematic approach to community health planning. The CHA Committee is made up of members from Adirondack Health, Alice Hyde Medical Center, Elizabethtown Community Hospital, Essex County Public Health, Franklin County Public Health, Fulton County Public Health, Glens Falls Hospital, Hamilton County Public Health Services, Moses Ludington Hospital & Inter-Lakes Health, Nathan Littauer Hospital, UVM Health Network CVPH, Warren County Health Services, and Washington County Public Health Services

4 New York State s Prevention Agenda : 1 The Prevention Agenda is a blueprint for local, regional, and state action to improve the health of New Yorkers in five priority areas, and to reduce health disparities for racial, ethnic, disability, and low socioeconomic groups, as well as other populations who experience them. In addition, the Prevention Agenda serves as a guide to local health departments as they work with their community to develop mandated Community Health Improvement Plans and Community Health Assessments and to hospitals as they develop mandated Community Service Plans and Community Health Needs Assessments required by the Affordable Care Act. The Prevention Agenda establishes goals for each priority area and defines indicators to measure progress toward achieving these goals. The plan features five priority areas and an additional action plan was added to improve health and reduce health disparities. Each priority has focus areas: Improve Health Status and Reduce Health Disparities Focus Area 1-Improve Health Status and Reduce Health Disparities Prevent Chronic Disease Focus Area 1-Reduce Obesity in Children and Adults Focus Area 2-Reduce Illness, Disability and Death Related to Tobacco Use and Secondhand Smoke Exposure Focus Area 3-Increase Access to High-Quality Chronic Disease Preventive Care and Management in Clinical and Community Settings Promote Healthy and Safe Environment Focus Area 1-Outdoor Air Quality Focus Area 2-Water Quality Focus Area 3-Built Environment Focus Area 4-Injuries, Violence and Occupational Health Promote Healthy Women, Infants and Children Focus Area 1-Maternal and Infant Health Focus Area 2-Child Health Focus Area 3-Reproductive, Preconception and Inter-Conception Health Promote Mental Health and Prevent Substance Abuse Focus Area 1-Promote Mental, Emotional and Behavioral Well-Being in Communities Focus Area 2 - Prevent Substance Abuse and other Mental Emotional Behavioral Disorders Focus Area 3 - Strengthen Infrastructure across Systems Prevent HIV, Sexually Transmitted Diseases, Vaccine-Preventable Diseases and Health Care-Associated Infections Focus Area 1-Prevent HIV and STDs Focus Area 2-Prevent Vaccine-Preventable Diseases Focus Area 3-Prevent Health Care-Associated Infections *The Prevention Agenda was originally a five year plan ( ); it was extended to 2018 to align its timeline with other state and federal health care reform initiatives. 1 Excerpt from New York State Department of Health website - 4 -

5 New York State s Health Care Transformation: Public Health Departments and Hospitals are key partners working with providers, agencies and community based organizations to transform the way that our community members think about and receive health care. There are a number of federal, state, and regional initiatives to restructure the delivery system focusing on the Triple Aim. The Triple Aim is a framework that organizations and communities can use to navigate the transition from a focus on clinical care to optimizing health for individuals and populations. The Triple Aim is improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities. Delivery System Reform Incentive Payment (DSRIP) Programs: On April 14, 2014 Governor Cuomo announced that Center of Medicaid and Medicare Services approved New York s waiver request to reinvest the $8 billion generated by Medicaid Redesign Team (MRT) reforms. DSRIP s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over 5 years. Each DSRIP project has specific milestones and metrics with an incentive based payment model that allocates payout upon achieving predefined results in system transformation, clinical management and population health. Additionally, a number of quality goals must be achieved including access measures, preventive care and care coordination. The DSRIP program covers a five-year period beginning April 1, 2015 and ending March 31, Nathan Littauer Hospital and Fulton County Public Health are participating partners in Adirondack Health Institute (AHI) Performing Provider Systems (PPS). Nearly 100 Regional Partners are part of the AHI PPS. Partners are organized by Regional Health Innovation Teams (RHIT). RHITs provide a forum for collaborative planning, monitoring, and development of innovative health system programs/projects. AHI has 11 projects from New York State approved list organized by three domains: system transformation, clinical improvement and population health. System Transformation projects are designed to accomplish New York s State Innovation Plan, a roadmap to achieve the Triple Aim for all New Yorkers: improved health, better health care quality and consumer experience, and lower costs. This multi-faceted approach has at its core an advanced primary care model that integrates care with all parts of the health care system, including behavioral health and community-based providers and aligns payment with this care model. o 2ai Integrated Delivery System o 2aii Advancing Primary Care o 2aiv Medical Village o 2bviii Hospital-Home Collaboration Solutions o 2di Patient Activation Clinical Improvement projects focus on a specific disease or service category (ex, behavioral health, substance abuse, palliative care) that have been identified as a significant cause of avoidable hospital use by Medicaid beneficiaries in our region. o 3ai Integrating Behavioral Health with Primary care o 3aii Crisis Stabilization o 3aiv Withdrawal Management o 3gi Integration of Palliative Care into the PCMH Model Population-Wide Strategy Implementation projects focus on progress on measures from the New York State Prevention Agenda

6 The Prevention Agenda is a blueprint for state and local action to improve the health of New Yorkers in five priority areas (prevent chronic disease; promote a healthy & safe environment; promote healthy women, infants & children; promote mental health and prevent substance abuse; prevent HIV, sexually transmitted diseases, vaccine preventable disease and healthcare associated infections) and to reduce health disparities for racial, ethnic, disability and low socio-economic groups, as well as other populations who experience them. o 4aiii Strengthening the Mental Health & Substance Abuse Infrastructure o 4bii Chronic Care: COPD Population Health Improvement Programs: The Population Health Improvement Programs (PHIP) will promote the Triple Aim of: better care, better population health and lower health care costs by convening regional stakeholders and establishing neutral forums for identifying, disseminating, and implementing best practices and strategies to promote population health and reduce health care disparities in their respective regions. The PHIP will help achieve improvements in population health through stakeholder collaboration, data-driven priorization, and regional strategies for addressing health disparities. The PHIP supports and advances the ongoing activities of New York State Prevention Agenda and the State Health Innovation Plan, as well as, serves as a resource for the local Performing Providers Systems. Nathan Littauer Hospital and Fulton County Public Health are active members of the Mohawk Valley PHIP board. The Bassett Healthcare Network s Bassett Research Institute is the contractor for the Mohawk Valley PHIP which comprises Fulton, Herkimer, Montgomery, Otsego and Schoharie counties. Following a careful review of local health data and extensive discussion, the Mohawk Valley PHIP board and stakeholders have identified two regional population health priorities of Behavioral Health and Obesity. Workgroups were formed to tackle these health priorities. NYS Health Innovation Plan and State Innovation Model: New York s State Innovation Model (SIM) testing grant seeks to transform primary care delivery and payment models across the State, eventually reaching 80 percent of New York s primary care providers, payers, and patients. The SIM is a part of New York s larger State Health Innovation Plan (SHIP), which is driving evolution of health delivery and payment systems through numerous initiatives. The intent and goal is to identify and stimulate the spread of promising innovations in health care delivery and payment that result in optimal health outcomes for all New Yorkers. Community Health Assessment Process and Methods: The process of identifying the important healthcare needs of the residents of Nathan Littauer Hospital involved both data analysis and consultation with key members of the community. The data was collected from multiple sources including publicly available health indicator data and data collected from a survey conducted by the Adirondack Rural Health Network. The health indicator data is collected and published by New York State and contains over 300 different health indicators. Since 2002, The Adirondack Rural Health Network has been compiling this data for the region and producing reports to inform healthcare planning on a regional basis. In March and April of 2016, the Adirondack Rural Health Network (ARHN) conducted a survey of selected stakeholders representing health care and service-providing agencies within an eight-county region. The results of the survey are intended to provide an overview of regional needs and priorities, to inform future planning and the development of a - 6 -

7 regional health care agenda. The survey results were presented at both the county and regional levels. Using the results of the indicator analysis, the survey, and other community assessments, a group of stakeholders was convened to identify and prioritize the current healthcare challenges for the residents of the service region. Additionally, local stakeholders met to review the findings. NLH s executive team met to review the datat and discuss our response to the area population health needs. Community Profile: Geography Fulton County is located in the central portion of New York State 45 miles northwest of Albany. Situated in the foothills of the Adirondacks, it is roughly rectangular in shape encompassing 533 square miles of which 495 square miles is land and 37 square miles is water. About 36 percent of the County s land area is occupied by Wild, Forested and Conservation Lands and Public Parks. Nearly 28 percent of the land area is developed for residential, commercial, or industrial use, and additionally 6 percent of the land area is used for agricultural needs. Approximately 24 percent of the County s land area is considered vacant land or unknown usage. Finally, 5 percent of the County s land area is used for public and community services; while recreation and entertainment occupies less than one percent of the land area. (Fulton County Hazard Mitigation Plan 2010) The terrain is a mix of rolling ridges, valleys and fields to the south, and gentle hills to the north. The average mean temperature is 45 degrees Fahrenheit. In January, the mean is 19 degrees and in July, 70 degrees. The most abundant natural resource in Fulton County is water. Damming of the Sacandaga River in the 1920 s produced the Great Sacandaga Lake. Originally intended as flood control for the Mohawk and Hudson Rivers, it presently serves as a recreational area and swells the population of Fulton County during the summer months. Fulton County is bordered by Hamilton County to the north, Herkimer County to the west, Montgomery County to the south and Saratoga County to the east. Fulton, Montgomery and Hamilton Counties share many of the same medical, educational and service providers and have increased cooperative efforts to meet the needs of our collective residents. The County consists of 15 municipalities: the cities of Gloversville and Johnstown, the villages of Broadalbin, Northville and Mayfield and the towns of Bleecker, Broadalbin, Caroga, Ephratah, Johnstown, Mayfield, Northampton, Oppenheim, Perth and Stratford. Approximately 317 square miles of Fulton County lies within the Adirondack Park. The Towns of Bleecker, Caroga, Northampton, and Stratford lie entirely within the Park. The Towns of Broadalbin, Ephratah, Johnstown, Mayfield and Oppenheim partially lie within the Park

8 Figure 1: Map of Fulton County Infrastructure and Services 2 Fulton County has more than 1,200 businesses and industries that provide services and produce yogurt, cheese and other dairy products, bakery items, boating accessories, canvas items, chemicals, cleaning products, furniture, knitted and leather goods, medical equipment, paint, recycled products, refrigeration units, and textiles. Electronic and print media include one daily newspaper, two regional newspapers that have Fulton County editions, and several regional, weekly and monthly newspapers serving specific geographic locations and subscribers. Three county radio stations broadcast both AM and FM programs. Two public access television stations are available, and there is a locally owned television. Fulton County is located just north of the New York State Thruway (I-90), west of Interstate 87 and northwest of Interstate 88, providing direct linkage to all major population areas in the Northeast. State Routes 30, 30A, 10 and 29 connect to the interstate highways. Fulton County Airport provides 24-hour, year round corporate and leisure service. Taxi or limousine service is offered by local firms. Adirondack Trailways and the Gloversville Transit Authority provide local and long distance bus service. Gas and electric is provided by National Grid. Municipal water and sewer facilities are located in Johnstown and Gloversville. Gloversville is the only municipality in the county with water fluoridation. Cable television is available through Time Warner Cable and there are satellite television options available. Frontier, the major telephone provider, offers Fit TV, and internet based television. Internet service is provided by Frontier and by Time Warner Cable. Satellite companies also provide service for internet. 2 Fulton County NY Tourism Website,

9 Health Care Facilities Nathan Littauer Hospital, located in the City of Gloversville, is the leading provider of health care and the only Article 28 hospital operating in Fulton County. The hospital has 74 beds for a rate of per 100,000 population, substantially lower than the rate for the ARHN region (204.9) or Upstate New York (277.4). Nathan Littuera also has an 84 bed skilled nursing facility adjacent to the hospital. The County has two other nursing homes and three adult care facilities with a total of 360 and 134 beds respectively. Residents of the County also have access to facilities in surrounding counties, including Montgomery, Herkimer, Saratoga, Albany, and Schenectady. Residents are served by 13 hospital extension clinics 10 primary care clinics, one addiction and mental health treatment clinic, one pediatric specific clinic and one ambulatory surgery center. Nathan Littauer Hospital operates 74 beds, of which 8 are intensive care, 7 maternity, 47 medical surgical and 12 pediatric. Health Care System Fulton County Montgomery County ARHN Counties Upstate New York Health Care Workforce (per 100,000) Total Physician Primary Care Obstetrics/Gynecology Health Care Beds (per 100,000) Total Hospital Beds Total Psychiatric Beds ,390 Total Nursing Home Beds Total Adult Home Beds In Fulton County, there are 638 registered nurses, 317 licensed practical nurses, 20 nurse practitioners, 19 registered physician assistants and 92 physicians licensed to practice in the County. According to the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) data, Fulton County is considered to be a Health Professional Shortage area for Primary Care, Mental Health and Dental Care. Services Administration Population and Demographics According to the Adirondack Rural Health Network (ARHN) Summary of Demographics, Fulton County s population is 54, % of the population is 65 and over and 21.2% is 17 and younger

10 Figure 2: Population Distribution by age, 2014 Fulton County Population Distribution by Age < The City of Gloversville has the highest population, followed by the City of Johnstown and the Town of Johnstown. Figure 3: Population Distribution by Municipal Location Fulton County Population 18,000 16,000 15,315 14,000 12,000 10,000 8,479 8,000 7,098 6,495 6,000 5,250 4,000 2, ,205 1,682-2,670 1,924 3, There is little racial diversity in Fulton County. 93.5% are White non-hispanic, 1.5% Black non-hispanic, 0.7 Asian, 2.6% Hispanic/Latino, and 1.5% Multi-Race/Other. 95.3% of Fulton County residents speak only English at home. There is an

11 infrequent need for translation services or educational materials in languages other than English. A small number of Old Order Amish families reside in the town of Ephratah. These families are connected with the district located in Montgomery County and their children attend Amish schools. Figure 4: Population Distribution by Race, 2014 Fulton County White Black Asian Hispanic/Latino 93.5 Multi-Race/Other Figure 5: Population Characteristics Demographic Indicators Fulton County Montgomery County ARHN Counties Upstate New York Race and Age % of population, White, non-hispanic % Hispanic/Latino Number of ages 65 and older Number of ages 17 or younger Number of ages females Poverty % of population under federal poverty level 93.5% 84.1% 91.3% 2.6% 12.0% 2.6% 9,266 8,487 59,314 11,686 11,467 70,815 9,622 9,000 62, % 19.1% 14.5% 75.5% 10.2% 1,708,501 2,486,888 2,120, % % of population who received Medicaidd 21.9% 23.8% 17.6% services 16.9% % of students on free or reduced lunch 47.6% 48.4% 42.0% 35.7% The time when Fulton County was nationally recognized as the premier center for glove manufacturing is long past. The primary employment opportunities in the county are in the healthcare, social assistance sector and education at 29.5%; retail trade accounts for 15.9% while manufacturing accounts for only 12.4% of the workforce

12 Figure 6: Employment Employment Fulton County Montgomery County ARHN Region Upstate New York Total population ages 16 and Older in the workforce 44,744 39,78 298,968 9,064,295 % unemployment 7.6% 7.5% 6.8% 5.6% Employment Sector Agriculture, forestry, fishing, hunting, Mining 1.2% 2.9% 2.3% 1.0% Construction 6.9% 7.5% 7.2% 6.0% Education, Health Care & Social Assistance 29.5% 25.3% 27.7% 28.3% Manufacturing 12.4% 12.7% 10.5% 8.6% Arts, Entertainment, Recreation, Hotel, Food Service 7.0% 7.6% 10.1% 8.2% Retail trade 15.9% 14.1% 13.0% 11.5% The poverty rate and level of educational attainment for a community strongly influence the community s health. Although 85.7% percent of Fulton County residents 25 years or older had high school diplomas, only 15.7% had attained a bachelor s degree or higher level of education. There are 7 school districts within the confines of Fulton County. They are Northville, Mayfield, Broadalbin Perth, Gloversville, Johnstown, Wheelerville and Oppenheim-Ephratah St. Johnsville. Some Fulton County students reside in districts that are served by Saratoga (Galway) or Herkimer County (Dolgeville). In addition, students from Hamilton County attend Northville Central School and Johnstown High School. Wheelerville is a K-8 common school whose high school students attend Johnstown High School. Fulton County residents have a higher level of attainment of a high school diploma as compared to the NYS rate. However, the rate of attainment for higher education drops below the state average beyond an associate s degree. Fulton-Montgomery Community College is the only institute of higher education in the immediate vicinity and students wishing to continue their education beyond 2 years must travel out of the area. The closest SUNY College is in Albany. Although the Capital District s multiple private colleges provide a wealth of opportunities for education, the cost may be prohibitive for the residents of our county. Figure 7a: Education

13 45 Fulton Montgomery ARHN NYS % with Less than HS Education/GED % with HS Diploma/GED % Some College, No Degree % Associate Degree % Bachelor's Degree % Graduate or Professional Degree Figure 7b: Vulnerable Populationon Area (low educational attainment and High Poverty) P=percentage of poverty, HS= percentage with less than a high school diploma, H= Nathan Littauer Hospital Population counts for demographic groups and total area population data are acquired from the U.S. Census Bureau s American Community Survey. Data represent estimates for the 5 year period Mapped data are summarized to 2010 census tract boundaries. Area demographic statistics are measured as a percentage of the total populationon based on the following formula: Percentage = [Subgroup Population] /[Total Population] * Fulton County is disproportionally affected by poverty. 16.2% of the population is under the federal poverty level compared to 11.8% for Upstate New York and 15.6% for New York State. 18.6% of householdss are single parent households compared with 16.6% for Upstate New York and 19.8% for New York State. 21.9% of the population received Medicaid and 47.6% of children were eligible for free or reduced lunch

14 Figure 8: Poverty and Medicaid Status, Percent of Individuals Under the Federal Poverty Level 10 Percent of Individuals Receiving Medicaid 5 0 Fulton Montgomery ARHN NYS The median household income for Fulton County was $58,147 compared to the state-wide median of $85,736. Despite high levels of poverty, Fulton County has affordable housing. Only 30% of residents have monthly housing costs 30% or more of household income. The housing stock in Fulton County is very old, with 40.5% built prior to Gloversville has a high rate of families living in poverty and a high lead zip code. 67.3% of the homes in the City of Gloversville were built prior to 1940, and 89.2% prior to Figure 9a: Housing Age by Percent Built 80.0 Fulton County Montgomery County ARHN Region Built Before 1970 Built Built Built Built 2000 and Later Figure 9b: Percentage of Housing Units

15 Fulton County 40 Montgomery County ARHN Region 10 0 Housing Units Occupied Housing Units Owner Occupied Housing Units Renter Occupied The housing situation in the City of Gloversville has not changed since the last assessment. Lead abatement enforcement is a double-edged sword. Landlords, forced to abate homes or face fines, abandon property that is then foreclosed and removed from the tax rolls. In many cases, the city is forced to raze the homes at taxpayer expense. The housing authority allows the family of a child with a blood lead level of over 20 to move to the top of the housing waiting list, but not enough HUD public housing exists to meet the need. In addition, to some families the social challenges inherent in public housing make moving into lead-free housing undesirable. The age of the housing stock in Fulton County, combined with low real estate values contributes to the high rate of lead poisoning among our children. 6.6% of homes were built in 2000 or later compared with 7.2% statewide. Health Indicators: Based on the 2016 County Health Rankings Fulton County ranks 47 th out of 62 New York State counties in overall health outcomes and 56 th out of 62 in overall health factors. Fulton County ranks as the 53 rd overall healthiest county in New York State and 11 TH in the ARHN region (see Tables 1). 3 Table 1: County Health Rankings, Outcomes and Factors for ARHN Region Health Outcomes Length of Life Quality of Life Health Factors Health Behaviors Clinical Care Social & Economic Factors Physical Environment 3 Source: County Health Rankings & Roadmaps, A Healthier Nation, County by County, Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute

16 County Rank Rank Rank Rank Rank Rank Rank Rank Clinton Essex Franklin Fulton Hamilton Montgomery Saratoga Warren Washington Note: Yellow highlighted cells show the counties that have the best ranking by measures in the region. The leading causes of premature death in Fulton County are cancer, followed by heart disease and the leading causes of death are heart disease and cancer. 4 Table 2A: Leading Causes of Death in Fulton County 1st 2nd 3rd 4th 5th Causes of Death Heart Disease per 10,000 Cancer per 100,000 Chronic Lower Respiratory Disease (CLRD) per 100,000 Stroke per 100,000 Unintentional Injury per 100,000 Causes of Premature Death Cancer per 100,000 Heart Disease per 100,000 Chronic Lower Respiratory Disease (CLRD) per 100,000 Unintentional Injury per 100,000 Stroke per 100,000 Note: Premature Death is defined as death before age 75. The leading causes of premature death in Montgomery County are cancer, followed by heart disease and the leading causes of death are heart disease and cancer. 4 Source: New York State Website. Vital Statistics 2014 Data as of March

17 Table 2B: Leading Causes of Death in Montgomery County 1st 2nd 3rd 4th 5th Causes of Death Heart Disease per 100,000 Cancer per 100,000 Chronic Lower Respiratory Disease (CLRD) per 100,000 Diabetes per 100,000 Stroke per 100,000 Causes of Premature Death Cancer per 100,000 Heart Disease per 100,000 Unintentional Injury per 100,000 Chronic Lower Respiratory Disease (CLRD) per 100,000 Diabetes per 100,000 Health Disparities: While there are not significant health disparities based on race and ethnicity in Fulton County, there are access to care issues and issues related to physical limitations. The rate of age-adjusted preventable hospitalizations per 100,000 population (129.8) is higher than in the Upstate New York (107.3) and New York State (119.0), and higher than the Prevention Agenda benchmark (122). The rate of ED visits per 100,000 population in Fulton County (5,868.2) is higher than the ARHN region (4,418.4) and Upstate New York (3,752.5) rates. The percentage of adults with a regular health care provider (82.4%) was lower than the ARHN region (84.6%) as well as the Prevention Agenda benchmark (90.8). Both the percentages of adults with poor physical health (14.8%) and physical limitations (29.1%) were higher than the ARHN region; (13.4%) for physical health and (25.2%) for physical limitations, and Upstate New York percentages of (12.3%) for physical health and (22.4%) for physical limitations. Healthy and Safe Environment: Falls and occupational injuries are a challenge for Fulton County residents. The rate of hospitalizations due to falls for people ages 65 and older per 100,000 population has improved since the 2013 report. In 2013 reports, falls for people ages 65+ were (205.3) and are now (168.9) and the rate is better than the Prevention Agenda benchmark (204.6). Hospitalizations due to falls for ages 25 to 64 per 100,000 population (22.8) continue to be above the ARHN region (17.1) and Upstate New York rate of (18.4). Additionally, the rate of ED visits for falls for children ages 1 to 4 per 10,000 population in Fulton County has decreased from (782.9) in 2013, but it remains higher than ARHN region (486.6) and New York State (440.1). The rate of work related hospitalizations for working individuals ages 16 and over per 100,000 population (25.5) was higher than the respective rates for the ARHN region (13.9), Upstate New York (19.1), and the NEW York State rate (15.6). Finally, the rates of speed related accidents and motor vehicle deaths per 100,000 population were both higher than Upstate New York and New York State. Chronic Disease: Obesity and smoking rates are high in Fulton County. More than (30.9%) of adults in the County are obese, which is slightly higher than ARHN rate of (29.8%) and it is higher than the Upstate New York rate of (27.0%) and the Prevention Agenda benchmark of (23.2%). (19.5%) of public school children are obese, higher than the Prevention Agenda benchmark of (16.7%). Nearly one-third of age-adjusted adults have ever been diagnosed with high blood pressure, compared to approximately 26% in New York State as a whole. The rates of cardiovascular, diseases of the heart,

18 coronary heart disease, and congestive heart failure deaths per 100,000 and hospitalizations per 10,000 were all higher than their respective rates for the ARHN region and for Upstate New York. The rates of stroke deaths per 100,000 and stroke hospitalizations per 10,000 were both higher than their respective rates for the ARHN region and for Upstate New York. The smoking rate of Fulton County adults has continued to increase from (25%) in the 2013 report to (29.0%), which remains higher than the percentages in the ARHN region (22.5%), Upstate New York (17.3%) and significantly higher than the Prevention Agenda benchmark of (12.3%). The rates of chronic lower respiratory disease deaths per 100,000 and hospitalizations per 10,000 were significantly higher than their respective ARHN and Upstate New York rates. Asthma hospitalizations ages per 10,000 population in Fulton County were also higher than their respective ARHN and Upstate New York rates. The rates of asthma ED visits per 10,000 population for 18 to 64, and ages 65 and older were higher than both the ARHN and Upstate New York rates. Finally, the rate of short-term diabetes hospitalizations for ages 18 and over per 10,000 population were worse than ARHN, Upstate New York and New York State. Cancer remains a challenge for Fulton County. The rate of ovarian cases per 100,000 female population, rate colorectal cancer cases per 100,000 population and rate of prostate cancer late stage cases per 100,000 male population are higher than Upstate New York and New York State. Women, Infants, and Children: The rates of births and pregnancies ages and were higher than Upstate New York. The percent of unintended births to total births (28.1%) in Fulton County are higher than those of Upstate New York and higher than the prevention agenda benchmark of (23.8%). The rate of newborn drug related hospitalizations per 10,000 births (169.9) is higher than AHRN region (119.4), Upstate New York (123.2) and New York State (95.0). A couple of noted health disparities are related to the percent of early prenatal care of Hispanic/Latinas (61.0%) compared to the Upstate New York percent of (68.2%) and percent of WIC women breastfeeding at six months (10.9%) compared to the Upstate New York percent of (27.8%). The rate of asthma hospitalizations per 10,000 population for children ages 5 to 14 were significantly worse than their respective ARHN and Upstate New York rates. Additionally, the rates of asthma ED visits per 10,000 for children ages 0 to 4 were higher than their respective ARHN and Upstate New York rates. The rates of unintentional injury hospitalizations for children under age 10 and ages 15 to 24 were higher than their respective ARHN region and Upstate New York rates per 10,000. Finally, the rate of children younger than 6 with confirmed blood lead levels greater than or equal to 10 mg/dl per 1,000 children tested has improved from the 2013 CHNA reported rate of (90.8) but at (28.8) remains higher than the ARHN rate of (12.7) and the Upstate New York rate of (8.8). HIV/STDs, Vaccine-Preventable Disease, and Health Care-Associated Infections: The rate of Chlamydia for females ages per 100,000 female population (1539.8) is higher than AHRN (1184.5), Upstate New York rate of (1249.6) and the Prevention Agenda benchmark of (1458.0). The rate of Chlamydia cases females ages per 10,000 female population (3400.9) is higher than ARHN (2563.4) and Upstate New York (2743.8). The percentage of children ages 19 to 35 months with the appropriate immunization series in the County has improved from the 2013 CHNA report of (53.2%), but at (69.1%) it is lower than the Prevention Agenda benchmark of (80%). Additionally, the percentage of females ages 13 to 17 with the 3 dose HPV vaccine (31.9%) was lower than the Prevention Agenda benchmark of (50%). Preventing Substance Abuse and Promoting Mental Health The rates of age-adjusted suicides per 100,000 population as well as the overall rate of self-inflicted hospitalizations per 10,000 population in Fulton County were significantly worse than their respective rates in the ARHN region or in Upstate New York. Additionally, the rate of self-inflicted hospitalizations for ages 15 to 19 per 10,000 population was higher than both the ARHN region and the Upstate New York rates

19 The rate of alcohol-related accidents per 100,000 population was higher than both the ARHN and Upstate New York rates. Finally, the rate of alcohol-related injuries and deaths per 100,000 population for Fulton County was worse than their respective ARHN region and Upstate New York rates. Health Care Challenges by Prevention Agenda Priority Area: Improve Health Status and Reduce Health Disparities Focus Area: Disparities Prevention Agenda Indicators Percentage of Overall Premature Deaths (Ages 35-64), 2013 Rate of Adult Age-Adjusted Preventable Hospitalizations per 100,000 Population (Ages 18+), 2013 Percentage of Adults ( Ages 18-64) with Health Insurance, '2013 Age-Adjusted Percentage of Adults with Regular Health Care Provider (Ages 18+), 13/14 Other indicators: Rate of Total Deaths per 100,000 Population, '11 13 Rate of Emergency Department Visits per 10,000 Population, Rate of Total Hospital Discharges per 10,000 Population, '11 13 % of Adults (18 and Older) Who Did Not Receive Care Due to Costs, '13/14 % of Adults (18 and Older) with 14 days or more of poor physical health, '13/14 Percentage of Adults (18 and Older) with Disabilities, '13/14 Regional Challenges Indicator Fulton County Montgomery County Benchmark The rate of total ED visits per 10,000 population 5, , The rate of adult, 18 plus, age-adjusted preventable hospitalizations per 10,000 adults, 18 plus The percentage of adults with health insurance 89.1% 89.9% 100.0% The percentage of adults with regular care provider 82.4% 88.8% 90.8% The rate of total deaths per 100,000 population 1, , The rate of Hispanic/Latino premature deaths (prior to age 65) compare to White, non-hispanic Figure 10: Percentage of adults (aged 18-64) with health insurance,

20 NYS Montgomery Fulton Promote a Healthy and Safe Environment Focus Area: Injuries, Violence and Occupational Health Prevention Agenda Indicators Rate of ED Visits due to Falls for Children Ages 1-4 per 10,000 Population Children Ages 1-4, 2014 Rate of ED Occupational Injuries Among Working Adolescents Ages per 10,000 Population Ages 15-19, 2013 Focus Area: Outdoor Air Quality Air quality data is not available at the county level Focus Area: Built Environment Percentage of the Population that Live in Jurisdictions that Adopted Climate Smart Communities Pledge, 2012 Percentage of Commuters Who Use Alternative Modes of Transportation to Work, '10-14 Percentage of Population with Low-Income and Low-Access to a Supermarket or Large Grocery Store, 2010 Percentage of Adults Experiencing Food Insecurity Focus Area: Water Quality Percentage of Residents Served by Community Water Systems with Optimally Fluoridated Water, 2014 Fluoride is provided to a majority of our children through prescription or treatment since the only municipality with fluoridated water is the City of Gloversville

21 Other Indicators Rate of Hospitalizations for Falls for Adults Ages per 10,000 Population, '11-13 Rate of Property Crimes per 100,000 Population, 2014 Rate of Total Crimes per 100,000 Population, 2014 Rate of Work-Related Hospitalizations, Employed Ages 16 Plus per 10,000 Individuals Employed Ages 16 Plus, '11 13 Rate of Speed-Related Accidents per 100,000 Population, Rate of Motor Vehicle Accident Deaths per 100,000 Population, '11-13 Rate of Unintentional Injury Hospitalizations per 10,000 Population, '11-13 Rate of Poisoning Hospitalizations per 10,000 Population, '11 13 Regional Challenges Indicator Fulton County Montgomery County Benchmark Rate of ED Visits for falls for Children ages 1 4 per 10,000 children ages 1-4 Rate of Hospitalizations for Falls for Adults Ages per 10,000 Population Rate of ED occupational injuries among working adolescents ages per 10,000 working adolescents ages Rate of Speed-Related Accidents per 100,000 Population Rate of poisoning hospitalizations per 10,000 population Prevent Chronic Disease Focus Area: Reduce Obesity in Children & Adults Prevention Agenda Indicators Percentage of Adults Ages 18 Plus Who are Obese, '13/14 Percentage of Public School Children Who are Obese, '12 14 Other Indicators Percentage of Elementary Students Obese, Percentage of Middle and High School Students Overweight, Percentage of Middle and High School Students Obese, Percentage of Age Adjusted Adults (Ages 18 Plus) Overweight or Obese, 13/14 Number of Recreational and Fitness Facilities per 100,000 Population, 2014 Percentage of Age Adjusted Adults (Ages 18 Plus) with Cholesterol Check, '13/14 Percentage of Age Adjusted Adults (18 Plus) With Physician Diagnosed High Blood Pressure, '13/14 Rate of Cardiovascular Disease Deaths per 100,000 Population, '11-13 Rate of Cardiovascular Premature Deaths ( Ages 35-64) per 100,000 Population Ages 35-64, '11-13 Rate of Pretransport Deaths per 100,000 Population, '12-14 Rate of Cardiovascular Hospitalizations per 10,000 Population, '11-13 Rate of Diseases of the Heart Deaths per 100,000 Population, '11-13 Rate of Diseases of the Heart Premature Deaths ( Ages 35-64) per 100,000 Population Ages 35-64, '11-13 Rate of Disease of the Heart Hospitalizations per 10,000 Population, '

22 Rate of Coronary Heart Diseases Deaths per 100,000 Population, '11-13 Rate of Coronary Heart Diseases Premature Deaths (Ages 35-64) per 100,000 Population Ages 35-64, '11-13 Rate of Coronary Heart Disease Transport Deaths per 100,000 Population, '11-13 Rate of Coronary Heart Disease Hospitalizations per 10,000 Population, '11-13 Rate of Congestive Heart Failure Deaths per 100,000 Population, '11-13 Rate of Congestive Heart Failure Hospitalizations per 10,000 Population, '11-13 Rate of Cerebrovascular (Stroke) Deaths per 100,000 Population, '11-13 Rate of Cerebrovascular (Stroke) Hospitalizations per 10,000 Population, '11 13 Rate of Diabetes Deaths per 100,000 Population, Rate of Diabetes Hospitalizations (Primary Diagnosis) per 10,000 Population, '11-13 Rate of Diabetes Hospitalizations (Any Diagnosis) per 10,000 Population, '11-13 Focus area: Reduce Illness, Disability and Death Related to Tobacco Use & Secondhand Smoke Prevention Agenda Indicators Percentage of Adults Ages 18 Plus Who Smoke '13/14 Other Indicators Rate of Chronic Lower Respiratory Disease Deaths per 100,000 Population, '11-13 Rate of Chronic Lower Respiratory Disease Hospitalizations per 10,000 population, '11-13 Rate of Asthma Hospitalizations per 10,000 Population, '11-13 Rate of Asthma Hospitalizations, Ages 25-44, per 10,000 Population Ages 25-44, '11-13 Percentage of Adults with Asthma, '13/14 Rate of Lung and Bronchus Deaths per 100,000 Population, '10-12 Rate of Lung and Bronchus Cases per 100,000 Population, '10 12 Number of Registered Tobacco Vendors per 100,000 Population, Most of our chronic disease issues are associated with tobacco use. Although there are active partnerships in place to address tobacco use and advertising, tobacco use among adults is significantly higher than the NYS average. Focus Area: Increase Access to High Quality Chronic Disease Preventive Care & Management in both Clinical & Community Settings Prevention Agenda Indicators Percentage of Adults Ages Who Received Colorectal Screenings Based on Recent Guidelines, '13/14 Rate of Short-term Diabetes Hospitalizations for Ages 18 Plus per 10,000 Population, Ages 18 Plus, 2013 Rate of Heart Attack Hospitalizations per 10,000 population, 2013 Other Indicators Rate of Asthma ED Visits for Ages per 10,000 Population Ages 18-64, '11-13 Rate of Asthma ED Visits for Ages 65 Plus per 10,000 Population Ages 65 Plus, '11-13 Rate of All Cancer Cases per 100,000 Population, '10-12 Rate of all Cancer Deaths per 100,000 Population, '10-12 Percentage of Women Aged years Receiving Breast Cancer Screening Based on Recent guidelines, '13/14 Percentage of Women Aged years with annual household income of less than 25,000 receiving cervical cancer screening based on the recent guidelines, 13/14 Rate of Ovarian Cancer Cases per 100,000 Female Population, Rate of Ovarian Cancer Deaths per 100,000 Female Population, Rate of Colon and Rectum Cancer Cases per 100,000 Population, '10-12 Rate of Colon and Rectum Cancer Deaths per 100,000 Population, '10-12 Percentage of Adults Aged years receiving colorectal cancer screening based on recent guidelines, 13/14 Rate of Prostate Cancer Deaths per 100,000 Male Population, '

23 Rate of Prostate Cancer Late Stage Cancer Cases per 100,000 Male Population, Percentage of Medicaid Enrollees with at Least One Preventive Dental Visit within the Year, '12-14 Oral Cavity and Pharynx Cancer Cases per 100,000 Population, '10-12 Regional Challenges Indicator Fulton County Montgomery County Benchmark Rate of cardiovascular deaths per 100,000 population Rate of cardiovascular premature deaths (Ages 35-64) per 100,000 population Rate of coronary heart disease deaths per 100,000 population Rate of congestive heart failure deaths per 100,000 population Rate of diseases of the heart deaths per 100,000 population Rate of diabetes hospitalizations (primary diagnosis) per 10,000 population Rate of diabetes hospitalizations (any diagnosis) per 10,000 population Promote Healthy Women, Infants and Children Focus Area: Maternal and Infant Health Prevention Agenda Indicators Rate of Maternal Mortality per 100,000 Births, 2013 Other Indicators Percentage Preterm Births < 37 Weeks of Total Births Where Gestation Period is Known, '11 13 Percentage of Singleton Births with Weights less than 1,500 grams, Percentage of Total Births with Weights less than 2,500 grams, Percentage of Singleton Births with Weights less than 2,500 grams, Rate of Deaths (28 Weeks gestation to seven days) per 1,000 live births and perinatal deaths, Early prenatal care for Hispanic/Latinas, Percentage of APGAR scores of less than five at five minute mark of births where APGAR score is known, Rate of Newborn drug related hospitalizations per 10,000 births, Percentage WIC Women Breastfed at Six months, '10-12 Focus Area: Preconception and Reproductive Health Prevention Agenda Indicators Percent of Births within 24 months of Previous Pregnancy, 2014 Percent of Unintended Births to Total Births, 2013 Percentage of Women Ages with Health Insurance, 2014 Other Indicators Percent C-Section to total births, Rate of Births Ages per 1,000 females,

24 Rate of Births Ages per 1,000 females, Rate of Pregnancies Ages per 1,000 females, Rate of Births Ages per 1,000 females, Rate of Pregnancies Ages per 1,000 females, Rate of Abortions All Ages per 1,000 live births, Percentage of WIC Women Pre-Pregnancy Obese, Percentage of WIC Women with Gestational Weight Gain Greater than Ideal, Focus Area: Child Health Prevention Agenda Indicators Percentage of Children Ages 3-6 Years with Government Insurance with Recommended Well Visits, 2011 Percentage of Children Ages 0-19 with Health Insurance, 2014 Other Indicators Rate of Asthma Hospitalizations Children Ages 5-14 per 10,000 Population Children Ages 5-14, Rate of Asthma Hospitalizations Children Ages 0-17 per 10,000 Population Children Ages 0-17, '10-12 Rate of Pneumonia Hospitalizations Children Ages 0-4 per 10,000 Population Children Ages 0-4, '10-12 Rate of ED Asthma Visits Children Ages 0-4 per 10,000 Population Children Ages 0-4, 2014 Rate of Children Ages < 6 with Confirmed Blood Lead Levels >= 10 mg/dl Cases Per 1,000 Children Tested, '08-10 Rate of Unintentional Injury Hospitalizations for Children Under Age 10 per 10,000 Population Children Under Age 10, '11-13 Regional Challenges Indicator Fulton County Montgomery County Benchmark Rate of births, ages 15 17, per 1,000 females Rate of births, ages 18 and 19 per 1,000 females Percentage of WIC women with pre-pregnancy obesity 34.3% 34.9% 28.0% Percentage of WIC women with gestational weight gain greater than the ideal 50.7% 49.9% 47.1% Rate of Maternal Mortality per 100,000 Births, Prevent HIV/STDs, Vaccine Preventable Diseases & Healthcare-Associated Infections Focus Area: Prevent HIV and STD s Rate of Chlamydia for Females Ages per 100,000 Female Population, 2014 Other indicators Rate of Chlamydia Cases Females Ages per 100,000 Female Population, '

25 Focus Area: Vaccine Preventable Disease Prevention Agenda Indicators Percent of Children Ages months with 4:3:1:3:3:1:4, 2014 Percent females with 3 dose HPV vaccine, 2014 Other indicators Rate of Pneumonia/Flu Hospitalizations Ages 65 Plus per 100,000 Population, Percent of Adults Ages 65+ ever Received a Pneumonia Shot, 13/14 Focus Area: Healthcare Associated Infections Prevention Agenda Indicators Rate of Community Onset, Healthcare Facility Associated CDIs per 10,000 Patient Days, 2011 Regional Challenges Indicator Fulton Montgomery Benchmark County County Rate of Chlamydia Ages per 100,000 Female Population 1, , ,458.0 Rate of Chlamydia Cases Ages per 100,000 Female Population 3, , ,743.8 Percentage of children, ages months with 4:3:1:3:3:1:4 immunization series 69.1% 59.3% 80.0% Percentage of females, ages years, with 3 dose HPV vaccine 31.9% 26.7% 50.0% Percent of Adults Ages 65+ ever Received a Pneumonia Shot 68.9% 69.3% 70.0% Promote Mental Health and Prevent Substance Abuse Substance Abuse Focus Area: Prevent Substance Abuse and Promote Positive Mental, Emotional, and Behavioral Health Prevention Agenda Indicators Percent of Adults Binge Drinking within the Last Month, '13/14 Percent of Adults with Poor Mental Health (14 or More Days) in the Last Month, '13/14 Rate of Age Adjusted Suicides per 100,000 Adjusted Population, '11-13 Other Indicators Rate of Self-inflicted Hospitalizations 10,000 Population, '11-13 Rate of Self-inflicted Hospitalizations for Ages per 10,000 Population, '11-13 Rate of Cirrhosis Deaths per 100,000 Population, '11-13 Rate of Cirrhosis Hospitalizations per 10,000 Population, '11-13 Percentage of Alcohol-Related Crashes, '11-13 Rate of Alcohol-Related Injuries and Deaths per 100,000 Population, '11-13 Rate of People Served in Mental Health Outpatient Settings Ages 17 and Below per 100,000 Population, 2013 Rate of People Served in Mental Health Outpatient Settings Ages per 100,000 Population, 2013 Rate of People Served in Mental Health Outpatient Settings Ages 65 Plus per 100,000 Population, 2014 Regional Challenges Indicator Fulton County Montgomery County Benchmark

26 Rate of Self-inflicted Hospitalizations 10,000 Population Rate of People Served in Mental Health Outpatient Settings Ages 17 and Below per 100,000 Population 1, , Rate of Cirrhosis Deaths per 100,000 Population Rate of adults 65 and above served in mental health outpatient per 100,000 adults ages 65 and above Community Input Stakeholder Survey Process Under contract with the Adirondack Health Institute (AHI) and as part of the Adirondack Rural Health Network (ARHN) coordination of community needs assessment, the Center for Health Workforce Study (CHWS) surveyed health care, social services, educational, governmental and other community stakeholders in the ARHN region to provide the Community Health Assessment (CHA) Committee with stakeholder input on regional health care needs and priorities. The ARHN region is made up of Clinton, Essex, Franklin, Fulton, Hamilton, Warren and Washington Counties. The survey was developed using Qualtrics Software. It included 15 questions and a number of sub-questions based on an initial response. A pdf of the survey is attached as Appendix H to this report. In working with the participating counties, ARHN provided CHWS a list of health care, social service, educational, government and other community stakeholders by county. Using these lists, CHWS staff created an unduplicated list of 658 providers that cut across all seven counties. An initial was sent to this list explaining the survey and providing an electronic link to the survey. The survey was available to potential respondents for approximately six weeks. As follow-up, CHWS sent an additional reminding potential respondents of the survey. CHWS also provided ARHN with a list of those who responded, and county staff also followed up with non-respondents. As an incentive, respondents were told there would be a random drawing of twenty $10 gift cards from Stewart s for participating in the survey. A total of 217 completed responses were received to the survey through May 31, 2016 for a response rate of 33%. CHWS staff also provided technical assistance as requested by survey respondents. The survey requested that the respondent identify their top two priority areas from a list of the five following areas which they believe needed to be addressed within their service area: Preventing chronic disease; Providing a healthy and safe environment; Promoting healthy women, infants, and children; Promoting mental health and preventing substance abuse; and Preventing HIV, sexually transmitted diseases, vaccine preventable diseases, and health care associated infections. Once respondents identified their top two priorities, they were also asked to rank the focus areas within each priority area and identify potential barriers addressing that focus area

27 Analysis for this report was conducted by county. Many health care, social service, and educational providers deliver services in multiple counties. Their opinions are reflected in each county they provide services. Results of Fulton County Stakeholder Survey Service providers from Fulton County identified preventing chronic disease (17) as their top priority, followed by promoting mental health and preventing substance abuse (14) and providing a healthy and safe environment (11). Promoting mental health and preventing substance abuse (18) was the second priority for service providers in Fulton County, followed by providing a healthy and safe environment (16). Exhibit V.1: Identification of Priority Areas for Fulton County Top Priority Count Second Priority Prevent Chronic Disease 17 6 Provide a healthy and safe environment Promote Healthy Women, Infants, and Children 8 6 Promote Mental Health and Prevent Substance Abuse Prevent HV, Sexually Transmitted Diseases, Vaccine Preventable Diseases, and 1 4 Health Care Associated Infections Ranking the Focus Areas for Chronic Diseases Prevention when Chronic Disease Prevention is the Top Priority For service providers in Fulton County that identified preventing chronic disease as their top priority, they ranked increasing access to high quality chronic disease preventive care and management as their top focus area. Exhibit V.2: Ranking the Focus Areas for Chronic Diseases Prevention when Chronic Disease Prevention is the Top Priority for Fulton County Barriers to Addressing Chronic Diseases Prevention as the Top Priority for Fulton County Service providers in Fulton County that identified preventing chronic diseases as their top priority indicated that lack of financial resources/reimbursement in the short-term (8) was the biggest barrier for addressing this priority, followed by lack of financial resources/reimbursement in the long-term (7), travel distance and geography of the Adirondacks (7), and a shortage of professionals and staff (6). Exhibit V.3. Barriers to Addressing Chronic Diseases Prevention as the Top Priority for Fulton County

28 Ranking the Focus Areas for Providing a Healthy and Safe Environment when Providing a Healthy and Safe Environment is the Top Priority Service providers in Fulton County that identified providing a healthy and safe environment as their top priority ranked injuries, violence, and occupational health (5) as their main focus area, followed by built environment (4). Exhibit V.4: Ranking the Focus Areas for Providing a Healthy and Safe Environment when Providing a Healthy and Safe Environment is the Top Priority for Fulton County Barriers to Providing a Healthy and Safe Environment as the Top Priority for Fulton County Fulton County service providers who indicated that a healthy and safe environment was their top priority identified lack of financial resources/reimbursement in the short-term as the biggest barrier for addressing this priority. Exhibit V.5. Barriers to Providing a Healthy and Safe Environment as the Top Priority for Fulton County

29 Ranking the Focus Areas for Promoting Healthy Women, Infants, and Children when Promoting Healthy Women, Infant, and Children is the Top Priority For service providers in Fulton County that indicated that promoting healthy women, infants, and children were their top priority, they ranked child health (5) as their main focus area, followed by maternal and infant health (3). Exhibit V.6: Ranking the Focus Areas for Promoting Healthy Women, Infants, and Children when Promoting Healthy Women, Infant, and Children is the Top Priority for Fulton County Barriers to Promoting Healthy Women, Infants, and Children as the Top Priority for Fulton County Fulton County service providers that identified promoting healthy women, infants, and children as their top priority indicated that lack of financial resources/reimbursement in the long-term (4) was the biggest barrier for addressing this priority, followed by lack of financial resources/reimbursement in the short-term (2). Exhibit V.7. Barriers to Promoting Healthy Women, Infants, and Children as the Top Priority for Fulton County

30 Ranking the Focus Areas for Promoting Mental Health and Preventing Substance Abuse when Promoting Mental Health and Preventing Substance Abuse is the Top Priority Fulton County services providers that identified promoting mental health and preventing substance abuse as their top priority ranked strengthening (the mental health) infrastructure across systems (7) as their main focus area, followed by preventing substance abuse and other mental and emotional disorders (4). Exhibit V.8. Ranking the Focus Areas for Promoting Mental Health and Preventing Substance Abuse when Promoting Mental Health and Preventing Substance Abuse is the Top Priority for Fulton County Barriers to Promoting Mental Health and Preventing Substance Abuse as the Top Priority for Fulton County Service providers in Fulton County that identified promoting mental health and preventing substance abuse as their top priority indicated that a shortage of professionals and staff (10) was the biggest barrier to addressing this priority, followed by existing strategies have not been effective (8), and travel distance and geography in the Adirondacks (6). One respondent noted a desperate need for mental health crisis interventions. Exhibit V.9. Barriers to Promoting Mental Health and Preventing Substance Abuse as the Top Priority for Fulton County

31 Ranking the Focus Areas for Preventing HIV, Sexually Transmitted Diseases, Vaccine- Preventable Diseases, and Health Care Associated Infections when Preventing HIV, Sexually Transmitted Diseases, Vaccine-Preventable Diseases, and Health Care Associated Infections is the Top Priority Only one respondent in Fulton County identified preventing HIV, sexually transmitted diseases, vaccine-preventable diseases, and health care associated infections as his/her top priority and ranked that preventing HIV and sexually transmitted diseases as their main focus area to address. A lack of professionals and staff was the only barrier the one respondent listed. Exhibit V.10. Ranking the Focus Areas for Preventing HIV, Sexually Transmitted Diseases, Vaccine-Preventable Diseases, and Health Care Associated Infections when Preventing HIV, Sexually Transmitted Diseases, Vaccine- Preventable Diseases, and Health Care Associated Infections is the Top Priority for Fulton County Ranking the Focus Areas for Chronic Diseases Prevention when Chronic Disease Prevention is the Second Priority For service providers in Fulton County that identified preventing chronic diseases as their second priority, ranked reducing obesity in children and adults and increasing access to high quality chronic disease preventive care and management as their main focus areas, both with 3. Exhibit V.11: Ranking the Focus Areas for Chronic Diseases Prevention when Chronic Disease Prevention is the Second Priority for Fulton County

32 Barriers to Addressing Chronic Diseases Prevention as the Second Priority Fulton County service providers that identified preventing chronic diseases as their second priority indicated that a shortage of professionals and staff (4) was the biggest barrier to addressing the priority, followed by existing strategies have not been effective (3) and there are other priorities that are more important to address (3). Exhibit V.12. Barriers to Addressing Chronic Diseases Prevention as the Second Priority for Fulton County Ranking the Focus Areas for Providing a Healthy and Safe Environment when Providing a Healthy and Safe environment is the Second Priority Service providers in Fulton County that indicated that a healthy and safe environment was their second priority ranked built environment (8) as their top focus area, followed by injuries, violence, and occupational health (5). Exhibit V.13: Ranking the Focus Areas for Providing a Healthy and Safe Environment when Providing a Healthy and Safe Environment is the Second Priority for Fulton County Barriers to Providing a Healthy and Safe Environment as the Second Priority

33 Fulton County service providers that identified a healthy and safe environment was their second priority indicated that lack of financial resources/reimbursement in the short-term (6) was their biggest barrier to addressing this priority, followed by lack of financial resources/reimbursement in the long-term (4), and the existing population does not believe that this is an issue (4). Exhibit V.14. Barriers to Providing a Healthy and Safe Environment as the Second Priority for Fulton County Ranking the Focus Areas for Promoting Healthy Women, Infants, and Children when Promoting Healthy Women, Infant, and Children is the Second Priority For service providers in Fulton County that indicated that promoting healthy women, infants, and children were their second priority, they ranked child health (4) as the main focus area, followed by reproductive, preconception, and inter-conception health (2). Exhibit V.15: Ranking the Focus Areas for Promoting Healthy Women, Infants, and Children when Promoting Healthy Women, Infant, and Children is the Second Priority for Fulton County Barriers to Promoting Healthy Women, Infants, and Children as the Second Priority Service providers in Fulton County that identified promoting healthy women, infants, and children as their second priority identified lack of financial resources/reimbursement in the long-term (5) as the biggest barrier for addressing this priority, followed by lack of financial resources/ reimbursement in the short-term (3) and travel distance and geography of the Adirondacks (3)

34 Exhibit V.16. Barriers to Promoting Healthy Women, Infants, and Children as the Second Priority for Fulton County Ranking the Focus Areas for Promoting Mental Health and Preventing Substance Abuse when Promoting Mental Health and Preventing Substance Abuse is the Second Priority Fulton County service providers that indicated that promoting mental health and preventing substance abuse was their second priority ranked promoting mental, emotional, and well-being in communities (10) as their top focus area, followed by strengthening (the mental health) infrastructure across systems (6). Exhibit V.17. Ranking the Focus Areas for Promoting Mental Health and Preventing Substance Abuse when Promoting Mental Health and Preventing Substance Abuse is the Second Priority for Fulton County Barriers to Promoting Mental Health and Preventing Substance Abuse as the Second Priority Service providers in Fulton County that identified promoting mental health and preventing substance abuse as their second priority indicated that a shortage of professionals and staff (11) was the biggest barrier for addressing this priority, followed by lack of financial resources/ reimbursement in the short-term (8), lack of financial resources/reimbursement in the long-term (6), and travel distance and geography of the Adirondacks (6)

35 Exhibit V.18. Barriers to Promoting Mental Health and Preventing Substance Abuse as the Second Priority for Fulton County Ranking the Focus Areas for Preventing HIV, Sexually Transmitted Diseases, Vaccine- Preventable Diseases, and Health Care Associated Infections when Preventing HIV, Sexually Transmitted Diseases, Vaccine-Preventable Diseases, and Health Care Associated Infections is the Second Priority Service providers in Fulton County that identified preventing HIV, sexually transmitted diseases, vaccine-preventable diseases, and health care associated infections as their second priority ranked preventing vaccine-preventable diseases as their main focus area to address. Exhibit V.19. Ranking the Focus Areas for Preventing HIV, Sexually Transmitted Diseases, Vaccine-Preventable Diseases, and Health Care Associated Infections when Preventing HIV, Sexually Transmitted Diseases, Vaccine- Preventable Diseases, and Health Care Associated Infections is the Second Priority for Fulton County Barriers to Preventing HIV, Sexually Transmitted Diseases, Vaccine-Preventable Diseases, and Health Care Associated Infections as the Second Priority Fulton County services providers that indicated that preventing HIV, sexually transmitted diseases, vaccinepreventable diseases, and health care associated infections was their second priority identified lack of financial resources/reimbursement in the long-term as the biggest barrier in addressing this priority

36 Exhibit V.20. Barriers Preventing HIV, Sexually Transmitted Diseases, Vaccine-Preventable Diseases, and Health Care Associated Infections the Second Priority for Fulton County Priority Selection In response to the stakeholder feedback and the health related data Nathan Littauer Hospital selected Chronic Disease as a priority with a focus on Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings through increased colorectal cancer preventive screenings. Nathan Littauer Hospital s second priority is Improve Health Status and Reduce Health Disparities with a focus on increasing access to primary care by opening a clinic in Fonda. Promote Mental Health and Prevention of Substance Abuse was the second priority selected by stakeholders with a focus on Strengthening Infrastructure Across Systems. This is a focus of the population health domain for the Adirondack Health Institute PPS which Nathan Littauer Hospital is a member and committee participant. Nathan Littauer Hospital will work the AHI PPS to address mental health, but did not select it as a Prevention Agenda priority

37 Appendix A: Methodology and Data Sources The Center for Health Workforce Studies (CHWS) at the University at Albany School of Public Health under contract with the Adirondack Rural Health Network, a program of the Adirondack Health Institute, identified and collected data from a variety of sources on the seven counties in the Adirondack region and two adjacent counties to assist in developing individual county community needs assessments. Those counties include: Clinton, Essex, Franklin, Fulton, Hamilton, Montgomery, Saratoga, Warren, and Washington. The initial step in the process was determining which data elements from the 2013 community needs assessment were still available. In 2013, CHWS staff received an initial list of potential data elements from the ARHN Data Subcommittee and then supplemented that information with data from other sources. Since most of the health behavior, status, and outcome data were only available at the county level, the data for both 2013 and 2016 were displayed by county and aggregated to the ARHN region. 5 Additionally, other data was collected to further enhance already identified data. For example, one Prevention Agenda indicator was assault-related hospitalizations. That indicator was augmented by other crime statistics from the New York State Division of Criminal Justice. The overall goal of collecting and providing this data to ARHN members was to provide a comprehensive picture of the individual counties within the Adirondack region as well as for two adjacent counties, including providing an overview of population health as well as an environmental scan. In total, counties and hospitals were provided with about 400 data elements across the following four reports: Demographic Data; Educational Profile; Health Behaviors, Health Outcomes, and Health Status; and Health Delivery System Profile. All sources for the data were listed and made available to the counties and hospitals. The sources for the data elements in the Health Behaviors, Health Outcomes, and Health Status report were listed in a separate file and included their respective internet URL links. The data in each of the four reports were aggregated, when feasible, into the ARHN region, Upstate New York (all counties but the five in New York City), and statewide. Demographic Data Demographic data was primarily taken from the American Community Survey, and supplemented with data from the Bureau of Labor Statistics, Local Area Unemployment Statistics for 2014; the New York State Department of Health (NYSDOH) Medicaid Data for 2014; and employment sector data also from American Community Survey. Among the information incorporated into the demographic report included: Race/Ethnicity; Age by groups (0 4, 5 17, 18 64, and 65 plus); Income and poverty, including the percent who received Medicaid; Housing stock; Availability of vehicles; Education status for those 25 and older; Employment status; and 5 Aggregated data for the ARHN region included Clinton, Essex, Franklin, Fulton, Hamilton, Warren, and Washington counties but did not include Montgomery and Saratoga counties

38 Employment sector. Educational Profile The education profile was taken mainly from the New York State Education Department (NYSED), School Report Card for , supplemented with data from the National Center for Education Statistics, Integrated Post-Secondary Data System on Post-Secondary graduations for 2014 and registered nurse graduation data from CHWS. Among the data displayed in the educational profile included: Number of school districts; Total school district enrollment; Number of students on free and reduced lunch; Dropout rate; Total number of public school teachers; Number of and graduations from licensed practical nurse programs; and Number of and graduations from registered nurse programs. Health Behaviors, Health Outcomes, and Health Status The vast majority of health behaviors, outcomes, and status data come from NYSDOH. Data sources included the: Community Health Indicators Report ( County Dashboards of Indicators for Tracking Public Health Priority Areas, ( dashboard); and Behavioral Risk Factor Surveillance System (BRFSS) ( Information on NYSDOH s methodologies used to collect and display data from the above sources can be found on their respective data pages. NYSDOH data was also supplemented from other sources such as the County Health rankings, the New York State Division of Criminal Justice Services, the New York State Institute for Traffic Safety Management and Research, and the New York State Office of Mental Health Patient Characteristics Survey, among others. To the extent possible, Center staff used similar years for the additional data that was collected. Over 270 data elements are displayed in this report broken out by the Prevention Agenda focus areas. The availability of data elements did change from the 2013 community needs assessment analysis, and certain data was reported differently between the two time periods. Data were downloaded from their various sources and stored in separate Excel files, based on their respective focus area. The Health Behaviors, Health Outcomes, and Health Status report was created in Excel and linked to the raw data, and population rates were recalculated based on the number of cases as well as the population listed in the data source. Data in the report were organized by the six priority areas as outlined by NYSDOH at The data was also separated into two subsections, those that were identified as Prevention Agenda indicators and those that were considered other indicators. The data elements were organized by 17 focus areas as outlined in the table below

39 Number of Indicators Focus Area Prevention Agenda Other Health Disparities 8 6 Injuries, Violence, and Occupational Health 7 20 Outdoor Air Quality 2 0 Built Environment 6 0 Water Quality 1 0 Obesity in Children and Adults 2 33 Reduce Illness, Disability, and Death Related to Tobacco Use and Secondhand Smoke Exposure Increase Access to High Quality Chronic Disease Preventive Care and Management Maternal and Infant Health 9 17 Preconception and Reproductive Health 9 20 Child Health 4 29 HIV 2 1 STDs 5 10 Vaccine Preventable Diseases 3 6 Healthcare Associated Infections 2 0 Substance Abuse and other Mental, Emotional, and Behavioral Disorders 3 15 Other Illnesses 0 8 The data elements that were Prevention Agenda indicators were compared against their respective Prevention Agenda benchmarks. Other indicators were compared against either Upstate New York benchmarks, when available or then New York State benchmarks when Upstate New York benchmarks were not available. The report also included a status field that indicated whether indicators were met, were better, or were worse than their corresponding benchmarks. When indicators were worse than their corresponding benchmarks, their distances from their respective benchmarks were calculated. On the report, distances from benchmarks were indicated using quartiles rankings, i.e., if distances from their corresponding benchmarks were less than 25%, indicators were in quartile 1, if distances were between 25% and 49.9% from their respective benchmarks, indicators were in quartile 2, etc

40 The Health Behaviors, Health Outcomes, and Health Status Report also indicated the percentage of total indicators that were worse than their respective benchmarks by focus area. For example, if 20 of the 33 child health focus area indicators were worse than their respective benchmarks, the quartile summary score would be 61% (20/33). Additionally, the report identified a severity score, i.e., the percentage of those indicators that were either in quartile 3 or 4 compared to all indicators which were worse than their corresponding benchmarks. Using the above example, if 9 of the 20 child health focus indicators that were worse than their respective benchmarks were in quartiles 3 or 4, the severity score would be 45% (9/20). Quartile summary scores and severity scores were calculated for each focus area as well as for Prevention Agenda indicators and for other indicators within each focus area. Both quartile summary scores and severity scores were used to understand if the specific focus areas were challenges to the counties and hospitals. In certain cases, focus areas would have low severity scores but high quartile summary scores indicating that while not especially severe, the focus area offered significant challenges to the community. Health Delivery System Profile The data on the health system came from NYSDOH list of facilities, NYSED licensure file for 2015, the Health Resources and Services Administration Data Warehouse for health professional shortage (HPSAs) areas for 2016, the Uniform Data System (UDS) for 2014, and Center data on 2014 physicians. Among the data incorporated into this report included: Hospital, nursing home, and adult care facility beds; Number of community health center patients; Number of and population within primary care, mental health, or dental care HPSAs; Total physicians and physicians by certain specialties and sub-specialties; and Count of individuals licensed. 6 Community Stakeholder Survey A survey of stakeholders was conducted by CHWS in April and May of The purpose of the survey was to provide the Community Health Assessment (CHA) Committee with stakeholder input on regional and/or county health care needs and priorities. Stakeholders included health care, social services, educational, governmental and other agencies in the ARHN region. Results were presented for each of the seven ARHN counties 7 and aggregated for the region. The initial survey in 2013 included 81 questions. The data subcommittee in 2016 felt that the previous survey was too extensive, and CHWS, working in conjunction with AHI and the data subcommittee, reduced the survey to 15 questions. The survey requested that the respondent identify the two priority areas from a list of five which they believe need to be addressed with their county or counties, and then respondents were also asked to rank the focus areas within each priority area and identify potential barriers to that addressing that focus area. Stakeholder responses were assessed in multiple counties if there service area covered more than one county. The survey was administered electronically using the web-based Qualtrics software and distributed to stakeholders based on an contact list of 658 individuals that were identified by AHI working in conjunction with county health departments. CHWS sent out the initial notification of the survey as well as two reminder notices to those who had not yet completed the survey. Additionally, participation was also incentivized through an opt-in gift card drawing, with 20 6 County is determined by the main address listed on the licensure file. The address listed may be a private residence or may represent those with active licenses but not actively practicing patient care. Therefore, the information provided may not truly reflect who is practicing in a profession in the county. 7 Montgomery and Saratoga counties were not included in the survey

41 entrants randomly selected to receive a $10 Stewart s gift card at the conclusion of the survey. Ultimately, 217 surveys were completed during the six-week survey period for a response rate of 33%. Response rates varied by individual county, with certain respondents being counted in more than one county depending on the extent of their service area. Appendix B: Prevention Agenda

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44 Appendix C: Demographic Profile

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46 Appendix D: Education Profile