Kaleida Health

Community Health Needs Assessment Community Service Plan 2014 - 2016

Building a healthier future Table of Contents

We are Kaleida Health ...... 1 Population Demographics Erie County ...... 2 Niagara County ...... 4 Populations Served ...... 5 Collaboration – Health of the Community ...... 9 Health Indicators Erie County Health Survey ...... 11 Niagara County Health Survey ...... 11 United Way of Buffalo & Erie County ...... 12 Kaleida Health ...... 12 New York State ...... 13 Kaleida Health’s Prevention Agenda Priorities Erie County – Breastfeeding ...... 13 Erie County and Niagara County – Cardiovascular Disease ...... 16 Niagara County – Falls Prevention ...... 20 Other Community Needs ...... 23 Monitoring Plan ...... 24 Dissemination to the Public ...... 24 Approval ...... 24

Community Health Needs Assessment Community Service Plan

Community Health Needs Assessment Community Service Plan 2014 - 2016

We are Kaleida Health Kaleida Health is the largest healthcare provider in Western New York with four hospitals - Buffalo General Medical Center/Gates Vascular Institute, DeGraff Memorial Hospital, Millard Fillmore Suburban Hospital, Women & Children’s Hospital of Buffalo - two long-term care facilities, 80 outpatient clinics including school-based health centers and home health care through the Visiting Nursing Association of Western New York.

Kaleida Health’s mission is to advance the health of our community with a vision to be a regional healthcare system providing excellent quality services, and a commitment to education and research. Recording more than one million patient visits each year, Kaleida Health has a strong commitment to provide health care to all residents of the community through its close to 10,000 employees, including 3,000 nursing personnel and 1,700 affiliated physicians.

The commitment to education is solidified as Kaleida Health serves as a major teaching affiliate of the State University of New York at Buffalo School of Medicine and Biomedical Science. In addition, through affiliations with approximately 63 educational institutions, Kaleida Health provides a clinical experience for healthcare professionals-in-training in the fields of pharmacy, registered nursing, licensed practical nursing, certified nursing assistants, physician assistants, and social work and rehabilitation services.

Buffalo General Medical Center/Gates Vascular Institute Founded as Buffalo General Hospital in 1858, Kaleida Health’s Buffalo General Medical Center at 100 High Street and the adjoining Gates Vascular Institute at 875 Ellicott Street combined are a 548-bed acute care medical center located on the Buffalo Niagara Medical Campus. Buffalo General offers a wide spectrum of clinical inpatient and outpatient care with specialized programs in advanced cardiac, stroke, and vascular services at the Gates Vascular Institute including being designated as the region’s Primary Stroke Center by the New York State Department of Health. A helipad also provides immediate access to life-saving intervention and the region’s largest emergency department that is divided in four separate pods for critical, subacute, vascular, and urgent care to serve over 64,000 patients per year.

DeGraff Memorial Hospital Kaleida Health’s DeGraff Memorial Hospital, 445 Tremont Street, North Tonawanda, is a 70-bed community acute care facility that offers inpatient and outpatient surgical services, and cardiac, medical, subacute and outpatient rehabilitation services. The hospital is home to the Geriatric Center of Western New York and is the Western New York site for the Alzheimer’s Disease

Community Health Needs Assessment Community Service Plan 1 Assistance Center. The Geriatric Center specializes in the care of patients over the age of 70, with an emphasis on those dealing with complex medical issues and/or memory loss. The emergency department provides care for approximately 15,000 patients annually, and also has geriatric specific amenities.

Millard Fillmore Suburban Hospital Millard Fillmore Suburban Hospital at 1540 Maple Road, Williamsville, is a full service, 261-bed acute care, community hospital with inpatient and outpatient services that include ambulatory surgery, cardiology, GI, imaging, interventional radiology, obstetrics and gynecology, palliative care, pulmonary and respiratory therapies, women’s services, and specialty surgical services including minimally invasive robotic surgery. More than 40,000 patients are served annually in the emergency department where specialized pediatric emergency services are also available.

Women & Children’s Hospital of Buffalo Kaleida Health’s Women & Children’s Hospital of Buffalo, located at 219 Bryant Street, Buffalo, is a regional center for comprehensive and state-of-the art pediatric, neonatal, perinatal, and obstetrical services. Ranked among the top 20 pediatric hospitals in the nation by U.S. News and World Report for various specialties, the 200-bed facility can accommodate 160 children, including medical/surgical, ICU and neonatal patients, and 40 adult maternity patients. Women & Children’s Hospital of Buffalo is designated by New York State as the Regional Perinatal Center, New York State Regional Level III Neonatal Intensive Care Unit, and New York State Level I Regional Pediatric Trauma Center to care for critically ill infants and high-risk expectant mothers. Nearly 123,000 patients are treated annually in the emergency department or one of the hospital’s other 45 specialty clinics.

A physician-led steering committee is fulfilling the vision to construct the new John R. Oishei Children’s Hospital on the Buffalo Niagara Medical Campus. Opening in 2016, the 12-floor, free- standing, state-of-the-art facility will continue to be the only hospital in Western New York to provide infants, children and adolescents immediate access to a full panel of pediatric medical subspecialists.

Population Demographics Three Kaleida Health hospitals are located in Erie County and one, DeGraff Memorial Hospital, is located in Niagara County less than one mile from the Erie County border.

Erie County As illustrated in the following chart, according to MedStat Market Expert 2013 data, less than one million people reside in Erie County. The population continues to decline and has done so even since the 2010 census where there were 925,717 residents in comparison to the 922,988 who live in the county today. Similar to New York State, there are more females than males. However, there are fewer children under age 18 and more residents over age 55 in comparison to New York and the United States. Erie County residents also have a lower household income than the New York State average, which is evident in a higher percentage of residents earning

Community Health Needs Assessment Community Service Plan 2 less than $25,000 per year and fewer earning over $100,000.1 In addition, 67 census tracks are identified as medically underserved areas/populations.2

City of Erie United 2013 Amherst New York Buffalo County States

Population total 277,681 137,415 922,988 19,560,723 314,861,807 % Male 47.9 47.5 48.2 48.4 49.2 % Female 52.1 52.5 51.8 51.6 50.8 Age % Under 18 23.0 19.0 20.2 21.5 23.7 % Over 55 26.3 33.8 32.8 29.5 26.3 Average household income $44,979 $86,524 $63,175 $81,625 $69,637 % Less than $25,000 42.3 19.0 27.2 23.9 25.4 % Over $100,000 8.4 29.0 16.9 25.0 19.5 Education % No high school degree 17.6 5.2 10.7 15.2 14.6 % Bachelor's or higher 22.1 51.5 29.6 32.4 28.1 Race % White - non-Hispanic 47.1 82.1 77.2 57.4 62.3 % Black - non-Hispanic 35.6 5.3 13.0 14.3 12.3 % Hispanic 10.7 2.4 4.8 18.3 17.3 % Asian/Pacific Islander 3.5 8.2 2.8 7.8 5.1 % All others 3.1 1.9 2.2 2.3 2.9 As reported for 2013 in MedStat Market Expert

The largest municipality in Erie County is the City of Buffalo with 277,681 residents. The average household income in the City of Buffalo, $44,979, is significantly less than the state average. Over 42 percent of households earn less than $25,000 per year including 26.8 percent earning less than $15,000 and only 8.4 percent earning over $100,000. A direct correlation can be drawn to income from the fact that over 17 percent of residents over age 25 do not have a high school degree. The population in the City of Buffalo also has a higher percentage of black non- Hispanics and Hispanics as compared to the rest of the county, 35.6 percent to 13 percent respectively.3

Amherst, an eastern suburb of the City of Buffalo where Millard Fillmore Suburban Hospital is located, has an average household income above the state average as 29 percent of the population earns over $100,000, and 51.5 percent have a bachelor’s degree or higher. Over 82 percent of the population is white non-Hispanic and only 19 percent of the population earns less than $25,000 with 10 percent earning less than $15,000.4

Community Health Needs Assessment Community Service Plan 3 Niagara County As detailed below, according to MedStat Market Expert 2013 data, just over 215,000 people reside in Niagara County. Like other upstate New York municipalities, the population continues to decline and has done so even since the 2010 census where there were 216,149 residents. Also similar to neighboring counties, there are more females than males, a low percentage of children under age 18 and a high percentage of residents over age 55. Niagara County residents also have a lower household income than the New York State and national averages. Here, 21 census tracks are identified as medically underserved areas/populations.5

City of North Niagara United 2013 New York Niagara Falls Tonawanda County States

Population total 64,910 45,429 215,035 19,560,723 314,861,807 % Male 47.8 48.6 48.5 48.4 49.2 % Female 52.2 51.4 51.5 51.6 50.8 Age % Under 18 20.5 19.4 20.1 21.5 23.7 % Over 55 33.8 35.0 34.4 29.5 26.3 Average household income $46,972 $64,545 $59,551 $81,625 $69,637 % Less than $25,000 39.4 22.9 28.6 23.9 25.4 % Over $100,000 9.5 18.9 15.8 25.0 19.5 Education % No high school degree 13.8 7.8 10.6 15.2 14.6 % Bachelor's or higher 14.0 25.3 20.6 32.4 28.1 Race % White - non-Hispanic 73.2 94.7 86.6 57.4 62.3 % Black - non-Hispanic 17.2 1.1 6.8 14.3 12.3 % Hispanic 2.9 1.7 2.4 18.3 17.3 % Asian/Pacific Islander 1.3 1.0 0.9 7.8 5.1 % All others 5.3 1.5 3.2 2.3 2.9 As reported for 2013 in MedStat Market Expert

The City of Niagara Falls is the largest municipality in Niagara County. Residents in Niagara Falls have an average salary equivalent to the City of Buffalo. Like most inner cities in comparison to the suburbs, there are a high percentage of households, here close to 40 percent, that earn less than $25,000. As compared to North Tonawanda and the county, there are fewer white non- Hispanics, fewer residents over age 25 with a bachelor’s degree or higher and a higher percentage of residents that do not have a high school degree.

North Tonawanda, where DeGraff is physically located on the Erie County border, has a high percentage of white non-Hispanics and only one percent of non-Hispanic blacks. Residents in North Tonawanda also have a higher average household income in comparison to the rest of the county as more residents have a bachelor’s degree and earn over $100,000. However, the average income is still less than the New York State and U.S. averages.6

Community Health Needs Assessment Community Service Plan 4 Populations Served Kaleida Health’s primary and secondary service areas are defined based on the zip codes and number of inpatient discharges from the 2012 patient census.

Overall, Kaleida Health had 59,439 inpatient discharges in 2012.7 The primary service area, shown in blue, accounts for the area where 70 percent of the patients reside. The area shown in green illustrates the secondary service area where approximately 15 percent of patients reside. The remaining 15 percent of discharges are scattered across numerous zip codes and cannot be deemed statistically significant, especially when the zip code with the highest number has 4,222 discharges and another at the bottom of the list has only one discharge.8

Of the close to 330,000 households in Kaleida Health’s combined primary service area, 28.5 percent have an income less than $25,000. 9

Further analysis of the primary service area shows the population in these areas is 75.9 percent white non- Hispanic and 14.3 percent black non-Hispanic.

For the age distribution, 22 percent are under 18 and 28.3 percent are 55 or older. The age range with the fewest residents is 18-24 which accounts for only 9.3 percent of the population.

In the secondary service area, the population is 83.9 percent white non-Hispanic and 7.8 percent black non-Hispanic. The age distribution has 22.4 percent under 18 and 28.3 percent 55 or older.

Only 13.3 percent of the households have an income under $25,000.10

Community Health Needs Assessment Community Service Plan 5 Kaleida Health’s primary service areas differ for each facility. This is in part linked to specialties offered at each location and the Centers of Excellence created in response to the New York Commission on Health Care Facilities in the 21st Century - Berger Commission.

Buffalo General Medical Center/Gates Vascular Institute is located in Erie County, zip code 14203, in downtown Buffalo. The patient census for 2012 shows that the most patients come from zip code 14209 which is in close proximity. Interestingly, the second highest number of patients come from 14221, a suburban zip code 10 miles away and part of the Town of Amherst.11

Out of Buffalo General’s 23,272 discharges in 2012, the top 59 discharge zip codes in the primary and secondary service area include 42 zip codes for municipalities other than the City of Buffalo, and seven in Niagara County.12

Demographics for Buffalo General’s primary service area show that while 16.2 percent have household incomes of less than $15,000, 13.3 percent are greater than $100,000. Further analysis shows 76.4 percent of the population is white non-Hispanic and of those over age 25, 28 percent have a bachelor’s degree or higher.13

Buffalo General’s secondary service area has 15.2 percent with household incomes of less than $15,000, while 14.2 percent are greater than $100,000. Further analysis shows 85.6 percent of the population is white non-Hispanic and of those over age 25, 24.7 percent have a bachelor’s degree or higher.

Age distribution in both service areas is similar with 22 percent under age 18 and 16 percent over age 65.14

Community Health Needs Assessment Community Service Plan 6 Women & Children’s Hospital of Buffalo is located in the City of Buffalo, County of Erie, zip code 14222. However, as the regional pediatric, perinatal, neonatal and obstetrics facility, it serves patients well beyond the immediate neighborhoods.

The patients who make up the 13,654 total discharges travel from 321 different zip codes for specialized inpatient care.

Of the 49 zip codes in Women & Children’s Hospital of Buffalo’s primary and secondary service area, only 14 are Buffalo zip codes.15

The average household income for the primary service area is $55,307. This includes 30.1 percent of households that earn less than $25,000 per year and 12.8 percent that earn over $100,000. The race/ethnicity breakdown has 75 percent white non- Hispanic and 15.1 percent black non-Hispanic. Twenty- two percent of residents in the primary service area are under 18 and 16 percent are over age 65.16

Of the over 330,000 residents in the Women & Children’s Hospital of Buffalo secondary service area, 21.9 percent are under age 18 and 15.2 percent are over 65.

Similar to that of the primary service area, 28.3 percent of household incomes are under $25,000 and 19.4 percent earn over $100,000. Here, the race/ethnicity breakdown has 85 percent white non- Hispanic and only 5.6 percent black non- Hispanic.17

Community Health Needs Assessment Community Service Plan 7 Millard Fillmore Suburban is located in the Town of Amherst, Erie County in zip code 14221. Of the 18,119 inpatient discharges from 378 unique zip codes in 2012, the majority of the patients come to this facility from neighboring suburban towns and villages.18

Interestingly, while Millard Suburban is located in one of the area’s wealthier suburbs (See chart on page 3), 22 percent of the 186,938 households in the primary service area defined by discharge zip codes earn less than $25,000 and 12.6 percent earn over $100,000.19

Unlike other sample groups where there is a more direct correlation between income level and education, here only 8.5 percent of the population over age 25 does not have a high school degree and 33.3 percent have a bachelor’s degree or higher. While this is lower than Amherst on its own, where over 51 percent at least have a bachelor’s degree, it is higher than the Erie County, New York State and U.S. totals.

The race distribution for the primary service area has 88.9 percent as white non-Hispanic and 3.9 percent black non-Hispanic. This distribution compares to Amherst with 82.1 percent and 5.3 percent respectively.

The secondary service area has a similar household income breakdown with 22 percent of the 102,671 households earning less than $25,000 and 13.7 percent over $100,000.

The difference comes in education as 11.2 percent of the population over age 25 does not have a high school degree and only 25.1 percent have a bachelor’s degree or higher.

The race distribution for the secondary service area has 74.8 percent as white non- Hispanic and 16.9 percent black non- Hispanic. This is similar to the distribution in Erie County.20

Community Health Needs Assessment Community Service Plan 8 DeGraff Memorial Hospital, in zip code 14120, is located in North Tonawanda, Niagara County, but almost evenly serves residents from Erie and Niagara counties due to its proximity to the border.

For the top nine zip codes that make up the primary and secondary service area, 1,585 patients are from Niagara County and 911 are from Erie County.21

Demographics for DeGraff’s primary service area show that while 10.9 percent have household incomes of less than $25,000, the average household income is $55,292 and 11.6 percent are greater than $100,000.

The data also shows 92.8 percent of the population is white non- Hispanic and of those over age 25, 21.6 percent have a bachelor’s degree or higher.

Demographics for DeGraff’s secondary service area show that while 10.6 percent have household incomes of less than $15,000,

19.5 percent are greater than $100,000.

Here 87.2 percent of the population is white non- Hispanic and of those over age 25, 37.8 percent have a bachelor’s degree or higher.

The age of residents in both the primary and secondary service areas is very similar with 30 percent being over age 55 including 17 percent over age 65.22

Collaboration - Health of the Community Kaleida Health participated in both the Erie County and Niagara County Community Health Needs Assessment and County Health Improvement Plan collaborative efforts.

In Erie County, the Department of Health led the community health initiative. Partners included the Erie County Department of Health, Kaleida Health, Catholic Health, Buffalo State College Center for Health and Social Research, P2 Collaborative of Western New York, United Way of Buffalo & Erie County, and University at Buffalo Family Medicine.

While the county began the process by developing the survey tool and its distribution methods in the Fall of 2012, the Department of Health brought its community partners together in February 2013. The subsequent meetings in March, July and August 2013 solidified the health department, local hospitals, and academia efforts. In addition to relying on NY Prevention Agenda data, Erie County conducted a county-wide health assessment and held a Living Healthy

Community Health Needs Assessment Community Service Plan 9 Task Force Town Hall meeting for professional input. Erie County also capitalized on existing relationships with various groups including the P2 Collaborative and United Way especially for the breastfeeding initiatives.

In Niagara County, the Niagara County Health Department, Niagara Falls Memorial Medical Center, Mt. St. Mary’s Hospital, Kaleida Health - DeGraff Memorial Hospital, Eastern Niagara Hospital, Niagara County Department of Mental Health, and University at Buffalo Preventive Medicine Residency with assistance from the P2 Collaborative of Western New York, joined together for the community health assessment efforts.

The Niagara County group launched their efforts on March 7, 2013 and held subsequent meetings in April, May, July, August, September and October. In addition to the Niagara County Community Health Survey, which had 1,455 responses, outreach events included hosting three focus groups and a county-wide Community Health meeting.

In addition to the outreach and feedback in both counties, Kaleida Health also reached out to other partners in the community including, but not limited to, the Near East and West Side (NEWS) Task Force, Lasting Education for Women, Adults & Children (LEWAC) and Greater Buffalo United Accountable HealthCare Network (GBUAHN).

The NEWS Task Force exists to promote the well-being and self-sufficiency of racial and ethnic communities in Buffalo through advocacy. With a primary focus on the health disparities of those who reside in Buffalo’s east and west side communities, the organization was formed to address identifiable needs. Meeting with the president and other members of the executive committee, the discussion included their current outreach efforts and priorities. Of particular interest is their approach to wellness events where participants are given a passport that gets stamped by each booth/table visited. Events always include a screening component and health incentives instead of having participants just pick up paper at the tables.

LEWAC is a community-based nonprofit that partners with providers and faith based communities to bring culturally sensitive health education in Erie and Niagara counties. Kaleida Health has previously worked with LEWAC on educating target groups with a program from the American Association of Black Cardiologists. The president founded the organization after a very personal experience of family members struggling with chronic diseases – obesity, high blood pressure, diabetes – which ultimately led to cardiovascular issues. Today, the same issues are still prevalent in these targeted communities.

GBUAHN is a designated health home in the City of Buffalo. The intent is to offer Medicaid participants who suffer from multiple or severe chronic conditions the possibility to benefit from better coordination and management of their healthcare services. Using Kaleida Health facilities, services and physicians, GBUAHN helps facilitate access to and coordination of primary and acute physical health services, behavioral health care and long-term community- based services and support.

Community Health Needs Assessment Community Service Plan 10 As a founding partner, Kaleida Health supports the person-centered care philosophy to treat the whole individual. The Health Home model fosters health and community agencies agreeing to work together to help people with many health issues get the services and care they need to stay healthy and safe in the community.

Health Indicators

Erie County Health Survey The Erie County Department of Health facilitated numerous conversations and conducted a survey that was distributed electronically as well as in person by interns who assisted individuals in county department waiting rooms, clinics and senior centers complete the questionnaire.

Questions on the survey focused on health topics of concern, where residents get information, and health related choices from overall diet/grocery shopping selections, to vitamin, vegetable, and water consumption. In total, 1,198 individuals completed the survey.

Survey results indicate that physical activity, stress and obesity are the top three topics respondents are most interested learning about. Other topics in the top 10 responses include blood pressure, cholesterol and heart disease.

Analysis of the survey results by Buffalo State College Center for Health and Social Research shows that overall based on age, 43.6 percent were concerned about chronic disease (cancer, heart disease and diabetes). The population over age 60 had the highest concern about chronic disease at 59.7 percent, with the remainder of respondents having between a 33 and 44 percent interest. Males were more concerned about this topic compared to females, 48.5 percent versus 41.6 percent. African-American and American Indian populations had the highest level of concern with Asian/Pacific Islanders having the least concern about chronic disease. Also, those with the highest level of income, over $65,000, had the highest level of interest while those earning $35,000-$65,000 had the least interest.

Respondents also had a 26.2 percent interest in maternal and child health with those aged 18- 30 and 30-39 having the most interest at 35.7 and 44.2 percent respectively. Females were more interested than males. By race, Asian/Pacific Islanders had the highest level of interest with Hispanic/Latino, African-American and Multiple Races/Ethnicities having significant levels of interest too. Those earning under $35,000 had the highest interest in maternal and child health topics however, those with higher income levels ($35,000 to $65,000 and over $65,000) had similar interest, respectively at 28.7, 25.4 and 26.4 percents.

Niagara County Health Survey Niagara County survey life style questions focused on broader health topics and resources. A total of 1,455 individuals completed the survey. The top five issues respondents were concerned about included cancer, heart-related issues, obesity, alcohol consumption/drug use and nutrition/healthy diet.

Community Health Needs Assessment Community Service Plan 11 The top barrier to health was that survey participants “do not have enough time,” and the second highest response was that they take care of their family’s health and well-being more. This directly ties to survey demographics as 75 percent of survey participants were female.

From the survey pool, only 8.1 percent indicated that DeGraff is their primary hospital and a high level of respondents, 87.7 percent, indicated they get their information from their doctor’s office to which 80.9 percent indicate they visit at least once per year or more.

Focus group discussions reflected the same issues and concerns in the community around chronic disease and also included mental health concerns as barriers to care.

United Way of Buffalo & Erie County The local United Way chapter conducted a 2011-2012 Community Needs Assessment. The report examined various aspects of the area including academic performance, social supports, financial issues and health and wellness. For the health and wellness section, safe, nurturing relationships, healthy choices, healthy behaviors and access to care were addressed. Key findings in the report reflect some of the same issues as other studies of the area. Erie County has an aging population and many do not have the support they need. The survey shows that there are significant needs for pregnant women ages 10-19, including assistance to reduce breastfeeding barriers. Specifically, only 13 percent of mothers utilizing the Women, Infant and Children (WIC) program breastfed their children at six months compared to 41 percent in New York State. The study also shows nearly 15 percent of two to four year olds involved in WIC are obese. This epidemic continues to grow as 26 percent of elementary and 33 percent of middle and high school students in Erie County are overweight or obese. For adults, 29 percent are considered obese and combined with those overweight the total is over 64 percent.

Kaleida Health Kaleida Health’s discharge codes for each adult facility validated there is a high number of vascular related diseases and comorbidities in the population. This includes cardiac related incidents for open heart, electrophysiology and angiography as well as neurosurgery and stroke care.23

Specifically at Buffalo General, cardiac medical, orthopedic-surgical, general medicine, neurology-medical, general surgery, cardiac surgical-angioplasty, pulmonary, gastroenterology, neurology-surgical and nephrology/urology make the top 10 discharge codes followed by cardiac surgical-open heart. At DeGraff, the highest number of patients are admitted for general medicine, pulmonary, cardiac medical, gastroenterology, nephrology/urology, orthopedic-surgical care. Millard Suburban provides obstetrics-delivery and newborn, general medicine, orthopedic-surgical, cardiac medical and pulmonary care. Finally, Women & Children’s Hospital of Buffalo, because of its specialization, top codes include obstetrics- delivery and newborn, general medicine, pulmonary, newborn-neonatology and obstetrics-non- delivery.24

Community Health Needs Assessment Community Service Plan 12 New York State New York State’s 2013- 2017 Prevention Agenda is supported by a plethora of information from the New York State 2012 Health Assessment. Extensive research and analysis by the New York State Department of Health guides required healthcare institutions to focus their community health efforts under the following priorities:  Prevent Chronic Disease  Promote Healthy and Safe Environment  Promote Healthy Women, Infants and Children  Promote Mental Health and Prevent Substance Abuse  Prevent HIV, STDs, Vaccine-Preventable Diseases and Health Care-Associated Infections

At a minimum, hospital providers need to identify two focus areas under the priorities and work on a goal with a targeted objective to move the measurable health indicators in the community.

Kaleida Health’s Prevention Agenda Priorities With hospitals located in both Erie and Niagara counties, Kaleida Health, working collaboratively with both county groups, identified three projects to undertake as part of the Community Service Plan. In Erie County, Kaleida Health will work to increase breastfeeding rates and cardiovascular disease screenings. In Niagara County, Kaleida Health will also increase cardiovascular disease screenings and work to reduce the number of falls for those over age 65.

Erie County

Priority Promote Healthy Women, Infants and Children Focus Area Maternal and Infant Health Goal Increase the proportion of New York State babies who are breastfed Objective Increase the percentage of babies breastfed upon discharge at Millard Fillmore Suburban Hospital three percent and at Women & Children’s Hospital of Buffalo six percent by December 2016.

Why Breastfeeding Research shows that breastfed infants have lower rates of obesity, diabetes, asthma, respiratory infections and other chronic conditions.25 Mothers who breastfeed also reduce their risk of breast and ovarian cancers, lose weight quicker which in turn contributes to lowering the risk of cardiovascular disease and diabetes, comorbidities of obesity.

In New York State as a whole, 43.5 percent of infants were exclusively fed breast milk in the delivery hospital. If New York City is excluded, 52.3 percent of babies in the rest of New York meet this criteria. White non-Hispanic babies are more like to be breastfed than black non- Hispanic babies, 55.5 percent compared to 29.0 percent.26 In Erie County, 65.5 percent of babies were fed at least some breast milk and 57.7 percent were exclusively fed breast milk in the delivery hospital. After discharge, there is currently no mandatory reportable follow-up except through WIC mothers. In Erie County, only 13.2 percent of WIC mothers breastfed for at least six months compared to 39.7 percent in New York from 2008 – 2010.27 At the two Kaleida

Community Health Needs Assessment Community Service Plan 13 Health hospitals with obstetrics programs, the breastfeeding rates of mothers during their postpartum stay vary by 20 percent.28

Women & Children’s Hospital of Buffalo Millard Fillmore Suburban Hospital Breast Feeding Rates Breast Feeding Rates Births Breast Fed Total Births Breast Fed Total

2012 3031 1808 60% 2012 2506 2012 80%

2013* 2163 1273 59% 2013 * 1698 1382 81%

From Birth Certificate Vital Records *January through September 2013

Kaleida Health’s Implementation Plan To achieve the aforementioned objective to increase breastfeeding rates at Women & Children’s Hospital of Buffalo and Millard Fillmore Suburban Hospital, Kaleida Health will:  Increase collaboration between Millard Fillmore Suburban Hospital and Women & Children’s Hospital of Buffalo Women’s Services on breastfeeding initiatives.  Build out a better continuum of breastfeeding support in both outpatient and inpatient settings from prenatal through labor and delivery and all postpartum care.  Link existing internal and community breastfeeding initiatives to maximize efficiency and resources including Great Beginnings NY and Healthy Start Healthy Future for All Coalition.  Increase staff education of and expectation to follow breastfeeding friendly practices in support of baby-friendly hospital practices.

Kaleida Health’s Milestones Kaleida Health will work to achieve the following milestones as part of the community plan:

By November 2014 1. Identify breastfeeding project champions at Millard Fillmore Suburban Hospital and Women & Children’s Hospital of Buffalo. (January 2014) 2. Convene a standing committee meeting where champions will collectively evaluate, identify, implement and monitor breastfeeding initiatives. (January 2014) 3. Review current outpatient and inpatient breastfeeding practices throughout Kaleida Health including the Women’s Health Centers, labor and delivery, NICU, nursery and postpartum units. (March 2014) 4. Develop plan to implement a comprehensive approach to recommended best breastfeeding practices at identified patient interactions from prenatal through postpartum care. This may include but is not limited to using the Breastfeeding Bill of Rights, and Ten Step to Successful Breastfeeding. (June 2014) 5. Comprehensively integrate community resources including Great Beginnings NY and Healthy Start Healthy Future for All Coalition in Kaleida Health breastfeeding initiatives. 6. Devise tools to monitor and track compliance with the developed implementation plan. 7. Execute plan devised by breastfeeding champions committee.

Community Health Needs Assessment Community Service Plan 14 8. Provide training for staff that interacts with mothers at various points along the continuum of care.

By November 2015 1. Continue role of breastfeeding champions to evaluate, identify, implement and monitor breastfeeding initiatives. 2. Consistently execute and track the use of tools identified in the implementation plan. 3. Provide training for additional staff at various levels along the continuum of care.

By November 2016 1. Continue role of breastfeeding champions to evaluate, identify, implement and monitor breastfeeding initiatives. 2. Consistently execute and track the use of tools identified in the implementation plan. 3. Provide training for additional staff at various levels along the continuum of care.

Implementation Tools This implementation plan is supported by existing and new initiatives.

 Both hospitals are participating in the Great Beginnings NY program. As part of this initiative, the hospitals agree to ensure breastfeeding infants do not receive supplementation, unless medically indicated; educate mother about the impact of non- medically indicated supplementation; discontinue the distribution of infant formula; provide all breastfeeding mothers with post-discharge lactation support and referrals. This also includes providing mothers the Breastfeeding Bill of Rights while offering the corresponding support services including, but not limited to, prenatal education, skin to skin, rooming in, trained lactation support in order to foster successful breastfeeding.

 Women & Children’s Hospital of Buffalo currently participates in the United Way of Buffalo & Erie County Collaborative, in partnership with UBMD and P2 Collaborative, which is a coalition of over 40 agencies committed to promote the health and well-being of children from birth - elementary school, and specifically addressing the root causes of childhood obesity, a growing public health issue.

 The Healthy Start, Healthy Future for All portion of this coalition promotes breastfeeding in Erie County and a comprehensive series of breastfeeding friendly strategies. Participation in this collaboration has funded a Baby Café at Women & Children’s Hospital of Buffalo, only the fourth of its kind in New York State. The Baby Café is a drop in center run by lactation professionals who provide lactation assistance.

 Plans for the new NICU at Millard Fillmore Suburban include installing breast milk warmers in all patient rooms as well as a nutrition and formula room where breast milk can be stored. A breast milk label printer will be placed at the entrance of the unit for new mothers bringing breast milk for their NICU patient.

Community Health Needs Assessment Community Service Plan 15 Erie County and Niagara County

Priority Prevent Chronic Disease Focus Area Increase access to high quality chronic disease preventative care and management in both clinical and community settings Goal Increase screening rate for cardiovascular disease, especially among disparate populations Objective Increase the percentage of women screened for cardiovascular disease at their annual OB/GYN visits from zero to 60 percent Target Disparity Women

Why Cardiovascular Disease Heart disease was the leading cause of death in New York State from 2000 – 2009.29 While the rate has declined from close to 300 per 100,000 to 207 per 100,000 over the same period of time, even when broken down by race and ethnicity, it still is very prevalent in the population as 4.4 percent of adults reported in 2010 that they have cardiovascular disease.30

Over the three year period from 2008 – 2010, the cardiovascular disease mortality rate in Erie County was 9,603, which equates to 350.7 per 100,000 and 1,628 died from cerebrovascular disease/stroke or 59.5 per 100,000.31 During the same timeframe, 36,172 people were hospitalized for heart disease and 9,401 were hospitalized for cerebrovascular disease/stroke.32

In Niagara County, from 2008 – 2010, the cardiovascular disease mortality rate was 2,718, which equates to 421.1 per 100,000 and 322 died from cerebrovascular disease/stroke or 49.9 per 100,000. During the same timeframe, 5,402 people were hospitalized for heart disease and 2,576 were hospitalized for cerebrovascular disease/stroke.33 This makes Niagara County one of the areas of the state with the highest heart disease death rates.34 Benchmarked against the state indicators, where the cardiovascular disease mortality rate was 289.2 per 100,000 and the cerebrovascular disease mortality rate was 30.5 per 100,000, Western New York is higher.35

At Kaleida Health, the patient discharge data for 2012 shows that between Buffalo General/Gates Vascular Institute and the former Millard Fillmore Gates Circle Hospital close to 7,500 individuals received inpatient cardiac or stroke care. This equates to close to one-third of the discharges for Buffalo General being cardiovascular or cerebrovascular.36

2012 Discharges Cardiac Stroke Combined Buffalo General 5,300 1,461 6,761 Millard Fillmore Gates * 315 383 698 5,615 1,844 7,459 SPARCS Data - HANYS MEDSTAT Market Data *January through March 2012

Community Health Needs Assessment Community Service Plan 16 Even more alarming, heart disease claims more women’s lives in the United States than all forms of cancer combined.37 According to the American Heart Association, nearly one death every minute for American women is the result of heart disease, stroke or other cardiovascular diseases. Unfortunately, there are widespread misconceptions that heart disease is a man’s disease.

Based on 2008 data, one in three women died of cardiovascular disease while one in 25 died from breast cancer.38 By 2011, this increased to one in two women dying of heart disease or stroke. The severity and likelihood of mortality is partially linked “to the fact that the survival rate for breast cancer is high, whereas 40 percent of women do not survive their first heart attack.”39 The disparity exists as women are not screened as often, or if screened, treated as aggressively. Also, it is documented that women do not present with the same symptoms. As a result, women are under diagnosed, misdiagnosed and inadequately treated for heart disease.

For women of child bearing age, being overweight is a national epidemic and can have a significant impact on their well-being. Among pregnant Erie County women enrolled in WIC from 2007-2009, 4.3 percent were prepregnancy underweight (BMI < 18.5) while 24.7 percent were overweight but not obese (BMI 25 - < 30) and 29.2 percent were prepregnancy obese (BMI 30+>).40 The Centers for Disease Control reports that obesity during pregnancy is now a common condition affecting approximately 1 of 5 pregnant women.41 At the Women’s Health Centers, approximately 41 percent of patients seeking prenatal care begin pregnancy already obese. These patients more than likely have other risk factors which would further increase their likelihood of having cardiovascular disease as well. Studies show that 90 percent of adult women in the United States had one or more risk factors for heart disease. 42

In addition, the aforementioned responses from the Erie and Niagara counties community needs assessments are all related to cardiovascular disease as physical inactivity, poor diet, high blood pressure, high cholesterol, obesity and diabetes are all major risk factors.

Kaleida Health’s Implementation Plan To address the high rates of cardiovascular disease in Erie and Niagara counties among women, Kaleida Health will:

 Integrate a Clinical Risk Assessment for Cardiovascular Disease in the annual OB/GYN visits at the Women’s Health Centers.  Have practitioners view HeartCaring module and register as HeartCaring staff.  Build out the EMR to trigger screening questions and automatically calculate risk based on data already present. (Weight/BP/Smoking history/BMI)  Provide patients at risk for cardiovascular disease HeartCaring materials and referral to a primary care physician or cardiologist. (Have task verification in EMR.)  Encourage patient to join Spirit of Women to provide support and education (nutrition, clinical speakers, self-check guidance).  Solidify referral structure.

Community Health Needs Assessment Community Service Plan 17 Kaleida Health’s Milestones This plan will be benchmarked as follows:

By November 2014 1. Identify lead team with Women’s Health Centers, UBMD OB/GYN physicians, Kaleida Health Cardiology, Performance Improvement and IST support. (January 2014) 2. Women’s Health Center practitioners from all six locations view HeartCaring module and register as HeartCaring staff. (April 2014) 3. Integrate HeartCaring questions and auto-risk calculator features in EMR. Include feature to track number of patients screened, education and referrals provided. (April 2014) 4. Train Women’s Health Center HeartCaring practitioners on new EMR prompts and follow up procedures. (May 2014) 5. Launch new integrated risk assessment program in Women’s Health Centers. (June 2014) 6. Provide women identified at risk for cardiovascular disease HeartCaring education and encourage enrollment in Spirit of Women. (June 2014)

By November 2015 1. Continue risk assessment screening during annual OB/GYN visit. 2. Continue providing women identified at risk for cardiovascular disease HeartCaring education and Spirit of Women membership. 3. Develop and execute a full year of educational programming to support individuals at- risk for or living with cardiovascular disease. 4. Analyze data collected at to be determined intervals. 5. Explore referral and follow through opportunities for at-risk women with primary care or cardiology specialties. 6. Adjust program, if needed, for 2016 based on data.

By November 2016 1. Continue risk assessment screening during annual OB/GYN visit. 2. Continue providing women identified at risk for cardiovascular disease HeartCaring education and Spirit of Women membership. 3. Develop and execute another full year of educational programming to support individuals at-risk for or living with cardiovascular disease.

Implementation Tools This model for cardiovascular screening meets the evidence based programming, geographic and disparate population criteria.

 The Women & Children’s Hospital of Buffalo network of neighborhood OB/GYN centers recently expanded to have six locations across the region. Four are in Erie County - Lancaster OB/GYN in Lancaster; McKinley OB/GYN in Hamburg; Elmwood OB/GYN at Women & Children’s Hospital of Buffalo in Buffalo; and Kensington OB/GYN in the

Community Health Needs Assessment Community Service Plan 18 Grider Family Health Center, also in Buffalo. North Tonawanda OB/GYN at DeGraff in North Tonawanda and Lockport OB/GYN in Lockport are the two centers located in Niagara County. The OB/GYN centers each have a dedicated physician, nurse practitioner and other staff. The location of the centers improves access and results in demonstrated improved compliance with annual health maintenance and gynecological screenings.

 The HeartCaring platform is an evidence-based program through Spirit of Women that was developed in partnership with the National Heart, Lung and Blood Institute The Heart Truth, with educational support by the Vascular Disease Foundation, the Peripheral Arterial Disease Coalition and the Venous Disease Coalition. The HeartCaring module that all practitioners will take as a training tool reviews evidence- based guidelines for cardiovascular disease prevention in women. The program also provides gender sensitive, clinically based materials for practitioners and their patients.

 The HeartCaring program focuses on prevention and emphasizes screening and patient education to support lifestyle changes. It also addresses the varying epidemiology of cardiovascular disease for women. The goal is to assess and modify women’s cardiovascular disease risk through gender-specific strategies including the different interventions, therapies and prevention guidelines.

 As a leader in cardiovascular and stroke care, the Gates Vascular Institute/Buffalo General Medical Center received the Get With The Guidelines®- Heart Failure Gold Quality Achievement Award from the American Heart Association for the exceptional treatment of heart failure patients according to the guidelines of care recommended by the American Heart Association/American College of Cardiology. They also received the American Heart Association/American Stroke Association’s Get With The Guidelines®- Stroke Gold Plus Quality Achievement Award for their commitment to and success in implementing excellent care for stroke patients, according to evidence-based guidelines.

 BlueCross BlueShield of Western New York named the Gates Vascular Institute/Buffalo General Medical Center a Blue Distinction Centers+ for excellence in cardiac care.

Community Health Needs Assessment Community Service Plan 19 Niagara County

Priority Promote a Healthy and Safe Environment: Injuries, Violence and Occupational Health Focus Area Injury Prevention Goal Reduce falls risks among vulnerable populations Objective Reduce the rate of fall related hospitalizations for the 65+ population in Niagara County by 10 percent. Niagara County rate is 216.3 per 10,000.43

Why Falls Prevention Each year, one in every three adults age 65 and older falls. One in 10 falls end up with a hospitalization. In fact, falls are the leading cause of injury deaths, hospitalizations and emergency department visits among adults 65 and older.44 Falls can result in lasting, serious consequences that affect a person's mobility, independence and mental health. Falls are also costly - according to the Centers for Disease Control, medical costs for treating falls totaled more than $19 billion in 2000. By 2020, those medical costs are expected to reach $54.9 billion.

According to New York State, 60 percent of adults 65 and older who are hospitalized due to a fall end up in a nursing home or rehabilitation center. Of those hospitalized due to a fall, 11 percent suffer a traumatic brain injury and 27 percent experience a hip fracture.

In Niagara County the percentage of fall related injuries is higher than the rest of New York. According to the Behavioral Risk Factor Surveillance System January 2012, the New York State average for those 60 and older experiencing a fall related injury was 5.0 percent versus Niagara County at 7.3 percent. Of the five hospitals serving Niagara County, EMS responders identified the areas surrounding DeGraff Memorial Hospital as one with some of the highest numbers of fall related calls for those over age 60.

DeGraff Emergency Department visits for 2012 and January through July 2013 show that over 10.8 and 10.4 percent respectively were fall related.45

2012 2013 (January – July)

Community Health Needs Assessment Community Service Plan 20 Gender analysis over the same period for the DeGraff Emergency Department shows everyone is at risk. However, slightly more females received care over the same periods.46 2012

2013 (January – July)

The New York State Department of Health Injury Prevention Program also indicates that males have a higher risk of death due to falls while females have a higher risk of hip fracture. Age increases the risk of falling and the severity of a fall injury, and people who have previously fallen are at an increased risk to fall again.

The good news is many falls and the devastating physical and financial impact resulting from falls are preventable.

Kaleida Health’s Implementation Plan To address the high number of falls within Niagara County, DeGraff will:  Increase collaborations with Niagara County hospitals and partner organizations.  Offer training, resources and technical assistance to expand the Niagara County Falls Coalition Stay Well On Your Feet/Falls Prevention Outreach Program.  Broaden outreach and training of falls prevention education to targeted groups.

Kaleida Health’s Milestones The objective will be benchmarked by the following steps:

By November 2014 1. Reaffirm the elements of the Niagara County Falls Coalition Stay Well On Your Feet/Falls Prevention Outreach Program. (March 2014) 2. Expand existing collaboration with Niagara County Department of Health and Niagara County Office of Aging to include other Niagara County hospitals. (March 2014) 3. Share best practices, resource materials and demonstrate the Stay Well On Your Feet/Falls Prevention program to new partners. (April 2014) 4. Continue working with the Health Foundation for Western & Central New York.

Community Health Needs Assessment Community Service Plan 21 5. Provide Stay Well On Your Feet/Falls Prevention programs to 15 percent of the McLaughlin Center for Senior Wellness members. 6. Support McLaughlin Center for Senior Wellness members with post-training outreach and referrals. 7. Develop a Falls Prevention Outreach program tailored to caregivers. (October 2014) 8. Provide falls prevention educational material at community outreach events. 9. Present four Stay Well On Your Feet/Falls Prevention Outreach programs.

By November 2015 1. Conduct Train the Trainer programs to new partners from other Niagara County hospitals. 2. Launch newly developed Caregiver Falls Prevention program with DeGraff Adult Day Care Center families. 3. Provide Stay Well On Your Feet/Falls Prevention programs to another 15 percent of the McLaughlin Center for Senior Wellness members. 4. Continue supporting McLaughlin Center for Senior Wellness members with post-training outreach and referrals. 5. Evaluate effectiveness of programming from year one and on an ongoing basis. 6. Provide falls prevention educational material at community outreach events. 7. Present four Stay Well On Your Feet/Falls Prevention Outreach programs.

By November 2016 1. Continue offering Caregiver Falls Prevention program to DeGraff Adult Day Care Center families. 2. Evaluate newly developed Caregiver Falls Prevention program. 3. Determine viability of expanding Caregiver Falls Prevention program to other caregiver groups. 4. Provide Stay Well On Your Feet/Falls Prevention programs to another 15 percent of the McLaughlin Center for Senior Wellness members. 5. Continue supporting McLaughlin Center for Senior Wellness members with post-training outreach and referrals. 6. Evaluate effectiveness of all programming on an ongoing basis. 7. Provide falls prevention educational material at community outreach events. 8. Present four Stay Well On Your Feet/Falls Prevention Outreach programs.

Implementation Tools  For the past two years, DeGraff has been a partner in a Step Up To Stop Falls initiative supported by a grant from the Health Foundation for Western & Central New York. Members of the falls coalition include DeGraff Memorial Hospital and its McLaughlin Center for Senior Wellness, Niagara County Health Department, Niagara County Office for the Aging and the Visiting Nursing Association of WNY.

 The Stay Well On Your Feet/Falls Prevention program targets individuals over age 60 to address their needs to maintain a high level of independence. The focus is to educate

Community Health Needs Assessment Community Service Plan 22 older adults on self-management of behaviors geared toward good health and wellness with an emphasis on falls prevention. The program, designed to be presented in four weekly one-hour sessions, covers topics including Timed Up and Go (TUG), blood pressure monitoring, the Home Safety Self Assessment Tool (HSSAT) Book, falls prevention education, active participant participation and QiGong.

 HSSAT was developed by the Occupational Therapy Geriatric Group of the Department of Rehabilitation Science at the University as Buffalo. The guide provides step by step instructions, illustrates risk factors and offers solutions. HSSAT has been tested for its effectiveness and has shown to have quantifiable results.47 For example, using a pre and post session review, a group of 25 adults with a mean age close to 80 who had a previous fall used the HSSAT by themselves and identified their home fall risks to be 12.2. After HSSAT training, they identified their risks a month later as 7.1. Similarly, another group of older adults without previous falls originally identified the fall risk as 6.5. A month after using the HSSAT guide, the fall risk was 2.9. The reduction of 5.1 and 1.6 respectively is significant. After completing the program, participants should identify at least three environmental risks for falls in their home through completion of the HSSAT checklist.

 Participants are also encouraged to adopt a movement program such as QiGong in their routine. QiGong, is the art and science of using breathing techniques, gentle movement and meditation to strengthen and circulate life force/energy and enhance health and healing of the mind and body. Clinical research studies show that the routine practice of QiGong has a positive impact on posture, balance, strength and flexibility, reducing falls and/or the risk of falls in adults of all ages. Although Tai Chi is more often cited in clinical research than QiGong, it has been noted that “health oriented Tai Chi and QiGong emphasize the same principles and practice elements. Given these similar foundations, it is suggested that the research literature for these two forms of meditative movement should be considered as one body of evidence...QiGong and Tai Chi, in the health promotion and wellness context, are operationally equivalent.”48

Other Community Needs These three aforementioned initiatives are in accordance with the needs identified by the community and supported through this detailed analysis. Two other topics identified by the community as areas of concern were cancer and behavioral health.

Buffalo is fortunate to have the Roswell Park Cancer Institute located on the Buffalo Niagara Medical Campus. Roswell holds the National Cancer Institute designation as a comprehensive cancer center and has a proven multidisciplinary approach. Kaleida Health works with Roswell, including the proposed integrated hematology/oncology floor in the new John R. Oishei Children’s Hospital. As such, Kaleida Health is confident that Roswell Park, although not required to submit a community service plan as a public benefit corporation, is an adequate cancer resource for the community.

Community Health Needs Assessment Community Service Plan 23

Under Great Lakes Health, Kaleida Health is jointly developing a $25 million Regional Behavioral Health Center of Excellence with the Erie County Medical Center on their Grider Street campus. The Center will house consolidated mental health and drug dependency treatment programs with a 180-bed inpatient psychiatric program and a comprehensive psychiatric emergency program. This Center of Excellence is in line with the Berger Commission and supported by the New York State Department of Health.

Monitoring Plan Each of the identified priorities has a group of clinical and/or site leaders who will implement the steps necessary to meet the milestones and ultimately achieve the objective. In addition, a member of the Community Health team will monitor the individual projects and their progress.

Dissemination to the Public This plan is available to the public in the Community Health section of the Kaleida Health, kaleidahealth.org, website specifically at www.kaleidahealth.org/community/publications.asp. A paper version of this report is available upon request.

Approval The Kaleida Health Board of Directors approved this document on November 6, 2013.

1 MedStat Market Expert, 2012. 2 U.S. Department of Health and Human Services, Health Resources and Services Administration, MUA/P by State and County, Retrieved October 29, 2013 from http://muafind.hrsa.gov/index.aspx. 3 MedStat Market Expert. 4 Id. 5 U.S. Department of Health and Human Services, Health Resources and Services Administration, MUA/P by State and County, Retrieved October 29, 2013 from http://muafind.hrsa.gov/index.aspx. 6 Id. 7 Magellan IP801, Internal Data, June 24, 2013. 8 Id. 9 MedStat Market Expert. 10 Id. 11 Magellan IP801, Internal Data. 12 Id. 13 MedStat Market Expert. 14 Id. 15 Magellan IP801, Internal Data. 16 MedStat Market Expert. 17 Id. 18 Magellan IP801, Internal Data. 19 MedStat Market Expert. 20 Id. 21 Magellan IP801, Internal Data.

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22 MedStat Market Expert. 23 Magellan IP801, Internal Data, October 2013. 24 Id. 25 Dash NY Increasing Breastfeeding, New York State Department of Health, 2013. 26 NYS DOH Biometrics and Health Statistics as reported in the New York State Health Assessment 2012. 27 Erie County Maternal and Infant Health Indicators, New York State Department of Health, Indicators Reports, 2008 – 2010. 28 Id. 29 New York State Bureau of Biometrics and Health Statistics, New York Department of Health, 2010. 30 CDC, Behavioral Risk Factor Surveillance System as reported in the New York State Health Assessment 2012. 31 Erie County Cardiovascular Disease Indicators, New York State Department of Health, Indicators Reports, 2008 – 2010. 32 Id. 33 Niagara County Cardiovascular Disease Indicators, New York State Department of Health, Indicators Reports, 2008 – 2010. 34 Adjusted 2000 U.S. Census as reported in the New York State Health Assessment 2012. 35 Id. 36 Magellan IP801, Internal Data. 37 American Heart Association. (2012, February). FACTS: Cardiovascular Disease: Women’s No. 1 Health Threat. Retrieved October 9, 2013, from American Heart Association: http://www.heart.org/idc/groups/ heart- public/@wcm/@adv/documents/ downloadable/ ucm_302256.pdf. 38 Harvard Medical School. (2003, March). Heart Disease - Differences Between Men and Women. Retrieved October 9, 2013, from Beth Israel Deaconess Medical Center : http://www.bidmc.org/Centersand Departments/Departments/Medicine/Divisions/CardiovascularMedicine/YourHeartHealth/TipsforHeartHealth/ HeartDiseaseDifferencesBetweenMenandWomen.aspx. 39 Id. 40 Health Risks and Behaviors Indicators – Erie County, 2007-2009, NYSDOH. 41 Pregnancy Complications. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PregComplications.htm 42 National Coalition of Women and Heart Disease. (2011). 2011 10Q Report: Advancing Women’s Heart Health through Improved Research, Diagnosis and Treatment. Washington, D.C.: The National Coalition for Women with Heart Disease and The Society for Women’s Health Research. 43 NYS Indicators for tracking Public Health as referenced in the Niagara County Community Health Improvement Plan, 2013. 44 Falls Prevention - Step up to Stop Falls: Fact Sheet. Retrieved October 21, 2013, Health Foundation for Western & Central New York: http://www.hfwcny.org/Tools/Broadcaster/frontend/itemcontent.asp?reset=1&ItemID=13. 45 Magellan IP801, Internal Data. 46 Id. 47 Today’s Geriatric Medicine Magazine. (2013, November/December). Tomita, Machiko R., PhD., and Nochajski, Susan M., PhD. 48 A Comprehensive Review of Health Benefits of QiGong and Tai Chi, Am J Health Promotion, author manuscript; PMC 2011 July 1, NIH Public Access.

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