St. Lawrence County Community Health Improvement Plan November 1, 2013
Contents Executive Summary... 3 What are the health priorities facing St. Lawrence County?... 3 Prevent Chronic Disease... 3 Promote Mental Health and Prevent Substance Abuse... 3 Background and Process... 4 Assessment Framework... 4 Organize for Success- Partner Development... 4 Assessments... 5 Identification of Strategic Issues... 6 Community Health Improvement Plan... 9
Executive Summary What are the health priorities facing St. Lawrence County? This was the question facing well over 1,000 people in a comprehensive process that involved health care organizations, hospitals, business and community leaders, academia, government agencies, non-profit organizations and county residents. Key partner agencies, five (5) hospitals and Public Health, led by a Rural Health Network) engaged a consultant in a 16 month process to collect data, solicit opinions, facilitate a process and guide a discussion to determine not only what are the most pressing problems facing our residents, but also what can we effectively and efficiently address as a community. In the end, the partner agencies decided to tackle two tough priorities: Prevent Chronic Disease Chronic diseases are among the leading causes of death, disability and rising health care costs in New York State (NYS). Specifically, they account for approximately 70% of all deaths in NYS, and affect the quality of life for millions of other residents, causing major limitations in daily living for about 10% of the population. Costs associated with chronic disease and their major risk factors account for more than 75% of our nation s health care spending. (NYS Prevention Agenda) Promote Mental Health and Prevent Substance Abuse At any given time, almost one in five young people nationally are affected by mental, emotional and behavioral (MEB) disorders, including conduct disorders, depression and substance abuse. About 75% of all MEB disorders are diagnosed between the ages of 14 and 24 years. (NYS Prevention Agenda)
Background and Process Assessment Framework The St. Lawrence County Health Initiative, along with Public Health and local hospitals (Claxton-Hepburn Medical Center, Canton-Potsdam Hospital, Massena Memorial Hospital, Clifton Fine Hospital and EJ Nobel Hospital) utilized the Mobilizing for Action through Planning and Partnership (MAPP) process to determine two priorities from the 2013 Prevention Agenda. The MAPP process is a strategic approach to community health improvement. This tool helps communities improve health and quality of life through community-wide strategic planning. Using MAPP, communities seek to achieve optimal health by identifying and using their resources wisely, taking into account their unique circumstances and needs, and forming effective partnerships for strategic action. The MAPP tool was developed by the National Association of County and City Health Officials (NACCHO) in cooperation with the Public Health Practice Program Office, Centers for Disease Control and Prevention (CDC). A work group comprised of local health officials, CDC representatives, community representatives, and academicians developed MAPP between 1997 and 2000. The vision for implementing MAPP is: "Communities achieving improved health and quality of life by mobilizing partnerships and taking strategic action. The MAPP process encompasses several steps. Organize for Success- Partner Development The goal of this step was to bring together key partners and familiarize them with the MAPP process, as well as to determine key local questions. To accomplish this, the partners invited participants from a wide range of the organizations throughout the county. While the main organizations involved in developing and organizing the process included The St. Lawrence County Health Initiative, St. Lawrence County Public Health, Claxton-Hepburn Medical Center, Canton-Potsdam Hospital, Massena Memorial Hospital, Clifton Fine Hospital and EJ Nobel Hospital, other organizations that participated in the community health assessment process were: Office for the Aging/NY Connects Head Start Seaway Valley Prevention Council North Country Prenatal Perinatal Network Saint Lawrence County Community Development Potsdam Neighborhood Center Cerebral Palsy of the North Country Hospice and Palliative Care of St. Lawrence Valley St. Lawrence County Community Services
Assessments Four Assessments inform the entire MAPP process. The assessment phase provides a comprehensive picture of a community in its current state using both qualitative and quantitative methods. The use of four different assessments is a unique feature of the MAPP process. Most planning processes look only at quantitative statistics and anecdotal data. MAPP provides tools to help communities analyze health issues through multiple lenses. The first assessment examined the Community Health Status Indicators. Two methods were used to examine indicators: The first was to collect relevant statistical data using the NYSDOH Community Health Indicator Reports and a variety of other secondary sources. This was completed by our consultant, Human Service Development. The second method was to collect primary data by conducting a comprehensive survey among a random sample of community residents to determine their opinions, health-related behaviors and health needs. A total of 809 people participated in completing surveys in St. Lawrence County. Surveys were conducted electronically through a Survey Monkey link, along with paper copies which were distributed to the public through employers, health, educational and human services agencies and through other community groups. The survey was designed to encompass questions in the five Prevention Agenda areas that the New York State Department of Health (NYSDOH) has identified as high priority issues on a statewide basis. The leadership team met several times to develop and refine the survey tool. The second assessment evaluated the effectiveness of the Public Health System and the role of the St. Lawrence County Public Health Department within that system. This was done using a modification of the Local Public Health System Assessment tool developed by the CDC and NACCHO. This was also conducted via an electronic survey on Survey Monkey. A diverse group of key informants were chosen to complete the survey, including community leaders who are familiar in some way with the local public health system. The assessment was completed through the use of a more user-friendly version of the CDC and NACCHO tool, Local Public Health System Assessment (LPHSA). Each of the ten essential public health services was rated by the group by ranking the series of indicators within each Essential Service to determine areas of strength and areas needing improvement within the Local Public Health System. The third assessment was the Community Themes and Strengths Assessment that was conducted through focus groups that were held throughout the County. This assessment looked at the issues that affect the quality of life among community residents and the assets the County has available to address health needs. These were held in conjunction with the fourth assessment that looked at the Forces of Change that are at work locally, statewide and nationally, and what types of threats and/or opportunities are created by these changes. The three focus groups conducted in St. Lawrence County included Fire Department, the key informants listed above and low-income group. These groups also helped to ensure that adequate representation of the public was included in the assessments, and provided additional input from lower income residents as well as younger male residents.
Identification of Strategic Issues Once these results were tallied, a finalized list of the top issues from all components of the assessment process was compiled, and the data was presented at a meeting of community representatives including the local hospital, Public Health staff and partners from a variety of the agencies listed above. They were charged with ranking the priorities based on their knowledge of health needs and available services, along with the data presented, to select two priorities and one disparity. The consultants presented a series of PowerPoint slides to the prioritization group that reviewed a summary of secondary data from the NYS DOH and other sources, survey results and focus group results and input so that they were as fully informed as possible prior to ranking. In order to accomplish the ranking, the Hanlon Method was used. This method of ranking focuses most heavily on how effective any interventions might be. The Hanlon Method utilizes the following formula to rank priorities: (A & 2B) X C A= the size of the problem, B= the severity of the problem C=the effectiveness of the solution The effectiveness of the solution is given a lot more weight than the size or seriousness of the problem, with the hope of making wise use of limited resources by targeting solutions that are known to be effective. Participants also consider the weight of the propriety, economic feasibility, acceptability, resources and legality (PEARL) of issues in this ranking system. Numerical values were determined by each participant for size, severity and effectiveness, and then plugged into the formula along with average PEARL scores. It is important to note that while the Hanlon Method offers a numerical and systematic method of ranking public health priorities, it is still a method that is largely subjective, but which represents a quantitative way to rank qualitative and non-comparable quantitative information. Since respondents ranked each component (size, seriousness and effectiveness of the solution) individually using a paper ranking form, the rankings were not heavily influenced by group dynamics. Based upon the ranking through the Hanlon Method, St. Lawrence County s scores on the top health related issues in the county were:
Hanlon Score PEARL Score 1. Cancer 162.53 5.69 2. Heart Disease 151.31 5.25 11. Mental Health 136.88 4.56 6. Diabetes 135.94 4.36 8. Obesity 135.56 4.21 3. Cerebrovascular disease stroke 125.66 5.44 9. Oral health 122.00 4.50 10. Substance Abuse 114.38 5.38 12. Tobacco use 112.13 4.00 4. Lead screening 111.68 5.25 13. CLRD 110.16 5.19 5. Cirrhosis 87.75 5.56 7. Breastfeeding 86.75 4.44 A great deal of time was then spent by community partners discussing all these issues, but concentrated on the top ranked issues. After reviewing, discussing and considering county assessments, data and previous initiatives the group decided to focus on the top two priorities of: 1. Chronic Disease- with a specific focus on obesity 2. Mental Health and Substance Abuse And the following disparity: Cancer screening for the low-income population It was felt that by focusing on obesity, we would also be addressing heart disease, cerebrovascular disease and diabetes as well as obesity. Cancer would be addressed through the disparity, with colo-rectal cancer being one of the cancers in the county that has rates significantly higher than the state. Breastfeeding would be incorporated as a part of our antiobesity strategy, and mental health, substance abuse and cirrhosis would be addressed by our focus area under the Mental Health/Substance Abuse Goal.
Community Health Improvement Plan Several meetings were then held to develop specific goals and strategies. During this stage research and evidence-based best practices were considered from many different sources including the Health Impact Pyramid developed by Thomas R. Frieden, MD, MPH. This is a pyramid approach to describe the impact of different types of public health interventions and provides a framework to improve health. The base of the pyramid indicates interventions with the greatest potential impact and in ascending order are interventions that change the context to make individuals' default decisions healthy, clinical interventions that require limited contact but confer long-term protection, on-going direct clinical care, and health education and counseling. Interventions focusing on lower levels of the pyramid tend to be more effective because they reach broader segments of society and require less individual effort. Policy and environmental changes were seen as the most practical way to effect desired change, but other levels of the pyramid were also incorporated. We decided to produce a CHIP Chart, essentially a work plan that designates responsibility for implementing the strategies outlined in the plan, incorporates specific focus areas from the NYS Prevention Agenda. The main outcome measure we incorporated was changing the rate of breastfeeding. This included a % increase of WIC mothers breastfeeding at 6 months, and a % increase of mothers who exclusively breastfeed in hospital. Both of these indicators were believed to be realistic and achievable, and research has demonstrated that they would lead to decreased obesity over the long term. Many other process measures were incorporated into the CHIP chart. While the goal is to reduce obesity over the five year period, without being aware of any additional resources available to accomplish this, it was unrealistic to state that we would reduce obesity by 5% over this period, though it is our intent to try to do so. With no additional resources however, the two breastfeeding outcomes should be realistic to achieve. Based on past experience and lessons learned, our CHIP should be achievable. Evidence-based best practices were incorporated in the CHIP Chart from the NYS Prevention Agenda, and are included on the following pages. The main partners (The St. Lawrence County Health Initiative, St. Lawrence County Public Health, Claxton-Hepburn Medical Center, Canton-Potsdam Hospital, Massena Memorial Hospital, Clifton Fine Hospital and EJ Nobel Hospital) have agreed to continue meeting at least quarterly over the next five years to report on progress, troubleshoot obstacles, make mid-course corrections and achieve objectives over the next five years.
St. Lawrence County Community Health Improvement Plan 2014-2017 New York State Prevention Agenda Domain, Focus Area and Goals Prevent Chronic Disease Focus Area: 1 - Reduce Obesity in Children and Adults Goal 1.1 Create community environments that promote and support healthy food and beverage choices and physical activity Activities Partners Timeframe Measurement/ Evaluation Conduct an assessment of what is currently being done in the community to promote and support healthy food and beverage choices and physical activity Promote existing opportunities for healthy choices in community through: links to information sites and local resources on partner websites and the Bridge Website Incorporate Educate partners and residents on Complete Streets vision through workshops and links to resources on Bridge Website. Short Term Medium Term Long Term Beyond 5 years All By 12/31/13 Assessment completed Reduce the percentage of adults who are obese All Begin 12/1/14 and continue through 2017 SLHI 1/1/14 thru 12/31/17 # of survey respondents using resources identified through Bridge # of materials downloaded and link click-throughs. # of presentations provided # of downloads of materials from the website # of municipalities adopting CS policies In each year from 2015 through 2017, at least 50 residents will download or click on physical activity or nutrition resource information from the Bridge Website. 1) 1 educational presentation on Complete Streets Policies will be provided each year that will be open to all municipalities in the county. 2) There will be at least two downloads of Complete Streets Resource packets from the Bridge Website. On the 2016 community health survey, 25% of respondents will report using community resources identified through Bridge partners. At least one municipality will adopt a Complete Streets Policy each year from 2015 through 2017. Reduce the percentage of children who are obese St. Lawrence County Community Health Improvement Plan 10 P age
New York State Prevention Agenda Domain, Focus Area and Goals Prevent Chronic Disease Focus Area: 1 - Reduce Obesity in Children and Adults Goal 1.3 Expand the role of health care and health service providers and insurers in obesity prevention. Local objectives: Increase number of physicians who provide or refer to obesity and diet counseling services that are included in health insurance coverage. Activities Partners Timeframe Measurement/ Evaluation Short Term Medium Term Long Term Beyond 5 years 1) Educate Bridge Partners about reimbursable diet and obesity counseling including services covered and the requirements for those providing the service. 2) Establish a baseline of physician practices that offer in-house diet and obesity counseling services, or refer patients to those services in the community. 3) Determine the resources that exist in the community for reimbursable diet and obesity counseling. 4) Provide education to PCPs about available community resources for reimbursable diet and obesity counseling services. Hospitals Public Health HI Hospitals Hospitals Training to be completed by December 31, 2014. Baseline survey of physician practices and available community resources will be completed by March 2015. Education to physicians will start in January 2015 and continue through 2017. # of physician practices demonstrating knowledge/awareness of covered services. # of providers referring clients # of survey respondents using services In each year from 2015 through 2017, at least one additional physician practice will demonstrate knowledge of resources for diet and obesity counseling services. By December 31, 2017, there will be a 5% increase in providers who provide or refer clients to reimbursable diet and obesity counseling services. By December 31, 2016, at least 5% of respondents on the Community Health Survey will report utilizing reimbursable diet or obesity counseling services. Reduce the percentage of adults who are obese Reduce the percentage of children who are obese St. Lawrence County Community Health Improvement Plan 11 P age
New York State Prevention Agenda Domain, Focus Area and Goals Prevent Chronic Disease Goal 1.4 Expand the role of public and private employers in obesity prevention Local Objectives: Increase the number of organizations that adopt and practice the Comprehensive Healthy Meeting Policies. Increase the number of vending machines in the county that offer healthy vending options and beverages that are not SS. Increase the number of organizations with vending machines that adopt Healthy Vending Policies. Activities Partners Timeframe Measurement/ Evaluation Short Term Medium Term Long Term Beyond 5 years 1) Survey organizations (anonymous) about food served at meetings and whether they have formal policies. 2) Provide sample policies to organizations. 3) Follow up to determine number of adopted policies 1) Conduct a survey of vending machines in targeted areas of the county for # of healthy options, 2) Promote the inclusion of healthier vending machine choices for food products and that there are fewer sugar sweetened beverage (SSB) choices and that SSBs are placed at the bottom of vending machines and healthier options at eye level by: a) Community Awareness Campaign b) Outreach to businesses and organizations with vending machines to encourage adoption of healthy vending policies c) outreach to vending companies Bridges Partners Bridges Partners SLHI Survey to be completed by March 31, 2015. Survey to be completed by March 31, 2015 Organizations will be contacted starting in January 2015. # of organizations requesting or downloading sample policies. # of organizations adopting comprehensive Healthy Meeting Policies Baseline # of vending machines with healthy options # of organizations requesting information on or downloading healthy vending In each year from 2015 to 2017, at least ten organizations will demonstrate awareness of healthy meeting guidelines. In each year from 2015 to 2017, at least ten organizations will demonstrate awareness of healthy vending guidelines. In each year from 2015 to 2017, at least one organization will adopt comprehensive Healthy Meeting Policies. In each year from 2015 to 2017, at least one organization will adopt comprehensive Healthy Vending Policies. Reduce the percentage of adults who are obese Reduce the percentage of children who are obese St. Lawrence County Community Health Improvement Plan 12 P age
New York State Prevention Agenda Domain, Focus Area and Goals Prevent Chronic Disease Focus Area: 2 - Reduce Illness, Disability and Death Related to Tobacco Use and Secondhand Smoke Exposure Goal 2.1 - Prevent initiation of tobacco use by New York Youth and Young Adults, especially among low socioeconomic status (SES) populations. Goal 2.2 Promote tobacco use cessation, especially among low SES populations and those with poor mental health. Local Objectives: Increase number of physicians who provide or refer to tobacco counseling services that are included in health insurance coverage. Activities Partners Timeframe Measurement/ Evaluation Short Term Medium Term Long Term Beyond 5 years 1) Support the adoption of antitobacco marketing 2) Promote adoption of tobacco free policies in organizations and businesses 3) Provide education to elected officials on health risks of tobacco use and second-hand exposure. 1) Educate Bridge Partners about reimbursable tobacco cessation services covered and the requirements for those providing the service. 2) Establish a baseline of physician practices that offer in-house tobacco counseling services, or refer patients to those services in the community. 3) Determine the resources that exist in the community for reimbursable tobacco counseling. 4) Provide education to PCPs about available community resources for reimbursable tobacco counseling services. Seaway Valley Prevention Council, Bridge Partners Hospitals Public Health HI Hospitals Hospitals January 2014 December 2017 Training to be completed by December 31, 2014. Baseline survey completed by March 2015. Physician education start in January 2015 and continue through 2017. # of organizations downloading information # of organizations # of physician practices demonstrating knowledge/awareness of covered services. # of providers referring clients # of survey respondents using services At least 2 organizations per year will download sample tobacco-free facility policies. In each year from 2015 through 2017, at least one additional physician practice will demonstrate knowledge of resources for tobacco counseling services. By December 31, 2017, six organizations will adopt tobacco free policies. By December 31, 2017, there will be a 5% increase in providers who provide or refer clients to reimbursable tobacco counseling services. By December 31, 2016, at least 5% of respondents on the Community Health Survey will report utilizing reimbursable tobacco counseling services. Decrease the number of adults and teens who use tobacco. Decrease lung and bronchus cancer rates among both men and women in SLC. St. Lawrence County Community Health Improvement Plan 13 P age
New York State Prevention Agenda Domain, Focus Area and Goals Prevent Chronic Disease Focus Area 3 - Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings Goal #3.1: Increase screening rates for cardiovascular disease, diabetes and breast, cervical and colorectal cancers, especially among disparate populations. - Disparity Goal #3.2: Promote evidence-based care Goal #3.3: Promote culturally relevant chronic disease self-management education. Activities Partners Timeframe Measurement/ Evaluation Short Term Medium Term Long Term Beyond 5 years Promote colo-rectal screening programs through SLHI (CSP) and Claxton Hepburn Medical Center to increase number and percentage of low-income adults who receive colorectal cancer screenings Develop and promote common messaging and PSA s regarding free preventive care and screenings. Work on marketing strategies. SLHI, SLPH, Hospitals 1/1/14 and ongoing Increase the number and percentage of colorectal cancers completed. By December 31, 2016, 25% of Community health Assessment respondents will be aware of free colorectal cancer screening resources in the community By December 31, 2017, there will be a 30% increase in the number of adults 50 and older who report being screened. Decrease the incidence of colorectal cancer among both men and women in St. Lawrence County. St. Lawrence County Community Health Improvement Plan 14 P age
New York State Prevention Agenda Domain, Focus Area and Goals Promote Mental Health and Prevent Substance Abuse Focus Area 1: Promote mental, emotional and behavioral (MEB) well-being in communities Goal 1 Promote mental, emotional and behavioral (MEB) in communities Goal 2.3 Prevent suicides among youth and adults Goal #3.1: Support collaboration among leaders, professionals and community members working in MEB health promotion, substance abuse and other MEB disorders and chronic disease prevention, treatment and recovery. Activities Partners Timeframe Measurement/ Evaluation Promote the use of Reach Out SLHI January 2014 # of click-throughs on Information and Referral for Hospitals through Bridge Website community access to MEB resources. Public Health December 2017 1) promote Reachout through partner Reach Out websites 2) Reachout link on Bridge website Educate referral agents regarding MEB-related programs and resources through use of Interagency Helpnet (IAHN) web portal. 1) Train Bridge partners in web portal 2) Bridge partners provide inhouse training at their facility. SLHI, Bridge Partners 1)Training of Bridge Partners will take place in October 2014 2) training in partner organizations will # of organizations trained # of organizations providing staff training # of providers using IAHN. Short Term In each year from January 2015 December 2017, at least five people will contact Reachout through the Bridge Website. By December 31, 2014, 6 Bridge Partner Organizations will provide training to staff at their organization on using IAHN. Medium Term By the end of each year beginning with December 31, 2014 and ending December 31, 2017, there will be a 20% increase in the number of providers using IAHN. Long Term Beyond 5 years Increase the number of days per month adults report good or better mental health. Decrease the number of suicides among adults. Decrease the number of suicides among adolescents. Determine possibility of adding IAHN to EMR s 1) Contact physician practices to provide information on IAHN Bridge Partners January December 2015 # of physician practices approached # of physician practices adopting IAHN as part of EMR By December 31, 2015, three physician practices will be actively pursue including IAHN for MEB resources on their EMR system. By December 31, 2015, at least one physician practice will include IAHN in their EMR resource list for EMB referrals. St. Lawrence County Community Health Improvement Plan 15 P age