Chapter Ten

Tug Hill Seaway DSRIP Region Needs Assessment New York State Office of Mental Health

Executive Summary This community needs assessment of the Tug Hill Seaway DSRIP region summarizes specific health care service data to identify mental health and substance use disorder treatment needs in the region. The data included are intended to enable planners and others to identify service gaps and disparities and plan for improved service delivery.

Population Socioeconomic Characteristics The Tug Hill Seaway region includes Jefferson, Lewis, and St. Lawrence counties. Just over a quarter of a million people live in the region and two counties are designated rural. The population’s socioeconomic characteristics are more indicative of need than those in most DSRIP regions. The median household income of $44,953 is lowest among all regions, 17% of the population live below the poverty level, 3% are on cash public assistance, and 14% receive food stamps/SNAP benefits. The population percentages living below the poverty level and receiving food stamps/SNAP benefits are the second highest in any DSRIP region. Thirteen percent of adults in the region are without a high school diploma and 18% have a bachelor’s degree or higher, which is the lowest percentage in any DSRIP region.

In the Tug Hill Seaway, 35% of the population are on some type of public health insurance (the third highest percentage in any DSRIP region), 23% are on Medicaid, and 10% have no health insurance coverage. Special populations include 14% that are disabled and 12% that are Veterans. This is the second highest percentage of disabled and the highest percentage of Veterans in any DSRIP region. The 4% of the region’s population that are foreign born, 7% that speak a primary language other than English, and 2% who speak English less than “very well” are the second lowest percentages in any DSRIP region.

Health Care Resources Maldistributions and shortages of health care providers in the Tug Hill Seaway region are recognized by federal Health Resources and Services Administration (HRSA) health professional shortage area (HPSA) designations. All counties in the region have primary care Medically Underserved Area/ Population (MUA/P) designations, which include their Medicaid eligible populations. Each of the counties has a whole county mental health (MH) professional shortage designation and MH professional MUA/P designations. The Medicaid eligible populations in Jefferson and St. Lawrence counties are designated MH professional MUPs. The region has 437 licensed MH professionals or 17 per 10,000 population, which is the second lowest in any DSRIP region. Lewis County has 13 licensed MH professionals per 10,000, which is the second lowest rate in any NYS county.

Total psychiatric bed capacity in the region is 63 per 100,000 adults (the third highest in all DSRIP regions) and 39 per 100,000 children. The total average daily census (ADC) per 100,000 adults is 49 (the second highest in any DSRIP region), and the total ADC per 100,000 children is also 49 (the highest in any DSRIP region). Only the acute care hospitals in St. Lawrence County have chemical dependence rehab and detox beds.

The region has one SUD inpatient crisis program and two inpatient rehabilitation programs located in St. Lawrence County. The region’s six residential programs are located in Jefferson and St. Lawrence counties. These SUD programs have a total capacity of seven per 10,000 and an average daily enrollment (ADE) of six per 10,000, which are the third highest rates in all DSRIP regions. The Tug Hill Seaway is the only DSRIP region with no opioid treatment programs.

Health Status Challenges Among all DSRIP regions, the Tug Hill Seaway region has the highest: 1) Average percentages of adults with diabetes and/or who are overweight or obese.

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2) Average rate of premature death from stroke. The rate in Lewis County is the second highest in any NYS county. 3) Average death rate from cirrhosis of the liver. 4) Average percentage of adults who report binge drinking. Jefferson and St. Lawrence counties have the highest percentages of binge drinking among all NYS counties.

Compared to all DSRIP regions, the Tug Hill Seaway the second highest: 1) Average percentage of adults with high blood pressure. 2) Average death rates from accidents and suicide. Lewis County’s death rate from suicide is the highest in any NYS county.

The Tug Hill Seaway region has the third highest average death rate from diabetes among all DSRIP regions.

Behavioral Health Care Utilization Challenges Compared to all DSRIP regions, the Tug Hill Seaway region has the largest percentages of Medicaid beneficiaries with: 1) Inpatient admissions for alcohol use disorder, drug abuse: cannabis/NOS/NEC, and other SUD diagnoses. 2) ER visits for other SUD diagnoses.

Unmet Service Needs Measures of behavioral health medication management suggest unmet need in the region. Sixty percent of adults with schizophrenia adhere to anti-psychotic medications (40% do not). Region-wide, 55% of individuals with major depression remain on anti-depressant medication during the entire acute treatment phase and 37% remain on these medications during continuation phase treatment (63% do not). More than half (59%) of children prescribed ADHD medication have one follow-up visit with a practitioner within 30 days after starting the medication. Sixty-one percent of children with a new prescription for ADHD medication remain on the medication for seven months and/or have at least two follow-up visits in the nine month period after the initiation phase.

Follow-up care after hospitalization for mental illness and engagement in alcohol and other drug dependence (AOD) treatment also suggest unmet need. After hospitalization for mental illness, 32% of individuals have follow-up care within 7 days of discharge (68% do not) and 46% follow-up within 30 days (54% do not). These are the lowest rates of follow-up care after hospitalization for mental illness in all DSRIP regions. Twenty-four percent of individuals engage in AOD treatment within 30 days after initiation (76% do not). With regard to physical health, the Tug Hill Seaway’s rates of potentially avoidable hospital admissions for chronic diseases are highest among all regions and suggest a need for further outpatient resources.

Consumer and Provider Input Tug Hill Seaway region counties’ surveys of consumer and provider stakeholders to assess local needs indicate that access to crisis services and treatment services are issues that need attention for the populations with mental health and/or chemical dependency concerns.

Two clinics in the Tug Hill Seaway region surveyed a total of 578 consumers and 42 providers to assess local needs. The needs most frequently reported by both consumers and providers include: transportation to health care services; assistance with paying for services; reduced wait times for an appointment; convenient provider hours (evenings and weekends); behavioral health services for children; and local clinical training.

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I. Description of Communities to Be Served

1. Geographic Service Area The Tug Hill Seaway DSRIP region is in northwestern New York State and is east of Lake Ontario and west of the Adirondack Mountains. It includes three counties: Jefferson, Lewis, and St. Lawrence.

Overall, more than a quarter of a million people live in the region (Table 1). Estimated county populations range from 27,054 in Lewis County to 116,361 in Jefferson County. Two of the region’s counties have been designated rural by the U.S. Office of Management and Budget (OMB).1

Table 1. Tug Hill Seaway Region: Population Size, Density and Urban/Rural County Designations US Census ACS Population OMB County 2010-2014 Est. Density per Urban/Rural 1 Population Square Mile Designation Jefferson 116,361 91.7 Urban Lewis 27,054 21.2 Rural St. Lawrence 111,895 41.7 Rural Totals 255,310 48.9 Data is from the U.S. Department of Health and Human Services, Health Resources Services Administration Data Warehouse. Retrieved April 14, 2016 from http://datawarehouse.hrsa.gov/ tools/analyzers/geo/Rural.aspx

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Population density per square mile ranges from 21.2 in Lewis County to 91.7 in Jefferson County. The Tug Hill Seaway region has the second lowest population density of any DSRIP region and is among the most rural.

2. Population Characteristics

A. Gender, Race, Ethnicity and Age In the Tug Hill Seaway region slightly less than half (49%) of the population are female (Table 2).

Table 2. Tug Hill Seaway Region: Gender, Race/Ethnicity and Age American Community Survey Data 2010-2014 US Census ACS Gender Race/Ethnicity Age County 2010-2014 Est. African Hispanic or 19 and 65 and Population Male Female White Asian Other* American Latino Ethnicity Under Over Jefferson 116,361 52% 49% 87% 5% 1% 6% 6% 28% 11% Lewis 27,054 50% 50% 98% 1% 0% 1% 1% 27% 15% St. Lawrence 111,895 51% 49% 94% 3% 1% 3% 2% 27% 13% Totals 255,310 51% 49% 91% 3% 1% 4% 4% 27% 12% *Other includes American Indian and Alaska Native, Native Hawaiian and other Pacific Islander, some other race, and two or more races

The population in the region is primarily White with percentages varying from a low of 87% in urban Jefferson County to a high of 98% in rural Lewis County. The Tug Hill Seaway region is one of the least racially and ethnically diverse regions in NYS. Three percent of the region’s population are African American, 1% are Asian, and 4% each are some other race or of Hispanic or Latino ethnicity. More than a quarter of the region’s population are age 19 and under (27%, the largest percentage in any DSRIP region) and 12% are age 65 and over.

B. Income, Education, Unemployment and Poverty The median household income in the Tug Hill Seaway region is $44,953 (Table 3). Median household income ranges from a low of $43,508 in St. Lawrence County to a high of $46,123 in Jefferson County. The Tug Hill Seaway has the lowest median household income in any DSRIP region, and it is well below the New York State median household income of $58,687.2

Table 3. Tug Hill Seaway Region: Income, Education, Unemployment and Poverty American Community Survey Data 2010-2014 US Census ACS Educational Attainment1 Unemployment and Indicators of Poverty Median County 2010-2014 Est. Household Less than High Bachelor's Below Poverty On Cash Public On Food Stamps/ Population Unemployed2 Income School Degree or Higher Level Assistance SNAP Benefits Jefferson 116,361 46,123 12% 20% 7% 15% 2% 14% Lewis 27,054 45,229 13% 14% 7% 13% 2% 14% St. Lawrence 111,895 43,508 14% 20% 7% 20% 4% 14% Totals 255,310 44,953 13% 18% 7% 17% 3% 14% 1 Educational attainment are calculated based on population 25 years and older. 2 Unemployment data is the average for 2015 and is from the NYS Department of Labor.

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Thirteen percent of the Tug Hill Seaway region population age 25 and older does not have a high school diploma, and 18% have a bachelor’s degree or higher (the smallest percentage in any DSRIP region). Percentages of adults without a high school diploma are similar across counties. The percentage of adults with a bachelor’s degree or more range from a low of 14% in Lewis County (the smallest percentage in any NYS county) to a high of 20% each in Jefferson and St. Lawrence counties.

The Tug Hill Seaway region has a 7% unemployment rate (the highest percentage in any DSRIP region) and 17% of the region’s population live below the poverty level (the second highest percentage in any DSRIP region). Three percent of the region’s population are on cash public assistance and 14% receive food stamps/SNAP benefits (the second highest percentage in any DSRIP region).

C. Health Insurance Status In the Tug Hill Seaway region more than a third of the population are on some type of public health insurance3 and 10% of the population have no health insurance coverage (Table 4). The percentages of the population on public health insurance and with no health insurance coverage are both similar across counties.

Table 4. Tug Hill Seaway Region: Health Insurance Status American Community Survey Data 2010-2014 US Census ACS County 2010-2014 Est. Public Health No Health Unemployed Unemployed Population Insurance1 Insurance w/Public Health w/No Health Coverage Coverage Insurance Insurance Jefferson 116,361 35% 9% 27% 38% Lewis 27,054 34% 11% 25% 41% St. Lawrence 111,895 36% 11% 35% 30% Totals 255,310 35% 10% 31% 35% 1 Public coverage includes Medicare, Medicaid and other federal medical assistance programs; VA Health Care; the Children’s Health Insurance Program (CHIP); and individual state health plans.

Among the region’s unemployed, 31% are on public health insurance and more than a third have no health insurance. While the rates of the unemployed on public health insurance are generally less than those of the general population, the rates of the unemployed with no health insurance are more than three times as high as the general population (35% compared to 10%). The Tug Hill Seaway region’s percentage of unemployed with no health insurance is the highest in any DSRIP region.

Medicaid Population Nearly one quarter (23%) of the estimated population in the Tug Hill Seaway region are Medicaid beneficiaries (Table 5). By county, Medicaid beneficiaries range from a low of 21% each of the populations in Jefferson and Lewis counties to a high of 25% of the population in St. Lawrence County.

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Table 5. Tug Hill Seaway Region: Medicaid Beneficiaries as Percentage of Total Population US Census % Est. Population Total # Medicaid County ACS 2010-2014 Receiving Beneficiaries Est. Population Medicaid Jefferson 116,361 24,990 21% Lewis 27,054 5,574 21% St. Lawrence 111,895 28,013 25% Totals 255,310 58,577 23% Data is from the NYS Department of Health’s Medicaid Beneficiaries Inpatient Admissions and Emergency Room Visits data base; 2012 data. Retrieved May 12, 2016 from https://health.data.ny.gov/ Health/Medicaid-Beneficiaries- Inpatient-Admissions-and-Em/m2wt-pje4#About

In the Tug Hill Seaway region, 66% of Medicaid beneficiaries are adults and 34% are children (Table 6). By county, adult Medicaid beneficiaries range from a low of 65% in Lewis County to a high of 67% in St. Lawrence County.

Medicaid beneficiaries include individuals that receive Medicaid only and dual-eligible individuals that receive both Medicare and Medicaid benefits by virtue of their age or disability and low incomes.4 In the Tug Hill Seaway region, 82% of Medicaid beneficiaries receive Medicaid only and 18% are dual-eligible. Medicaid only beneficiaries range from a low of 80% in Lewis County to a high of 83% in Jefferson County.

Table 6. Tug Hill Seaway Region: Medicaid Beneficiaries by Population and Eligibility Type All Medicaid Medicaid Population Eligibility Type Dual Medicaid County Beneficiaries Adults Children Medicaid Only and Medicare # # % # % # % # % Jefferson 24,990 16,375 66% 8,615 34% 20,688 83% 4,302 17% Lewis 5,574 3,607 65% 1,967 35% 4,483 80% 1,091 20% St. Lawrence 28,013 18,789 67% 9,224 33% 22,757 81% 5,256 19% Totals 58,577 38,771 66% 19,806 34% 47,928 82% 10,649 18% Data is from the NYS Department of Health’s Medicaid Beneficiaries Inpatient Admissions and Emergency Room Visits data base; 2012 data. Retrieved May 12, 2016 from https://health.data.ny.gov/ Health/Medicaid-Beneficiaries-Inpatient-Admissions-and-Em/m2wt- pje4#About

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D. Special Populations, Foreign Born and Primary Language In the Tug Hill Seaway region, 14% of the population are disabled and 12% are Veterans, which are the highest percentages in any DSRIP region (Table 7). There are 257 children 19 years and younger in foster care and 312 individuals in jail in the region. Four percent of the population are foreign born, which is the smallest percentage in any DSRIP region.

Table 7. Tug Hill Seaway Region: Special Populations and Foreign Born American Community Survey Data 2010-2014 US Census ACS Special Populations County 2010-2014 Est. In Foster Foreign Born Population Disabled Veterans In Jail2 Care1 Jefferson 116,361 14% 14% 96 127 4% Lewis 27,054 13% 12% 13 31 2% St. Lawrence 111,895 15% 9% 148 154 4% Totals 255,310 14% 12% 257 312 4% 1 Foster care data includes individuals 19 and under during the 2014 calendar year and is from the NYS Office of Children and Families. 2Jail data is for 2014 calendar year and is from the NYS Division of Criminal Justice Services.

Table 8 describes the primary languages spoken at home and those who speak English less than ”very well” in the population aged five years and older. In the region, 93% of this population speak English as their primary language (the second highest percentage in any DSRIP region), 3% speak other Indo-European languages, 2% speak Spanish, 1% speak Asian and Pacific Islander languages, and 2% speak English less than “very well” (the lowest percentage in any DSRIP region).

Table 8. Tug Hill Seaway Region: Primary Language Spoken at Home American Community Survey Data 2010-2014 US Census ACS 2010-2014 Est. Language Spoken at Home County Asian and Speak English Population 5 Other Indo- English Spanish Pacific Other less than "very Years and Older European Islander well" Jefferson 107,452 92% 3% 3% 1% 0% 2% Lewis 25,339 97% 1% 2% 0% 0% 1% St. Lawrence 105,502 93% 2% 4% 1% 0% 2% Totals 238,292 93% 2% 3% 1% 0% 2%

Percentages of the population aged five and over that speak English as their primary language range from a low of 92% in Jefferson County to a high of 97% in Lewis County (the highest percentage in any NYS county). Those who speak English less than “very well” range from a low of 1% in Lewis County to a high of 2% each in Jefferson and St. Lawrence counties.

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1 Urban areas (metro areas) are geographic entities defined by the U.S. Office of Management and Budget (OMB) for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics. An urban area includes one or more counties containing a core urban area of 50,000 or more people, together with any adjacent counties that have a high degree of social and economic integration (as measured by commuting to work) with the urban core. The OMB defines rural as all counties outside metropolitan areas based on 2010 census data. There are currently 24 counties designated rural in New York State. Retrieved April 14, 2016 from http://datawarehouse.hrsa.gov/tools/analyzers/geo/Rural.aspx 2 Retrieved April 14, 2016 from http://www.census.gov/quickfacts/table/RHI225214/36 3 Public coverage includes the federal programs Medicare, Medicaid and other medical assistance programs, VA Health Care; the Children’s Health Insurance Program (CHIP); and individual state health plans. Retrieved April 14, 2016 from https://www.census.gov/hhes/www/hlthins/methodology/definitions/acs.html 4 In this analysis dual status was based upon the last month of enrollment/eligibility during the year. If the Medicaid beneficiary was indicated as being eligible for Part A, B, C or D Medicare services they are classified as dual eligible. The dual-eligible Medicare and Medicaid population is diverse and includes individuals with multiple chronic conditions, physical disabilities, and cognitive impairments such as dementia, developmental disabilities, and mental illness. It also includes some individuals who are relatively healthy. Retrieved May 12, 2016 from http://www.medpac.gov/documents/data-book/january- 2015-medpac-and-macpac-data-book-beneficiaries-dually-eligible-for-medicare-and-medicaid.pdf

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II. Physical and Behavioral Health Care Resources

This section describes physical and behavioral health care resources in the Tug Hill Seaway DSRIP region. Its findings should be considered with those in Sections V and VI of this report, which describe unmet service need by DSRIP region.

Physical Health Care Resources

1. Inpatient Physical Health Care Facilities The Tug Hill Seaway DSRIP region has four acute care hospitals and 10 nursing homes that provide inpatient health care (Table 1).

Table 1. Tug Hill Seaway Region: Inpatient Physical Health Care by Certified Beds Acute Care Hospitals Nursing Homes # Certified Beds # Certified Beds County Total # Chemical Chemical # Nursing # Hospitals BH Intervention All Bed Dependence Dependence Psychiatric Homes Total Beds Beds Types Rehab Detox Jefferson 1 290 0 0 32 4 559 0 Lewis − − − − − 1160 0 St. Lawrence 3 274 17 7 28 5 658 0 Totals 4 564 17 7 60 10 1,377 0 Acute care hospital data is from the NYS Open Data Health Facility General Information dataset. Retrieved April 12, 2016 from https://health.data.ny.gov/Health/Health-Facility-General-Information/vn5v-hh5r . Nursing home data is from the NYS Open Data Nursing Home Profile dataset. Retrieved April 12, 2016 from https://health.data.ny.gov/Health/Nursing-Home-Profile/dypu-nabu

In the Tug Hill Seaway region, only Jefferson and St. Lawrence counties have acute care hospitals. The region has a total of 564 beds where physical health care is the primary type of care provided. Among those beds are 60 psychiatric beds, 17 chemical dependence rehab beds, and seven chemical dependence detox beds.

The region’s 10 nursing homes have a total of 1,377 beds, but no behavioral health intervention beds.1 All counties in the region have at least one nursing home.

2. Outpatient Physical Health Care Facilities In the Tug Hill Seaway region, all of the counties have certified home health care facilities (n=5), and Jefferson and St. Lawrence counties each has one long-term home health care facility (Table 2). All of the counties, except St. Lawrence, have an ambulatory surgical center.

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Table 2. Tug Hill Seaway Region: Outpatient Physical Health Care Home Health Care Primary Health Care Ambulatory Diagnostic and Federally Certified Long-term School-based County Surgical Centers Treatment Qualified Home Health Home Health Health Centers Centers Health Centers # Facilities Jefferson 2 1 1 7 6 1 Lewis 1 0 1 0 1 1 St. Lawrence 2 1 0 2 4 2 Totals 5 2 2 9 11 4 Ambulatory surgical center data is from the NYS HCRA Provider List dataset. Retrieved April 12, 2016 from https://www.health.ny.gov/regulations/hcra/provider/provamb.htm. Federally qualified HC data is from the HRSA Data Warehouse. Retrieved April 21, 2016 from http://datawarehouse.hrsa.gov/tools/hdwreports/Filters.aspx?id=60#. All other data is from the NYS Open Data Health Facility General Information dataset. Retrieved April 12, 2016 from https://health.data.ny.gov/Health/ Health- Facility-General-Information/vn5v-hh5r .

There are three types of institutional providers that provide primary care: school-based health centers, diagnostic and treatment centers,2 and federally qualified health centers.3 All Tug Hill Seaway counties have diagnostic and treatment and federally qualified health centers. Collectively, the counties have 11 diagnostic and treatment centers, and four federally qualified health centers. Jefferson County has seven school- based health centers and St. Lawrence has two.

3. Physical Health Care Practitioners Physical health care providers include primary care providers, medical specialists, dentists, and physical rehabilitation specialists. Health practitioners in primary care and medical specialties include physicians, physician assistants, and nurse practitioners.

Primary Care Providers In the Tug Hill Seaway region, family medicine providers include 141 physicians and a total of 179 nurse practitioners and physician assistants (Table 3). The number of family medicine providers of all types is lowest in Lewis County (n=42) and highest in St. Lawrence County (n=157). Family medicine health care providers are the largest group of primary care providers in the region.

Internal medicine providers include 85 physicians and a total of 49 nurse practitioners and physician assistants. The number of internal medicine physicians is highest in St. Lawrence County (n=53) and lowest in Lewis (n=4). Internal medicine nurse practitioners and physician assistants are found in the greatest numbers in Jefferson County (n=27) and the fewest are in Lewis County (n=3).

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Table 3. Tug Hill Seaway Region: Primary Care Providers

US Census Family Internal Total per Pediatrics County ACS 2010-2014 Medicine Medicine Total 10,000 Est. Population population MD/DO NP/PA MD/DO NP/PA MD/DO NP/PA Jefferson 116,361 52 69 28 27 41 21 238 20 Lewis 27,054 25 17 4 3 2 2 53 20 St. Lawrence 111,895 64 93 53 19 24 8 261 23 Totals 255,310 141 179 85 49 67 31 552 22 MD=medical doctor; DO=doctor of osterpathy; NP=nurse practitioner; PA=physician assistant. Data is from the DSRIP Managed Care Provider Network Database. Retrieved April 21, 2016 from https://www.health.ny.gov/health_care/ medicaid/redesign/providernetwork/

Throughout the Tug Hill Seaway region, there are 67 physicians providing pediatric care and 31 pediatric nurse practitioners and physician assistants. The number of pediatric health providers is highest in Jefferson County (n=62) and lowest in Lewis County (n=4).

The maldistribution of primary care providers in the Tug Hill Seaway region is made clearer by looking at the number of providers per 10,000 population in the region’s counties. Jefferson and Lewis counties each has 20 primary care providers per 10,000 population and St. Lawrence County has 23. The region’s 22 primary care providers per 10,000 population is the lowest rate in any DSRIP region.

The maldistribution is also recognized by designations of county health professional shortage areas (HPSAs) made by the federal Health Resources and Services Administration (HRSA).4 In addition to county wide shortage area designations, HRSA also makes county census tract, special population, and health care facility shortage designations. Table 3a describes all of the HRSA primary care professional shortage designations for the counties in the Tug Hill Seaway region.

Table 3a. Tug Hill Seaway Region: HRSA Primary Care Health Professional Shortage Designations Census tract, Medicaid Eligible Low Income Whole County populations or County population Population facilities Jefferson Yes Yes Lewis Yes Yes St. Lawrence Yes Yes HRSA federal shortage designations retrieved March 17, 2016 from http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx

All counties in the Tug Hill Seaway region have a census tract, population or facility designated as a primary care Medically Underserved Area/Population (MUA/P). The counties’ Medicaid eligible populations have been designated primary care MUPs.

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Physical Health Medical Specialists The Tug Hill Seaway region has a total of 225 physical medical health specialists or nine providers per 10,000 population, which is the second lowest rate in any DSRIP region (Table 4).

Table 4. Tug Hill Seaway Region: Physical Medical Specialists Cardiology and Endocrinology and US Census ACS Allergy and Obstetrics and Total per Other Cardiology Other Endocrinology General Surgery County 2010-2014 Est. Immunology Gynecology Total 10,000 Specialties Related Specialties population Population MD/DO NP/PA MD/DO NP/PA MD/DO NP/PA MD/DO NP/PA MD/DO NP/PA Jefferson 116,361 3 2 13 6 1 5 26 8 24 8 96 8 Lewis 27,054 0 0 11 5 0 0 9 5 4 1 35 13 St. Lawrence 111,895 0 0 28 1 0 0 23 15 25 2 94 8 Total 255,310 3 2 52 12 1 5 58 28 53 11 225 9 MD=medical doctor; DO=doctor of osterpathy; NP=nurse practitioner; PA=physician assistant. Data is from the DSRIP Managed Care Provider Network Database. Retrieved April 21, 2016 from https://www.health.ny.gov/health_care/medicaid/redesign/providernetwork/

Allergy and immunology providers (n=5) and endocrinology providers (n=6) are in shortest supply, while those in obstetrics and gynecology (n=86) are most prevalent, followed by cardiology and general surgery (n=64 each). The number of medical specialists is highest in Jefferson County (n=96) and lowest in Lewis County (n=35).

Dentists In the Tug Hill Seaway region there is a total of 89 dentists serving the population of 255,310 residents (Table 5). The number of dentists ranges from a low of 11 in Lewis County to a high of 56 in Jefferson County. Region-wide there are three dentists per 10,000 population, which is the second lowest rate in any DSRIP region.

Table 5. Tug Hill Seaway Region: Dentists Number of Dentists US Census Per 10,000 County ACS 2010-2014 General Specialist Total Population Est. Population Dentist Dentist

Jefferson 116,361 49 7 56 5 Lewis 27,054 11 0 11 4 St. Lawrence 111,895 14 8 22 2 Totals 255,310 74 15 89 3 Data is from the DSRIP Managed Care Provider Network Database. Retrieved April 21, 2016 from https://www.health.ny.gov/health_care/medicaid/redesign/providernetwork/

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Physical Rehabilitation Specialists In the Tug Hill Seaway region there is a total of 102 physical rehabilitation specialists serving the population of 255,310 residents (Table 6).

Table 6. Tug Hill Seaway Region: Physical Rehabilitation Specialists Total per US Census ACS Occupational Physical Speech County 2010-2014 Est. Total 10,000 Therapy Therapy Therapy Population population Jefferson 116,361 6 42 2 50 4 Lewis 27,054 0 11 0 11 4 St. Lawrence 111,895 2 38 1 41 4 Totals 255,310 8 91 3 102 4 Data is from the DSRIP Managed Care Provider Network Database. Retrieved April 21, 2016 from https://www.health.ny.gov/health_care/medicaid/redesign/providernetwork/

In the region, speech therapists (n=3) and occupational therapists (n=6) are in shortest supply, while physical therapists are most prevalent (n=91). The number of physical rehabilitation specialists ranges from a low of 11 in Lewis County to a high of 50 in Jefferson County. Region-wide there are four physical rehabilitation specialists per 10,000 population, the lowest rate in any DSRIP region.

Behavioral Health Care Resources

4. Inpatient Behavioral Health Care Facilities and Programs The data presented in this section is by county of provider location, with the exception of psychiatric inpatient average daily census, which is by patient county of residence. Individuals may access services in a county other than the county in which they reside.

Mental Health Inpatient Facilities The Tug Hill Seaway region has a total of 117 adult psychiatric beds and 27 psychiatric beds for children (Table 7).5 The adult psychiatric beds are located in Jefferson and St. Lawrence counties. The psychiatric beds for children are located in St. Lawrence County. In the region, St. Lawrence County has the largest number of adult beds (n=85). Total psychiatric bed capacity in the region is 63 per 100,000 adults and 39 per 100,000 children. The psychiatric bed capacity rate for adults is the third highest in all DSRIP regions.

In the Tug Hill Seaway region the total inpatient average daily census (ADC) for adult beds is 90, and the ADC for child beds is 34, which is larger than the total number of child inpatient beds (n=27). St. Lawrence County has the highest total ADC for adults (n=58) and Lewis County has the lowest (n=3). Similarly, St. Lawrence County has the highest total ADC for children (n=19) and Lewis County has the lowest (n=3).

In the region the total ADC per 100,000 adults is 49, which is the second highest rate in any DSRIP region. The total ADC per 100,000 children is also 49, which is the highest rate in any DSRIP region. For adults the total ADC per 100,000 adults is highest for

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residents of St. Lawrence County (n=71, third highest in any NYS county) and lowest for residents of Lewis County (n=15). In comparison, the total ADC per 100,000 children is highest for residents of St. Lawrence County (n=65, third highest in any NYS county) and lowest for residents of Jefferson (n=37).

Table 7. Tug Hill Seaway Region: Total Psychiatric Inpatient Bed Capacity by Provider County and Average Daily Census by Patient County of Residence - Adults - - Children - Total Total Total County Total Bed Total Bed Total Inpatient Capacity per Inpatient Total ADC Inpatient Capacity per Inpatient Total ADC Beds1 100,000 ADC2,3 per 100,0004 Beds1 100,000 ADC per 100,0004 Jefferson 32 38 29 35 0 0 12 37 Lewis 00 3 15 0 0 3 41 St. Lawrence 85 104 58 71 27 91 19 65 Totals 117 63 90 49 27 39 34 49 Notes: 1. Includes General Hospital, Private Psychiatric Hospital and State Psychiatric Centers’ budgeted capacity for the county of the providers. Children’s capacity includes residential treatment facility (RTF) beds for the county of the providers. 2. Average Daily Census (ADC) covers General, Private Psychiatric, State Psychiatric hospital and RTF (children only). 3. ADC is shown for patient county of residence. 4. The ADC per 100,000 population of adults or children as indicated. Data Sources: Capacity -- General Hospital and Private Psychiatric Hospital current capacity: NYSOMH CONCERTS database, 10/2015. Current capacity includes all beds licensed for operation as of that date. State Psychiatric Center budgeted capacity: NYSOMH MHARS EHR, 10/2015. RTF capacity: NYSOMH CAIRS database, 10/2015. US Census 2014 Est. Populations. Average Daily Census -- General Hospital (Art. 28): SPARCS, CY 2014. Private Psychiatric Hospital (Art. 31): Medicaid, CY 2014. Institutional Cost Report (ICR), CY 2014: county distribution using the 2013 Patient Characteristics Survey (PCS). State Psychiatric Centers: MHARS, CY 2014. RTF: CAIRS, CY 2014. US Census 2014 estimates.

Substance Use Disorder Inpatient Programs In New York State substance use disorder (SUD) inpatient programs include crisis, inpatient rehabilitation, and residential programs.6 In the Tug Hill Seaway region (Table 8) there is one SUD crisis program and two inpatient rehabilitation programs located in St. Lawrence County. The region’s six residential programs are located in Jefferson (n=4) and St. Lawrence counties.

Table 8. Tug Hill Seaway Region: Substance Use Disorders Inpatient Program Capacity

US Census Inpatient Programs Total ACS 2010- Inpatient Total County Crisis Residential Capacity 2014 Est. Rehabilitation* Capacity per 10,000 Population # Programs Capacity # Programs Capacity # Programs Capacity Jefferson 116,361 –– – – 466 66 6 Lewis 27,054 – – – – – – – – St. Lawrence 111,895 1 7 2 57 2 45 109 10 Totals 255,310 1 7 2 57 6 111 175 7 Notes and Data Sources: *Includes State Addiction Treatment Centers. Data is from the NYS Office of Alcoholism and Substance Abuse Services (OASAS) Provider Directory System. Includes programs that were operational as of April 2, 2016. More information about OASAS inpatient programs is available at http://www.oasas.ny.gov/hps/state/CD_descriptions.cfm

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 533 New York State Office of Mental Health

The region’s crisis program capacity is seven (the second lowest in any DSRIP region), inpatient rehabilitation capacity is 57 (the third lowest in any DSRIP region), and its residential capacity is 111. The regional capacity per 10,000 for all SUD inpatient programs is seven.

Table 9 describes the average daily enrollment (ADE) in these programs. The ADE in the region for crisis is six, inpatient rehabilitation is 47 and 94 for residential. The regional ADE per 10,000 for these programs is six.

Table 9. Tug Hill Seaway Region: Substance Use Disorders Inpatient Program Average Daily Enrollment Inpatient Programs US Census Total Avg. Inpatient Total Avg. ACS 2010- Crisis Residential Daily County Daily 2014 Est. Rehabilitation* Enrollment Avg. Daily Avg. Daily Avg. Daily Enrollment Population # Programs # Programs # Programs per 10,000 Enrollment Enrollment Enrollment Jefferson 116,361 – – – – 4 60 60 5 Lewis 27,054 – – – – – – – – St. Lawrence 111,895 1 6 2 47 2 34 88 8 Totals 255,310 1 6 2 47 6 94 148 6 *Includes State Addiction Treatment Centers. Data is from the NYS Office of Alcoholism and Substance Abuse Services (OASAS) Provider Directory System. Includes programs that were operational as of April 2, 2016.

5. Outpatient Behavioral Health Care Services The data presented here is by county of provider location. Individuals may access services in a county other than the county in which they reside.

Mental Health Outpatient and Clinic Programs

Adults Adult mental health outpatient programs include: assertive community treatment (ACT), clinic, continuing day treatment (CDT), intensive psychiatric rehabilitative treatment (IPRT), partial hospitalization (PH), and personalized recovery-oriented services (PROS). The Tug Hill Seaway region’s capacity and service use in these programs are presented in Table 10.

Outpatient programs (other than clinic) are located in St. Lawrence County. There is a total of 48 non-clinic outpatient program slots in the region or 26 slots per 100,000 adults, the lowest rate in any DSRIP region.

Clinics may be locally- or state-operated. All counties in the region have locally- operated clinics. These clinics served a total of 2,598 adult Medicaid recipients and 1,036 adult non-Medicaid recipients. In the region, 3,019 adults received clinic treatment per 100,000 adults, the second highest rate in any DSRIP region.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 534 New York State Office of Mental Health

St. Lawrence County’s rate of 4,460 adults per 100,000 adults is the third highest rate in any NYS county. Jefferson County’s service rate of 1,743 adults per 100,000 adults is the lowest in the region.

Table 10. Tug Hill Seaway Region: Adult Mental Health Outpatient Capacity and Service Use by Provider County Outpatient Programs Clinics: Total Number of Adults (PH, IPRT, CDT, PROS, ACT) Locally Operated Clinics Recipients in Clinic Treatment County Slots Non-Medicaid Capacity1 Medicaid State-operated per 100,000 per 100,000 2 Recipients 4 5 (Slots) 5 Recipients Clinics Adults Adults (Estimated #)3 Jefferson ─ ─ 899 560 ─ 1,743 Lewis ─ ─ 247 240 ─ 2,483 St. Lawrence 48 59 1,452 236 1,943 4,460 Totals 48 26 2,598 1,036 1,943 3,019 Notes and Data Sources: Clinics are not licensed for specific slot capacities, therefore size is measured by estimated total number of persons served annually. 1. Includes the total capacity for Partial Hospitalization (PH), Intensive Psychiatric Rehabilitative Treatment (IPRT), Continuing Day Treatment (CDT), Personalized Recovery-Oriented Services (PROS) and Assertive Community Treatment (ACT) (Data Source: New York State Office of Mental Health (NYSOMH) CONCERTS database, 10/2015). 2. Includes adults and children enrolled in Medicaid and served annually in non-State clinic programs (Data Source: Medicaid, CY 2014). 3. Includes annual estimate of adults not receiving Medicaid and served in non-State clinics during the NYSOMH 2013 Patient Characteristics Survey (PCS). 4. Includes adults served annually in State-run clinics (Data Source: NYSOMH MHARS database, CY 2014). 5. US Census 2014 estimates.

Children Mental health outpatient programs that serve children include: assertive community treatment (ACT), clinic, day treatment (DT), and partial hospitalization (PH). The Tug Hill Seaway region’s capacity and service use in these programs are presented in Table 11.

Table 11. Tug Hill Seaway Region: Child Mental Health Outpatient Capacity and Service Use by Provider County Outpatient Programs Clinics: Total Number of Children (PH, DT, ACT) Locally Operated Clinics Recipients in Clinic Treatment County Slots Non-Medicaid Capacity1 Medicaid State-operated per 100,000 per 100,000 Recipients 4 5 (Slots) Recipients2 Clinics Children Children5 3 (Estimated #) Jefferson 24 74 264 300 1,730 ─ Lewis ─ ─ 71 64 ─ 1,853 St. Lawrence 12 40 624 88 589 4,368 Totals 36 52 959 452 589 2,871 Notes and Data Sources: Clinics are not licensed for specific slot capacities, therefore size is measured by estimated total number of children served annually. 1. Includes the total capacity for Partial Hospitalizations (PH), Day Treatment (DT) and Children's Assertive Community Treatment (ACT) (Data Source: New York State Office of Mental Health (NYSOMH) CONCERTS database, 10/2015). 2. Includes children enrolled in Medicaid and served annually in locally-operated (non-State) clinic programs (Data Source: Medicaid, CY 2014). 3. Includes annual estimate of children not receiving Medicaid and served in locally-operated (non-State) clinics during the week of the NYSOMH 2013 Patient Characteristics Survey (PCS). 4. Includes children served annually in State-run clinics (Data Source: NYSOMH MHARS database, CY 2014). 5. US Census ACS 2010-2014 Est. Population.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 535 New York State Office of Mental Health

There are child outpatient programs (other than clinic) in Jefferson and St. Lawrence counties. There is a total of 36 non-clinic outpatient program slots in the region or 52 slots per 100,000 children.

There are locally-operated clinics in all counties in the region and state-operated clinics in St. Lawrence County. The locally-operated clinics served a total of 959 Medicaid child recipients and 452 non-Medicaid child recipients, and the state-operated clinics served a total of 589 child recipients.

In the Tug Hill Seaway region, 2,871 children received clinic treatment per 100,000 children, which is the third highest rate in any DSRIP region. St. Lawrence County’s rate of 4,368 children per 100,000 children is the highest in the region and the third highest in any NYS county. Jefferson County’s service rate of 1,730 children per 100,000 children is the lowest in the region.

Mental Health Emergency and Community Support Programs

Adults Table 12 describes the Tug Hill Seaway region’s service use in adult mental health emergency and community support programs. A total of 2 adults were served in emergency programs located in St. Lawrence County. In the region one adult received emergency services per 100,000 adults, which is the lowest rate in any DSRIP region.

Table 12. Tug Hill Seaway Region: Adult Mental Health Emergency Programs and Community Support Programs by Provider County Emergency Programs Community Support Programs County # Served per # Adults # Served per # Adults Served 100,000 Adults Served 100,000 Adults Jefferson ─ ─ 113 126 Lewis ─ ─ 24 115 St. Lawrence 2 2 194 224 Totals 2 1 331 179 Data Sources: Includes adults receiving emergency services and support services (e.g., vocational, self-help, care coordination) as reported by the New York State Office of Mental Health 2013 Patient Characteristics Survey (PCS). US Census ACS 2010-2014 Est. Population. Service use is reported because there are no licensed capacities for nearly all of these programs.

There are adult community support programs (e.g., vocational, self-help and care coordination) in each county in the Tug Hill Seaway region which served 331 adults. In the region, 179 adults per 100,000 adults received services from community support programs. In the counties service rates per 100,000 adults ranged from a low of 115 in Lewis County to a high of 224 in St. Lawrence County.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 536 New York State Office of Mental Health

Children The Tug Hill Seaway region’s service use in child mental health emergency and community support programs is presented in Table 13. The region has no emergency programs for children.

Community support programs for children (e.g., vocational, home-based family treatment, and residential treatment facility transition) are located in all counties in the region and served 113 children. These programs served 162 children per 100,000 children. In the counties service rates per 100,000 children ranged from a low of 92 in St. Lawrence County to a high of 257 in Jefferson.

Table 13. Tug Hill Seaway Region: Child Mental Health Emergency

Programs and Community Support Programs by Provider County

Community Support Emergency Programs Programs County # Children # Served per # Children # Served per

Served 100,000 Children Served 100,000 Children

Jefferson ─ ─ 76 257

Lewis ─ ─ 14 221 St. Lawrence ─ ─ 23 92 Totals ─ ─ 113 162 Data Sources: Includes children receiving emergency services and support services (e.g., vocational, home-based family treatment, residential treatment facility transition) as reported by the New York State Office of Mental Health 2013 Patient Characteristics Survey (PCS). US Census ACS 2010-2014 Est. Population. Service use is reported because there are no licensed capacities for nearly all of these programs.

Behavioral Health Housing Programs

Adults In New York State adult behavioral health housing services are provided in licensed beds in family care, congregate treatment and apartment treatment programs, and in unlicensed beds in housing support and supported housing programs. More information about these programs is available on the NYS Office of Mental Health web page at http://bi.omh.ny.gov/adult_housing/index.

The adult housing services in the Tug Hill Seaway region are described in Table 14. Among licensed beds, the region has 86 family care beds, 71 congregate treatment beds, and 49 apartment treatment beds that are located in Jefferson and St. Lawrence counties. Lewis County has no licensed adult beds. There are no unlicensed housing support programs in the region. Unlicensed supported housing beds (n=217) are available in all counties. The housing capacity per 100,000 adults in the region is 229. In the counties housing capacity per 100,000 adults ranged from a low of 161 in Jefferson County to a high of 289 in St. Lawrence.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 537 New York State Office of Mental Health

Table 14. Tug Hill Seaway Region: Adult Behavioral Health Community-Based Housing Capacity by Provider County

Licensed Beds Unlicensed Beds Housing

Housing Capacity per County Family Congregate Apartment Supported Support 100,000 Care Treatment Treatment Housing Programs Adults Jefferson 1 35 33 ─ 66 161

Lewis ─ ─ ─ ─ 53 270

St. Lawrence 85 36 16 ─ 98 289 Totals 86 71 49 ─ 217 229 Data Sources: Licensed and unlicensed beds: New York State Office of Mental Health CONCERTS database; data as of 10/2015. US Census ACS 2010-2014 Est. Population.

Children In New York State, child behavioral health housing services are provided in licensed beds in teaching family homes and child and youth community residences, and in home and community-based services (HCBS). These child housing services in the Tug Hill Seaway region are described in Table 15.

The region has no teaching family home beds. Licensed child and youth community residence beds (n=8) are located in Jefferson County. The Tug Hill Seaway region has a capacity of 11 child and youth community residence beds per 100,000 children.

Table 15. Tug Hill Seaway Region: Child Behavioral Health Community-Based Housing Capacity and Home & Community-Based Services (HCBS) Slots by Provider County Number of Licensed Housing Beds HCBS Slots Child & Youth Capacity Slots per County Teaching Number of Community per 100,000 100,000 Family Home Slots Residence Children Children Jefferson ─ 8 25 18 55 Lewis ─ ─ ─ 6 82 St. Lawrence ─ ─ ─ 24 81 Totals ─ 8 11 48 69 Data Sources: New York State Office of Mental Health databases. Licensed housing capacity: CONCERTS, 10/2015. Home & Community-based Services (HCBS): CAIRS, CY 2014. US Census ACS 2010-2014 Est. Population.

All counties in the region have HCBS slots (n=48) ranging from a high of 24 in St. Lawrence County to a low of six in Lewis County. The region’s HCBS slots can serve 69 children per 100,000 children. In the counties HCBS slots per 100,000 children ranged from a low of 55 in Jefferson County to a high of 82 in Lewis County.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 538 New York State Office of Mental Health

Substance Use Disorder Outpatient Programs New York State has a variety of substance use disorder (SUD) outpatient programs including clinic and rehabilitation. In the Tug Hill Seaway region all counties except Lewis have SUD outpatient programs. The average daily enrollment (ADE) in these programs (n=613) is described in Table 16.

Table 16. Tug Hill Seaway Region: Substance Use Disorders Outpatient Program Average Daily Enrollment US Census ACS Outpatient County 2010-2014 Est. Avg. Daily Enrollment

Population Total Per 10,000

Jefferson 116,361 335 29

Lewis 27,054 0 0 St. Lawrence 111,895 278 25 Totals 255,310 613 24 Notes and Data Sources: Outpatient programs (OP) include Medically Supervised Outpatient, Outpatient Rehabilitation, Specialized OP – Traumatic Brain Injury, Outpatient Chemical Dependency for Youth, Specialized OP – Mobile, and Specialized Services OP Rehabilitation. Data is from the NYS Office of Alcoholism and Substance Abuse Services (OASAS) Provider Directory System. Includes programs that were operational as of April 2, 2016.

Jefferson County has the highest ADE (n=335), while Lewis has zero. Region-wide the SUD programs have an ADE of 24 per 10,000, which is the second lowest rate in any DSRIP region. In the counties ADE per 10,000 ranged from a low of 0 in Lewis County to a high of 29 in Jefferson County.

New York State also has outpatient opioid treatment programs (Table 17). The Tug Hill Seaway region has no opioid treatment programs. It is the only DSRIP region without these programs.

Table 17. Tug Hill Seaway Region: Substance Use Disorders Outpatient Opioid Treatment Program Capacity and Average Daily Enrollment US Census Opioid Treatment (Methadone) Number of County ACS 2010-2014 Capacity Avg. Daily Enrollment Programs Est. Population Total Per 10,000 Total Per 10,000 Jefferson 116,361 – – – – – Lewis 27,054 – – – – – St. Lawrence 111,895 – – – – – Totals 255,310 – – – – – Data is from the NYS Office of Alcoholism and Substance Abuse Services (OASAS) Provider Directory System. Includes programs that were operational as of April 2, 2016.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 539 New York State Office of Mental Health

6. Care Coordination New York State’s Medicaid health home initiative is designed to expand and improve care management for beneficiaries with intensive, high-cost service needs. The health home model provides the basis for unified systems of care to coordinate and integrate physical and behavioral health care, and social services provided to health home members. In the Tug Hill Seaway region there are two Health Home providers (Table 18). Jefferson County is served by one provider, and Lewis and St. Lawrence counties are served by both providers.

Table 18. Tug Hill Seaway Region: Health Homes Serving Medicaid Enrollees by County Total # Health Homes # Health Homes County Serving Region Serving County Jefferson 1 2 Lewis 2 St. Lawrence 2 Data is from the NYS Department of Health Designated Health Homes Web page. Retrieved May 4, 2016 from https://www.health.ny.gov/health_care/ medicaid/program/medicaid_health_homes/contact_information/list_by_county.htm #clinton

7. Behavioral Health Care Practitioners

Licensed Mental Health Professionals In New York State, the licensed mental health (MH) workforce includes psychiatrists, psychologists, clinical or master level social workers, nurse practitioners–psychiatry, marriage and family therapists, mental health counselors, psychoanalysts, and creative arts therapists.7 The number and distribution of these practitioners in the Tug Hill Seaway region is presented in Table 19.

Table 19. Tug Hill Seaway Region: Licensed Mental Health Professionals US Census Mental Nurse ACS 2010- Psychiatrists Psychologists LCSWs LMSWs Health Practitioner - *Other Total Per 10,000 County 2014 Est. Counseling Psychiatry Population Jefferson 116,361 8 23 50 72 40 6 5 204 18 Lewis 27,054 2 2 7 13 10 1 0 35 13 St. Lawrence 111,895 12 16 66 41 54 6 3 198 18 Totals 255,310 22 41 123 126 104 13 8 437 17 Data for psychiatrists is from the American Board of Psychiatry and Neurology, Inc. and was retrieved from https://application.abpn.com/verifycert/verifycert.asp on July 15, 2014. Data for all other professions is as of June 2, 2014 and was provided by the Office of the Professions at the New York State Education Department. *Other category includes marriage and family therapists, psychoanalysts, and creative arts therapists.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 540 New York State Office of Mental Health

The Tug Hill Seaway region has a total of 437 licensed MH professionals or 17 per 10,000 population, which is the second lowest rate in any DSRIP region. There are maldistributions of MH professionals across the region’s counties. Lewis County has the lowest (n=13) county distribution of MH professionals per 10,000 and Jefferson and St. Lawrence counties have the highest (n=18 each).

MH Professional Shortage Designations The maldistribution of licensed MH professionals in the Tug Hill Seaway region i s recognized by federally designated health professional shortage areas (HPSAs). HPSAs are designated on the county level by the federal Health Resources and Services Administration (HRSA). HPSAs are designated using several criteria, including population-to-clinician ratios. This ratio is usually 6,000 to 1 for mental health care.

Table 19a. Tug Hill Seaway Region: HRSA Federal Mental Health Professional Shortage Designations Census tract, Medicaid Eligible Whole County populations or County population facilities Jefferson Yes Yes Yes Lewis Yes Yes St. Lawrence Yes Yes Yes HRSA federal shortage designations retrieved March 17, 2016 from http://datawarehouse.hrsa.gov/tools/analyzers/hpsafind.aspx

In the Tug Hill Seaway region all counties have a whole county MH professional shortage designation (Table 19a). All of the counties in the region also have a census tract, population or facility designated as a MH Medically Underserved Area/Population (MUA/P). Jefferson and St. Lawrence counties’ Medicaid eligible populations are designated MH MUPs.

Certified and Credentialed Substance Use Disorder Professionals In New York State, the certified and credentialed substance use disorder (SUD) workforce includes physicians and counselors. The number and distribution of these practitioners in the Tug Hill Seaway region is presented in Table 20.

Table 20. Tug Hill Seaway Region: Certified and Credentialed Substance Use Disorder Professionals Physicians Counselors US Census Authorized for Per 10,000 County ACS 2010-2014 Board Certified Credentialed Alcoholism Certified Total Buprenorphine Population Est. Population Addiction Medicine and Substance Abuse Rehabilitation Prescription Jefferson 116,361 0 13 49 2 64 6 Lewis 27,054 1 2 10 1 13 5 St. Lawrence 111,895 0 11 43 3 57 5 Totals 255,310 1 26 102 6 134 5 Data is from the NYS Office of Alcoholism and Substance Abuse Services (OASAS) Human Resources Office and is as of May 13, 2016.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 541 New York State Office of Mental Health

SUD physicians include those board certified in addiction medicine and those authorized to prescribe buprenorphine to treat opioid addiction. In the Tug Hill Seaway region there is one physician certified in addiction medicine, the lowest number in any DSRIP region. All counties have physicians authorized to prescribe buprenorphine.

SUD counselors include those credentialed in alcoholism and substance abuse and those certified in rehabilitation. All counties in the region have these counselors. Overall, the Tug Hill Seaway region has a total of 134 certified and credentialed SUD professionals or five per 10,000 population.

While there are no HPSA shortage designations for SUD professionals, an area will be considered to have unusually high needs for mental health services if: 1) there is a high prevalence of alcoholism in the population, as indicated by prevalence data showing the area's alcoholism rates to be in the worst quartile of the nation, region, or State; or 2) there is a high degree of substance abuse in the area, as indicated by prevalence data showing the area's substance abuse to be in the worst quartile of the nation, region, or State.8

1 NYS Nursing Home Behavioral Intervention Services: This program must include a discrete unit with a planned combination of services with staffing, equipment and physical facilities designed to serve individuals whose severe behavior cannot be managed in a less restrictive setting. The program’s services are directed at attaining or maintaining the individual at the highest practicable level of physical, affective, behavioral and cognitive functioning. Retrieved April 21, 2016 from https://www.health.ny.gov/facilities/nursing/all_services.htm . 2 Diagnostic and Treatment Centers provide a comprehensive range of primary health care services to a population that includes uninsured individuals. 3 Federally qualified health centers (FQHCs) include all organizations receiving grants under Section 330 of the Public Health Service Act (PHS). FQHCs qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits. FQHCs must serve an underserved area or population, offer a sliding fee scale, and provide comprehensive services. 4 A primary care HPSA is a collection of census tracts that has been designated as having a shortage of primary care health professionals. HRSA uses two methodologies to determine whether there are adequate health care resources for specific geographical areas. Aggregate ZIP codes or census tracts can be designated as a Medically Underserved Area/Population (MUA/P) based on an analysis of four criteria: the ratio of primary care medical care physicians per 1,000 population, infant mortality rate, percentage of the population with incomes below the poverty level, and percentage of the population age 65 or over. A medically underserved population faces economic barriers (e.g. low-income or Medicaid-eligible populations), or cultural and/or linguistic access barriers to primary medical care services, and population specific information is assessed according to the above criteria to achieve MUP designation. 5 In this report adults are individuals aged 20 and older and children are individuals aged 19 and younger. 6 More information about OASAS inpatient programs is available at http://www.oasas.ny.gov/hps /state/CD_descriptions.cfm 7 Licensed Mental Health Workforce Data Sources and Limitations: Data for psychiatrists is from the American Board of Psychiatry and Neurology, Inc. and was retrieved from https://application.abpn.com/verifycert/verifycert.asp on July 15, 2014. Data for all other professions is as of June 2, 2014 and was provided by the Office of the Professions at the New York State Education Department. Licensees must be registered in order to practice and use a professional title in NYS; being registered, however, does not necessarily mean the licensee is actively engaged in practice. In addition, NYS licensing data show only “nurse practitioners-psychiatry” as a BH-psychiatric nurse specialty. All other nursing specialties that contribute to the licensed BH workforce are combined in the general category of “nurse” in the NYS licensing data and are not counted in the licensed BH workforce described here. This limitation also extends to other data sources such as professional

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 542 New York State Office of Mental Health

nursing organizations, which also combine a l l nursing specialties in a general category of “nurse” in their data collection processes. 8 HRSA Guidelines for Mental Health HPSA Designation. Retrieved May 24, 2016 from http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealthhpsaguidelines.html

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 543 New York State Office of Mental Health

III. Health Status

This section describes the health status of individuals in the Tug Hill Seaway DSRIP region. Its findings should be considered with those in Sections V and VI of this report, which describe unmet service need by DSRIP region.

1. Disease Prevalence Chronic Health Conditions Among all DSRIP regions, the Tug Hill Seaway region has the highest average percentages of adults with diabetes (11%) and that are overweight or obese (68%). It has the second highest average percentage of adults with high blood pressure (30%).

Table 1. Tug Hill Seaway Region: Prevalence of Chronic Health Conditions Among Adults Age-adjusted Percentage of Adults With physician With physician Ever told they Overweight or County diagnosed With current diagnosed have high obese angina, heart asthma diabetes blood pressure (BMI 25 or higher) attack or stroke Jefferson 11 7 33 70 11 Lewis 10 9 28 67 9

St. Lawrence 11 8 29 67 12

Region Average 11 8 30 68 10

Data Source is the NYS Department of Health Community Health Indicator Reports (CHIRS): Latest Data. Retrieved May 2, 2016 from https://health.data.ny.gov/Health/Community-Health-Indicator-Reports-CHIRS- Latest-Da/54ci-sdfi

In the region, Jefferson County has the highest percentages of adults with obesity (70%, the third highest in any NYS county) and high blood pressure (33%, the second highest in any NYS county) (Table 1). Lewis County has the highest percentage of adults with angina, heart attack or stroke (9%) and St. Lawrence County has the highest percentage with asthma (12%). Jefferson and St. Lawrence counties have the second highest percentages (11%) of adults with diabetes among all NYS counties.

HIV, AIDS and Cancer Compared to all other DSRIP regions, the Tug Hill Seaway has the lowest average case rates per 100,000 of both HIV and AIDS. The case rates of HIV and AIDS are highest in Jefferson County (n=4 each) and lowest in Lewis County (Table 2). The cancer incidence rate per 100,000 is lowest in Lewis County (n=457) and highest in St. Lawrence County (n=509).

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 544 New York State Office of Mental Health

Table 2. Tug Hill Seaway Region: Rates of HIV, AIDS, and Cancer Age-adjusted case rate Age-adjusted all cancers per 100,000 County incidence rate per HIV AIDS 100,000

Jefferson 4 4 508 Lewis 1 0 457 St. Lawrence 2 1 509 Region Average 22 492

Data Source is the NYS Department of Health Community Health Indicator Reports (CHIRS): Latest Data. Retrieved May 2, 2016 from https://health.data.ny.gov/Health/Community-Health-Indicator-Reports-CHIRS- Latest-Da/54ci-sdfi

2. Health Behaviors and Risk Factors Among all DSRIP regions the Tug Hill Seaway region has the highest average rate of binge drinking (21%). Jefferson and St. Lawrence Counties have the highest percentages of adults that report binge drinking (26% each) in any NYS county. (Table 3).

Table 3. Tug Hill Seaway Region: Adult Self-Reported Health Behaviors and Risk Factors Percentage of Adults Who Self-Reported: Survey Binge Food Housing Did not receive Poor mental Cigarette smoking County drinking insecurity in insecurity in Current medical care health for 14 among those who Sample Size Poor health during past past 12 past 12 smoker because of cost or more days report poor mental month months months in past 12 mos in last month health Jefferson 3,708 26% 23% 35% 4% 22% 10% 7% * Lewis 2,549 11% 20% 29% * 15% 6% 8% * St. Lawrence 3,484 26% 26% 42% 5% 20% 9% 17% * Region Total/Avg. 9,741 21% 23% 35% 5% 19% 9% 11% 0% *Suppressed due to small sample size. Data is from the CDC Expanded Behavioral Risk Factor Surveillance System (BRFSS) 2013-14 Survey. Retrieved April 27, 2016 from https://health.data.ny.gov/Health/Expanded-Behavioral-Risk-Factor-Surveillance-Surve/jsy7-eb4n?_sm_au_=iVVnMrPRnsfs8P5M

St. Lawrence County has highest percentages of adults that reported food (26%) and housing (42%) insecurity in the past 12 months and poor mental health for 14 or more days in the last month (17%). Jefferson County has the highest percentages of adults that reported smoking (22%) and not receiving medical care because of cost in the past 12 months (10%).

3. Hospitalization Rates by Disease or Cause In the Tug Hill Seaway region, cardiovascular disease is the leading cause of hospitalization (n=150 per 10,000) (Table 4). Lewis County has the highest hospitalization rate for cardiovascular disease (n=158) and Jefferson county has the highest hospitalization rate for stroke (n=24).

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 545 New York State Office of Mental Health

Table 4. Tug Hill Seaway Region: Hospitalization Rates by Disease or Cause Age-adjusted hospitalization rate per 10,000 Newborn drug- Diabetes Self- related diagnosis County Total Cardiovascular Cerebrovascular Drug- (primary Asthma inflicted rate per 10,000 hospitalizations disease disease (stroke) related diagnosis) injury newborn discharges Jefferson 1,190 150 24 13 6 8 17 20 Lewis 1,057 158 21 13 8 7 12 * St. Lawrence 1,215 142 21 17 11 10 41 112 Region Average 1,154 150 22 14 8 8 23 66 *Suppressed due to small sample size. Data Source is the NYS Department of Health Community Health Indicator Reports (CHIRS): Latest Data. Retrieved May 2, 2016 from https://health.data.ny.gov/Health/Community-Health-Indicator-Reports-CHIRS-Latest-Da/54ci-sdfi

St. Lawrence County has the highest rates of hospitalization for diabetes (n=17) and asthma (n=11). The rate of drug-related hospitalizations per 10,000 ranges from a high of 41 in St. Lawrence County to a low of 12 in Lewis County. The rate of newborn drug- related diagnoses per 10,000 is highest in St. Lawrence (n=112).

4. Mortality Rates Premature Mortality In the Tug Hill Seaway region, 43% of deaths in both Jefferson and St. Lawrence Counties are premature (Table 5). In Lewis County, the rate per 100,000 of premature death from cardiovascular disease is the lowest (n=90) in the region and from cerebrovascular disease is highest (n=24) in the region. Jefferson County has highest rate of alcohol related motor vehicle injuries and deaths in the region (n=58).

Table 5. Tug Hill Seaway Region: Percentage and Rates of Premature Death and Alcohol Related Motor Vehicle Injuries and Deaths Percentage Rate per 100,000 premature deaths County Premature Death (aged 35-64 years) Alcohol related motor (aged less than 75 Cardiovascular Cerebrovascular vehicle injuries and years) disease disease (stroke) deaths Jefferson 43 117 11 58 Lewis 38 90 24 50 St. Lawrence 43 116 14 53 Average % or Rate 41 108 16 54 Data Source is the NYS Department of Health Community Health Indicator Reports (CHIRS): Latest Data. Retrieved May 2, 2016 from https://health.data.ny.gov/Health/Community-Health-Indicator- Reports-CHIRS-Latest-Da/54ci-sdfi

Among all DSRIP regions, the Tug Hill Seaway has the highest average rate per 100,000 of premature death from stroke (n=16). The rate in Lewis County (n=24) is the second highest in any NYS county.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 546 New York State Office of Mental Health

Top Ten Causes of Death Among all DSRIP regions, the Tug Hill Seaway has the highest average death rate per 100,000 from cirrhosis of the liver (n=12) and the second highest from suicide (n=14). The death rates from cirrhosis of the liver (n=17) and suicide (n=24) are highest in Lewis County (Table 6). Lewis County’s death rate from suicide is the highest in any NYS county.

Table 6. Tug Hill Seaway Region: 2014 Top Ten Causes of Death — Rates* per 100,000 Population by Resident County Chronic Homicide or Heart Malignant Cerebrovascular Lower Diabetes Cirrhosis County AIDS Pneumonia Accidents Legal Suicide Disease Neoplasms Disease (Stroke) Respiratory Mellitus of Liver Intervention Disease Jefferson 201 178 41 0 12 35 31 19 1 7 10 Lewis 148 135 27 0 24 41 36 23 0 17 24 St. Lawrence 193 151 31 0 6 48 31 17 1 13 9 Region Average 180 154 33 0 14 41 33 19 0 12 14 Data is from the NYS Department of Health. Retrieved April 26, 2016 from https://www.health.ny.gov/statistics/vital_statistics/2014/table40.htm *Age-Sex adjusted rates are directly standardized using the age-sex distribution for the United States 2000 Census.

Compared to all other DSRIP regions, the region also the third highest death rate from diabetes (n=19), and that rate is highest in Lewis County (n=23). Lewis County also has the highest death rate in the region from pneumonia (n=24) and accidents (n=36).

Heart disease is the leading cause of death in all counties in the Tug Hill Seaway region. Jefferson County has the highest death rates due to malignant neoplasms (n=178) and cerebrovascular disease (n=41). St. Lawrence County had the highest death rate from chronic lower respiratory disease (n=48).

5. Patients in the Public Mental Health System Every other year, the NYS Office of Mental Health (OMH) collects information about patients served over a one week period in NYSOMH funded or licensed outpatient and inpatient facilities. Tables 7 and 8 report the chronic health conditions and behavioral health diagnoses of those served in 2015.

Chronic Health Conditions Overall, smoking (33%) and obesity and high blood pressure (20% each) are the leading chronic health conditions for the public mental health population in the Tug Hill Seaway region (Table 7).

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 547 New York State Office of Mental Health

Table 7. Tug Hill Seaway Region: Chronic Health Conditions Among Those Served in the NYS Public Mental Health System Percentage of Patients Served with Chronic Health Conditions Age Group Current High Blood Had a Heart Had a Diabetes Obesity Hyperlipidemia Smokers Pressure Attack Stroke Under 21 10 0 8 2 1 0 0 21-64 44 13 25 25 20 1 1 65+ 24 30 24 47 44 3 3 Total Average 33 10 20 20 16 1 1 Data is from the NYS Office of Mental Health 2015 Patient Characteristics Survey. Data retrieved April 28, 2016.

Among all DSRIP regions, the Tug Hill Seaway region has the highest percentages of patients that are smokers (33%), obese (20%) and that have hyperlipidemia (16%), and the second highest percentage of those with high blood pressure (20%).

 Among patients under the age of 21, the region has the highest percentages that are current smokers (10%), obese (8%) and have high blood pressure (2%) in all DSRIP regions.

 Among patients ages 21-64, the region has the highest percentages that are obese (25%), have high blood pressure (25%) and hyperlipidemia (20%), and the second highest percentages of those that are smokers (44%) and with diabetes (13%) in all DSRIP regions.

 For patients ages 65 and older, the Tug Hill Seaway region has the highest percentages with diabetes (30%), obesity (24%) and hyperlipidemia (44%), and the second highest percentages of those that smoke (24%) and with high blood pressure (47%) in all DSRIP regions.

Behavioral Health Diagnoses Overall, depressive disorders (29%) and co-occurring disorder (21%) are the leading behavioral health diagnoses for the public mental health population in the region (Table 8).

Table 8. Tug Hill Seaway Region: Behavioral Health Diagnoses Among Those Served in the NYS Public Mental Health System Percentage of Patients Served by Diagnostic Category Bipolar Neurodevelop- Schizophrenia Not a With a Co- Age Group Anxiety Depressive Disruptive Impulse Trauma Stress and related mental Spectrum & other Mental Occuring Disorder Disorders Conduct Disorder or Adjustment Disorders Disorders Psychotic Disorders Illness Disorder Under 21 10 6 25 8 27 2 18 5 4 21-64 12 18 31 1 2 17 10 1 30 65+ 7 15 20 1 0 38 6 1 7 Total Average 11 14 29 3 9 14 12 2 21 Data is from the NYS Office of Mental Health 2015 Patient Characteristics Survey. Data retrieved April 28, 2016.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 548 New York State Office of Mental Health

Among all DSRIP regions, the Tug Hill Seaway region has the highest percentages of patients served with anxiety disorder (11%) and neurodevelopmental disorders (9%), the second highest percentage with depressive disorders (29%), and the lowest percentage with schizophrenia and other psychotic disorders (14%).

 Among patients under the age of 21, the region has the highest percentage of those with a co-occurring disorder (4%), and the second highest percentage of those with depressive disorders (25%) in all DSRIP regions.

 Among patients ages 21-64, the region has the highest percentages of those with anxiety disorder (12%) and neurodevelopmental disorders (2%), the second highest percentage of those with depressive disorders (31%), and the lowest percentage of those with schizophrenia and other psychotic disorders (17%) in all DSRIP regions.

 For patients ages 65 and older, the Tug Hill Seaway region has the second highest percentage of those with trauma, stress or adjustment disorder (6%), and the lowest percentage of those with depressive disorders (20%) in all DSRIP regions.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 549 New York State Office of Mental Health

IV. Behavioral Health Care Utilization

This section describes behavioral health care utilization in hospitals and emergency rooms by Medicaid beneficiaries in the Tug Hill Seaway DSRIP region. Its findings should be considered with those in Sections V and VI of this report, which describe unmet service need by DSRIP region.

1. Medicaid Beneficiaries with Mental Health Diagnoses

Mental Health Diagnosis Inpatient Admissions Table 1 describes the number of Medicaid beneficiaries in the Tug Hill Seaway region with inpatient hospital admissions (n=4,549) by mental health diagnosis. By county, admissions ranged from a high of 2,269 in St. Lawrence to a low of 282 in Lewis. Region-wide, the largest percentages of Medicaid beneficiaries with a mental health inpatient hospital admission had depressive disorders (47%), followed by other mental health diagnoses (17%), chronic stress and anxiety diagnoses (13%), schizophrenia (12%), bi-polar disorder (8%), and PTSD (3%).

Table 1. Tug Hill Seaway Region: Number of Medicaid Beneficiaries with Inpatient Hospital Admissions by Mental Health Diagnosis Depressive Chronic Stress and Post Traumatic Other Mental Health Bi-Polar Disorder Schizophrenia Total Medicaid Disorders Anxiety Diagnoses Stress Disorder Diagnoses Beneficiaries with County Number/Percentage of Medicaid Beneficiaries MH Inpatient N % N % N % N % N % N % Admission Jefferson 185 9% 855 43% 244 12% 241 12% 83 4% 390 20% 1,998 Lewis 17 6% 153 54% 13 5% 40 14% 14 5% 45 16% 282 St. Lawrence 172 8% 1,132 50% 273 12% 296 13% 60 3% 336 15% 2,269 Totals 374 8% 2,140 47% 530 12% 577 13% 157 3% 771 17% 4,549 Data is from the NYS Department of Health Medicaid Chronic Conditions and Inpatient Admissions data base, 2012 data. Retrieved May 4, 2016 from https://health.data.ny.gov/ Health/Medicaid-Chronic-Conditions-Inpatient-Admissions-a/2yck-xisk#Export

In the region, the percentages of Medicaid beneficiaries hospitalized for mental health diagnoses were highest by diagnosis in the following counties: bipolar disorder (9%) and other mental health diagnoses (20%) in Jefferson County, schizophrenia in Jefferson and St. Lawrence counties (12% each), and depressive disorders (54%), chronic stress and anxiety diagnoses (14%), and PTSD (5%) in Lewis County.

Table 2 describes the number of Medicaid inpatient hospital admissions in the Tug Hill Seaway region (n=8,643) by mental health diagnosis. By county, admissions ranged from a high of 4,421 in St. Lawrence County to a low of 470 in Lewis.

Depressive disorders accounted for the largest number of inpatient admissions in all counties. Across counties, admissions for depressive disorders, schizophrenia, and chronic stress and anxiety disorder were highest in St. Lawrence County. Admissions for bipolar disorder, PTSD, and other mental health diagnoses were highest in Jefferson County.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 550 New York State Office of Mental Health

Table 2. Tug Hill Seaway Region: Number of Medicaid Inpatient Hospital Admissions by Mental Health Diagnosis Chronic Stress Other Mental Total Bi-Polar Post Traumatic Depressive Schizophrenia and Anxiety Health Number of County Disorder Stress Disorder Disorders Diagnoses Diagnoses MH Number of Admissions Admissions Jefferson 341 1,512 453 468 176 802 3,752 Lewis 32 243 24 54 28 89 470 St. Lawrence 332 2,161 496 574 156 702 4,421 Totals 705 3,916 973 1,096 360 1,593 8,643 Data is from the NYS Department of Health Medicaid Chronic Conditions and Inpatient Admissions data base, 2012 data. Retrieved May 4, 2016 from https://health.data.ny.gov/ Health/Medicaid-Chronic-Conditions-Inpatient-Admissions-a/2yck- xisk#Export

Mental Health Diagnosis Emergency Room Visits Table 3 describes the total number of Medicaid beneficiaries in the Tug Hill Seaway region with emergency room visits (n=11,258) by mental health diagnosis. By county, ER visits ranged from a high of 5,843 in St. Lawrence to a low of 927 in Lewis.

Table 3. Tug Hill Seaway Region: Number of Medicaid Beneficiaries with Emergency Room Visits by Mental Health Diagnosis Depressive Chronic Stress and Post Traumatic Other Mental Health Bi-Polar Disorder Schizophrenia Total Medicaid Disorders Anxiety Diagnoses Stress Disorder Diagnoses County Beneficiaries Number/Percentage of Medicaid Beneficiaries with MH ER Visit # % # % # % # % # % # % Jefferson 334 7% 1,794 40% 528 12% 627 14% 179 4% 1,026 23% 4,488 Lewis 42 5% 402 43% 82 9% 146 16% 40 4% 215 23% 927 St. Lawrence 416 7% 2,422 41% 645 11% 824 14% 219 4% 1,317 23% 5,843 Totals 792 7% 4,618 41% 1,255 11% 1,597 14% 438 4% 2,558 23% 11,258 Data is from the NYS Department of Health Medicaid Chronic Conditions and Emergency Room Visits database, 2012 data. Retrieved May 4, 2016 from https://health.data.ny.gov/Health/Medicaid-Chronic-Conditions-Inpatient-Admissions-a/wybq-m39t

Region-wide by diagnosis, the largest percentages of Medicaid beneficiaries with a mental health ER visit were for depressive disorders (41%), followed by other mental health diagnoses (23%), chronic stress and anxiety diagnoses (14%), schizophrenia (11%), bi-polar disorder (7%), and PTSD (4%).

In the region, the percentages of Medicaid beneficiaries with ER visits were highest by diagnosis in the following counties: depressive disorders (43%) and chronic stress and anxiety diagnoses (16%) in Lewis County, bipolar disorder in Jefferson and St. Lawrence counties (7% each), and schizophrenia in Jefferson County (12%). Percentages of Medicaid beneficiaries with ER visits for PTSD and other mental health diagnoses were consistent across counties.

Table 4 describes the total number of Medicaid ER visits in the Tug Hill Seaway region (n=39,862) by mental health diagnosis. By county, ER visits ranged from a high of 20,568 in St. Lawrence County to a low of 3,132 in Lewis.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 551 New York State Office of Mental Health

Table 4. Tug Hill Seaway Region: Number of Medicaid Emergency Room Visits by Mental Health Diagnosis Bi-Polar Depressive Chronic Stress and Post Traumatic Other Mental Total Number of County Disorder Disorders Schizophrenia Anxiety Diagnoses Stress Disorder Health Diagnoses ER Visits Number of ER Visits Jefferson 1,297 6,309 1,904 2,273 764 3,615 16,162 Lewis 161 1,367 253 615 119 617 3,132 St. Lawrence 1,794 8,201 2,304 2,941 861 4,467 20,568 Totals 3,252 15,877 4,461 5,829 1,744 8,699 39,862 Data is from the NYS Department of Health Medicaid Chronic Conditions and Emergency Room Visits database, 2012 data. Retrieved May 4, 2016 from https://health.data.ny.gov/Health/Medicaid-Chronic-Conditions-Inpatient-Admissions-a/wybq-m39t

Depressive disorders accounted for the largest number of ER visits in all counties and were highest in St. Lawrence (n=8,201). Across counties, ER visits were highest in St. Lawrence County for all diagnoses.

Medicaid Mental Health Beneficiaries Compared to All Medicaid Beneficiaries Table 5 describes Medicaid mental health beneficiaries compared to all Medicaid beneficiaries in the Tug Hill Seaway region. In the region, 8% of all Medicaid beneficiaries had a mental health inpatient hospital admission and 19% had a mental health ER visit.

Table 5. Tug Hill Seaway Region: Percentage of Medicaid Population with Mental Health Inpatient Hospital Admission or Emergency Room Visit Medicaid Beneficiaries with Medicaid Beneficiaries with All Medicaid MH Inpatient Admission MH ER Visit County Beneficiaries Number/Percentage of Medicaid Beneficiaries N % N % Jefferson 24,990 1,998 8% 4,488 18% Lewis 5,574 282 5% 927 17% St. Lawrence 28,013 2,269 8% 5,843 21% Totals 58,577 4,549 8% 11,258 19% Data is from the NYS Department of Health Medicaid Chronic Conditions and Inpatient Admissions data base, 2012 data. Retrieved May 4, 2016 from https://health.data.ny.gov/ Health/Medicaid-Chronic-Conditions- Inpatient-Admissions-a/2yck-xisk#Export

By county, Jefferson and St. Lawrence had the highest percentage of Medicaid beneficiaries with a mental health inpatient admission (8% each). St. Lawrence County had the highest percentage of Medicaid beneficiaries with a mental health ER visit (21%) and Lewis had the lowest (17%).

2. Medicaid Beneficiaries with Substance Use Disorders

Substance Use Disorder Inpatient Admissions Table 6 describes the total number of Medicaid beneficiaries in the Tug Hill Seaway region with inpatient hospital admissions (n=1,988) by substance use disorder (SUD). By county, admissions ranged from a high of 1,043 in St. Lawrence to a low of 55 in Lewis. Region-wide, the largest percentages of Medicaid beneficiaries with a SUD

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 552 New York State Office of Mental Health

inpatient hospital admission had alcohol use disorder (27%), followed by drug abuse: cannabis/NOS/NEC (26%), opioid use disorder (22%), other SUD diagnoses (17%), and cocaine use disorder (8%).

Table 6. Tug Hill Seaway Region: Number of Medicaid Beneficiaries with Inpatient Hospital Admissions by Substance Use Disorder Drug Abuse: Cocaine Use Alcohol Use Opioid Use Other SUD Total Medicaid Cannabis/ Disorder Disorder Disorder Diagnoses Beneficiaries with County NOS/NEC SUD Inpatient Number/Percentage of Medicaid Beneficiaries Admission # % # % # % # % # % Jefferson 79 9% 230 26% 168 19% 228 26% 185 21% 890 Lewis 0 0% 20 36% 15 27% 20 36% 0 0% 55 St. Lawrence 88 8% 292 28% 251 24% 259 25% 153 15% 1,043 Totals 167 8% 542 27% 434 22% 507 26% 338 17% 1,988 Data is from the NYS Department of Health Medicaid Chronic Conditions and Inpatient Admissions data base, 2012 data. Retrieved May 4, 2016 from https://health.data.ny.gov/ Health/Medicaid-Chronic-Conditions-Inpatient-Admissions-a/2yck-xisk#Export

In the region, the percentages of Medicaid beneficiaries hospitalized for SUDs were highest by disorder in the following counties: opioid use disorder (27%) and alcohol use disorder and drug abuse: cannabis/NOS/NEC (36% each) in Lewis County, and cocaine use disorder in (9%) and other SUD diagnoses (21%) in Jefferson County.

Compared to all other DSRIP regions, the Tug Hill Seaway region had the largest percentages of Medicaid beneficiaries hospitalized with alcohol use disorder (27%), drug abuse: cannabis/NOS/NEC (26%), and other SUD diagnoses (17%).

Table 7 describes the number of Medicaid inpatient hospital admissions in the Tug Hill Seaway region (n=4,309) by substance use disorder. By county, admissions ranged from a high of 2,307 in St. Lawrence County to a low of 90 in Lewis.

Table 7. Tug Hill Seaway Region: Number of Medicaid Inpatient Hospital Admissions by Substance Use Disorder Cocaine Alcohol Opioid Drug Abuse: Other SUD Total Number Use Use Use Cannabis/ County Diagnoses of SUD Disorder Disorder Disorder NOS/NEC Admissions Number of Admissions Jefferson 79 230 168 228 185 1,912 Lewis 0 20 15 20 0 90 St. Lawrence 88 292 251 259 153 2,307 Totals 167 542 434 507 338 4,309 Data is from the NYS Department of Health Medicaid Chronic Conditions and Inpatient Admissions data base, 2012 data. Retrieved May 4, 2016 from https://health.data.ny.gov/ Health/Medicaid-Chronic-Conditions-Inpatient-Admissions-a/2yck-xisk#Export

Alcohol use disorder accounted for the largest number of inpatient admissions in all counties, and were highest in St. Lawrence (n=292). Across counties, admissions for all disorders, except other SUD diagnoses, were highest in St. Lawrence County.

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Substance Use Disorder Emergency Room Visits Table 8 describes the total number of Medicaid beneficiaries in the Tug Hill Seaway region with emergency room (ER) visits (n=3,380) by substance use disorder. By county, ER visits ranged from a high of 1,877 in St. Lawrence to a low of 169 in Lewis. Region-wide, the largest percentages of Medicaid beneficiaries with a SUD ER visit were for cocaine use disorder (26%), followed by opioid use disorder (23%), drug abuse: cannabis/NOS/NEC (22%), other SUD diagnoses (21%), and alcohol use disorder (8%).

Table 8. Tug Hill Seaway Region: Number of Medicaid Beneficiaries with Emergency Room Visits by Substance Use Disorder Drug Abuse: Cocaine Use Alcohol Use Opioid Use Other SUD Total Cannabis/ Disorder Disorder Disorder Diagnoses Medicaid County NOS/NEC Beneficiaries Number/Percentage of Medicaid Beneficiaries with SUD ER # % # % # % # % # % Visit Jefferson 334 25% 125 9% 328 25% 266 20% 281 21% 1,334 Lewis 45 27% 17 10% 48 28% 34 20% 25 15% 169 St. Lawrence 508 27% 129 7% 399 21% 427 23% 414 22% 1,877 Totals 887 26% 271 8% 775 23% 727 22% 720 21% 3,380 Data is from the NYS Department of Health Medicaid Chronic Conditions and Emergency Room Visits database, 2012 data. Retrieved May 4, 2016 from https://health.data.ny.gov/Health/Medicaid-Chronic-Conditions-Inpatient-Admissions-a/wybq-m39t

In the region, the percentages of Medicaid beneficiaries with ER visits were highest by disorder in the following counties: cocaine use disorder in Lewis and St. Lawrence counties (27% each), alcohol use disorder (10%) and opioid use disorder (28%) in Lewis County, and drug abuse: cannabis/NOS/NEC (23%) and other SUD diagnoses (22%) in St. Lawrence County.

Compared to all other DSRIP regions, the Tug Hill Seaway region had the largest percentage of Medicaid beneficiaries with ER visits for other SUD diagnoses (21%).

Table 9 describes the number of Medicaid ER visits in the Tug Hill Seaway region (n=12,038) by substance use disorder.

Table 9. Tug Hill Seaway Region: Number of Medicaid Emergency Room Visits by Substance Use Disorder Cocaine Alcohol Opioid Drug Abuse: Other SUD Use Use Use Cannabis/ Total Number County Diagnoses Disorder Disorder Disorder NOS/NEC of ER Visits Number of ER Visits Jefferson 1,079 437 1,203 977 1,073 4,769 Lewis 132 76 213 199 88 708 St. Lawrence 1,655 467 1,435 1,541 1,463 6,561 Totals 2,866 980 2,851 2,717 2,624 12,038 Data is from the NYS Department of Health Medicaid Chronic Conditions and Emergency Room Visits database, 2012 data. Retrieved May 4, 2016 from https://health.data.ny.gov/Health/Medicaid-Chronic-Conditions-Inpatient-Admissions-a/wybq- m39t

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By county, ER visits ranged from a high of 6,561 in St. Lawrence County to a low of 708 in Lewis. Opioid use disorder accounted for the largest number of ER visits in Jefferson and Lewis counties, while cocaine use disorder accounted for the largest number of ER visits in St. Lawrence. Across counties, ER visits for all disorders were highest in St, Lawrence County.

Medicaid Substance Use Disorder Beneficiaries Compared to All Medicaid Beneficiaries Table 10 describes Medicaid SUD beneficiaries compared to all Medicaid beneficiaries in the Tug Hill Seaway region. In the region, 3% of all Medicaid beneficiaries had a SUD inpatient hospital admission and 6% had a SUD ER visit. By county, Jefferson and St. Lawrence counties have the highest percentage of Medicaid beneficiaries with a SUD inpatient admission (4% each). St. Lawrence County had the highest percentage of Medicaid beneficiaries with a SUD ER visit (7%) and Lewis had the lowest (3%).

Table 10. Tug Hill Seaway Region: Percentage of Medicaid Population with Substance Use Disorder Inpatient Hospital Admission or Emergency Room Visit Medicaid Beneficiaries with Medicaid Beneficiaries with All Medicaid SUD Inpatient Admission SUD ER Visit County Beneficiaries Number/Percentage of Medicaid Beneficiaries N % N % Jefferson 24,990 890 4% 1,334 5% Lewis 5,574 55 1% 169 3% St. Lawrence 28,013 1,043 4% 1,877 7% Totals 58,577 1,988 3% 3,380 6% Data is from the NYS Department of Health Medicaid Chronic Conditions and Inpatient Admissions data base, 2012 data. Retrieved May 4, 2016 from https://health.data.ny.gov/ Health/Medicaid-Chronic-Conditions- Inpatient-Admissions-a/2yck-xisk#Export

3. Medicaid Beneficiary Hospital Inpatient Admissions and Emergency Room Visits

Medicaid Beneficiaries by Eligibility Type In the Tug Hill Seaway region 23% of the estimated population are Medicaid beneficiaries (Table 11). By county, Medicaid beneficiaries range from a high of 25% of the estimated population in St. Lawrence County to a low of 21% each of the estimated populations in Jefferson and Lewis counties.

Medicaid beneficiaries include individuals that receive only Medicaid and individuals that are dually-eligible for Medicare and Medicaid benefits because of their age or disability and low incomes.1 In the Tug Hill Seaway region, 82% of Medicaid beneficiaries receive Medicaid only and 18% are dual-eligible. Medicaid only beneficiaries range from a low of 80% in Lewis County to a high of 83% in Jefferson.

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Table 11. Tug Hill Seaway Region: Medicaid Beneficiaries by Eligibility Type Total Medicaid Dual Medicaid US Census Medicaid Only ACS 2010- Beneficiaries and Medicare County % Total % Total 2014 Est. % # # Medicaid # Medicaid Total Pop Population Bene. Bene. Jefferson 116,361 24,990 21% 20,688 83% 4,302 17% Lewis 27,054 5,574 21% 4,483 80% 1,091 20% St. Lawrence 111,895 28,013 25% 22,757 81% 5,256 19% Totals 255,310 58,577 23% 47,928 82% 10,649 18% Data is from the NYS Department of Health’s Medicaid Beneficiaries Inpatient Admissions and Emergency Room Visits data base; 2012 data. Retrieved May 11, 2016 from https://health.data.ny.gov/Health/Medicaid- Beneficiaries-Inpatient-Admissions-and-Em/m2wt-pje4#About

Medicaid Beneficiary Hospital Inpatient Admissions Medicaid beneficiary hospital inpatient admissions in the Tug Hill Seaway region are described in Table 12.2 In the region, 11% of Medicaid only beneficiaries and 14% of Medicaid/Medicare dual-eligible beneficiaries experienced at least one hospital inpatient admission.

Table 12. Tug Hill Seaway Region: Total Medicaid Inpatient Hospital Admissions by Type of Beneficiary Number of Beneficiaries Total Inpatient Number of Beneficiaries with Inpatient Admissions Hospital Admissions County Medicaid Dual Medicaid Dual Medicaid Medicaid Dual Medicaid Medicaid Only Only and Medicare and Medicare Only and Medicare # # # % # % # # Jefferson 20,688 4,302 2,218 11% 643 15% 2,971 824 Lewis 4,483 1,091 488 11% 119 11% 621 158 St. Lawrence 22,757 5,256 2,574 11% 781 15% 3,790 1,041 Totals 47,928 10,649 5,280 11% 1,543 14% 7,382 2,023 Data is from the NYS Department of Health’s Medicaid Beneficiaries Inpatient Admissions and Emergency Room Visits data base; 2012 data. Retrieved May 11, 2016 from https://health.data.ny.gov/Health/Medicaid-Beneficiaries-Inpatient-Admissions-and- Em/m2wt-pje4#About

Percentages of Medicaid only beneficiaries with hospital inpatient admissions were consistent across counties. In comparison, hospital inpatient admissions in the dual- eligible Medicaid/Medicare population ranged from a low of 11% in Lewis County to a high of 15% each in Jefferson and St. Lawrence counties.

Medicaid Beneficiary Emergency Room Visits Emergency room (ER) visits among Medicaid beneficiaries in the Tug Hill Seaway region are described in Table 13.3 In the region, 37% of Medicaid only beneficiaries and 17% of Medicaid/Medicare dual-eligible beneficiaries experienced at least one ER visit.

Percentages of Medicaid only beneficiaries with ER visits ranged from a low of 30% in Lewis County to a high of 41% in St. Lawrence (the highest in any NYS county). In

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comparison, ER visits for the Medicaid/Medicare dual-eligible population ranged from a low of 7% in Jefferson County to a high of 20% in St. Lawrence.

Table 13. Tug Hill Seaway Region: Medicaid Emergency Room Visits by Beneficiary Type Number of Beneficiaries Number of Beneficiaries Total ER Visits with ER Visits County Dual Medicaid Dual Medicaid Medicaid Dual Medicaid Medicaid Only Medicaid Only and Medicare and Medicare Only and Medicare # # # % # % # # Jefferson 20,688 4,302 6,945 34% 648 15% 15,985 1,181 Lewis 4,483 1,091 1,359 30% 77 7% 2,968 149 St. Lawrence 22,757 5,256 9,305 41% 1,042 20% 22,182 2,258 Totals 47,928 10,649 17,609 37% 1,767 17% 41,135 3,588 Data is from the NYS Department of Health’s Medicaid Beneficiaries Inpatient Admissions and Emergency Room Visits data base; 2012 data. Retrieved May 11, 2016 from https://health.data.ny.gov/Health/Medicaid-Beneficiaries-Inpatient-Admissions-and- Em/m2wt-pje4#About

Compared to all other DSRIP regions, the Tug Hill Seaway had the highest percentage of Medicaid only beneficiaries with ER visits (37%).

In conclusion, in the Tug Hill Seaway region the Medicaid only population had a higher percentage of ER visits than the Medicaid/Medicare dual-eligible population, while the Medicaid/Medicare dual-eligible population had a higher percentage of hospital inpatient admissions than the Medicaid only population.

1 In this analysis, dual status was based upon the last month of enrollment/eligibility during the year. If the Medicaid beneficiary was indicated as being eligible for Part A, B, C or D Medicare services they are classified as dual eligible. The dual-eligible Medicare and Medicaid population is diverse and includes individuals with multiple chronic conditions, physical disabilities, and cognitive impairments such as dementia, developmental disabilities, and mental illness. It also includes some individuals who are relatively healthy. Retrieved May 12, 2016 from http://www.medpac.gov/documents/data-book/january- 2015-medpac-and-macpac-data-book-beneficiaries-dually-eligible-for-medicare-and-medicaid.pdf 2 In this analysis, inpatient utilization was based on all Medicaid inpatient admissions. To avoid duplication, admissions are counted per Medicaid beneficiary, per hospital, per admission. 3 Emergency room utilization was based on all Medicaid fee-for-service and managed care emergency room visits. To avoid duplication with multiple provider claims on a single ER visit for a Medicaid beneficiary, visits were counted per unique recipient per day.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 557 New York State Office of Mental Health

V. Unmet Service Needs

Access to an adequate amount of outpatient care and community resources can reduce hospitalizations and emergency room (ER) visits for both behavioral and physical health problems. For example, high rates of potentially avoidable ER visits and hospital admissions suggest a need for further outpatient resources in the community. This section describes the unmet service needs of individuals in the Tug Hill Seaway DSRIP region.

Quality indicators are one of several ways to measure the unmet needs of a community. Unmet service need is reported here using measures of initiation and engagement in behavioral health treatment and measures of potentially avoidable hospitalizations and ER visits. Further information about these measures is included below. Additional information about unmet need in the Tug Hill Seaway DSRIP region from needs assessments of local issues conducted by counties in the region is also included.

1. Behavioral Health Treatment Mental Health Medication Adherence and Management Adherence to Antipsychotic Medications for Individuals with Schizophrenia, and Antidepressant Medication Management are two Healthcare Effectiveness Data and Information Set (HEDIS)/New York State Quality Assurance Reporting Requirement (QARR) measures collected by Performing Provider Systems in the DSRIP program.

 Adherence to Antipsychotic Medications for Individuals with Schizophrenia refers to the percentage of members, ages 19 to 64 years, with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period.  Antidepressant Medication Management Effective Acute Phase Treatment refers to the percentage of members who remained on antidepressant medication during the entire 12-week acute treatment phase.  Antidepressant Medication Management Effective Continuation Phase Treatment refers to the percentage of members who remained on antidepressant medication for at least six months.

For adults with schizophrenia in the Tug Hill Seaway region, 60% adhere to antipsychotic medications (40% do not). In the region, the percentage of adults with schizophrenia that adhere to antipsychotic medications ranges from a low of 51% in St. Lawrence County to a high of 71% in Jefferson (Table 1).

In the region, 55% of individuals remain on antidepressant medication during the acute phase and 37% remain on antidepressant medication during the continuation phase (63% do not). Among all DSRIP regions, the Tug Hill Seaway region has the highest adherence to antidepressants for the acute phase.

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Table 1. Tug Hill Seaway Region: Mental Health Medication Adherence and Management Adherence to Antipsychotic Antidepressant Medication Management County Medications for Individuals with Effective Acute Effective Continuation Schizophrenia Phase Treatment Phase Treatment Jefferson 71% 54% 35% Lewis * 58% 47% St. Lawrence 51% 56% 37% Region Avg. % 60% 55% 37% *Sample size too small to report. Notes and Data Sources: Data is from the NYS Department of Health - Medicaid clinical metrics for Clinical Improvement Projects (Domain 3) of the DSRIP Program database, measurement year 2014 data.

Adherence to antidepressants is highest in Lewis County for both the acute (58%, the highest in any NYS county) and continuation (47%) phases. In comparison, the lowest rates of adherence are found in Jefferson County (54%, acute phase and 35%, continuation phase).

Mental Health Follow-up Care This section presents HEDIS/QARR measures related to mental health follow-up care.

 Follow-up after Hospitalization for Mental Illness within 7 Days refers to the percentage of members who were seen on an ambulatory basis or who were in intermediate treatment with a mental health provider within 7 days of hospital discharge.  Follow-up after Hospitalization for Mental Illness within 30 Days refers to the percentage of members who were seen within 30 days of hospital discharge.  Follow-Up Care for Children Prescribed ADHD Medication Initiation Phase refers to the percentage of children with a new prescription for ADHD medication who had one follow-up visit with a practitioner within the 30 days after starting the medication.  Follow-Up Care for Children Prescribed ADHD Medication Continuation & Maintenance Phase refers to the percentage of children with a new prescription for ADHD medication who remained on the medication for 7 months and who, in addition to the visit in the Initiation Phase, had at least 2 follow-up visits in the 9- month period after the initiation phase ended.

In the Tug Hill Seaway region, 32% of individuals follow-up after hospitalization for mental illness within seven days (68% do not) and 46% follow-up within 30 days (54% do not). Among all DSRIP regions, the region has the lowest percentages of seven and 30 day follow-up care after hospitalization for mental illness.

In the region, and among all NYS counties, St. Lawrence County has the lowest percentages for both seven (20%) and 30 (33%) day follow-up care after hospitalization for mental illness (Table 2). In the region, Lewis County has the highest seven (57%) and 30 (70%) day follow-up percentages.

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Table 2. Tug Hill Seaway Region: Mental Health Follow-Up Care Follow-up After Hospitalization for Follow-Up Care for Children County Mental Illness Prescribed ADHD Medication Within 7 Days Within 30 Days Initiation Phase Continuation Phase Jefferson 42% 59% 60% 53% Lewis 57% 70% 67% * St. Lawrence 20% 33% 55% 59% Region Avg. % 32% 46% 59% 61% *Sample Size Too Small to Report. Notes and Data Sources: Data is from the NYS Department of Health - Medicaid clinical metrics for Clinical Improvement Projects (Domain 3) of the DSRIP Program database, measurement year 2014 data.

In the Tug Hill Seaway region, 59% of children prescribed ADHD medication have follow-up care during the initiation phase and 61% have follow-up care during the continuation phase. The percentage of children prescribed ADHD medication with follow-up care is lowest in St. Lawrence County for the initiation phase (55%) and in Jefferson for the continuation phase (53%). Lewis County has the highest percentage (67%) for the initiation phase and St. Lawrence has the highest percentage (59%) for the continuation phase.

Alcohol and Other Drug Dependence Initiation and Engagement in Treatment Performing Provider Systems in the DSRIP program also collect two Alcohol and Other Drug (AOD) Dependence Treatment HEDIS/QARR measures: Initiation and Engagement in treatment.

 The Initiation measure is the percentage of members who initiate treatment within 14 days of the diagnosis of AOD dependence.  The Engagement measure is the percentage of members who engage in treatment within 30 days after initiation.

In the Tug Hill Seaway region, 48% of individuals initiate AOD treatment within 14 days of diagnosis and 24% of individuals engage in AOD treatment within 30 days after initiation (76% do not) (Table 3). In the region, the percentages for AOD initiation range from a low of 45% in St. Lawrence County to a high of 52% in Jefferson. Jefferson County has the highest percentage (28%) for AOD engagement and Lewis has the lowest (18%).

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Table 3. Tug Hill Seaway: Alcohol and Other Drug Dependence Treatment Alcohol and Other Drug Dependence Treatment County Initiation Engagement Jefferson 52% 28% Lewis 47% 18% St. Lawrence 45% 22% Region Avg. % 48% 24% Notes and Data Sources: Data is from the NYS Department of Health - Medicaid clinical metrics for Clinical Improvement Projects (Domain 3) of the DSRIP Program database, measurement year 2013 data.

2. Potentially Avoidable Hospitalizations The Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQIs) are a set of population-based measures that can be used with hospital inpatient discharge data to identify conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications. PQIs provide a good starting point for assessing quality of health services in the community.

 All PQIs apply only to adult populations (individuals over the age of 18 years).  The Observed Rate (per 100,000 people) is the number of PQI discharges divided by the population, multiplied by 100,000.  The Expected Rate (per 100,000 people) is the number of PQI discharges adjusted by age group, gender and race/ethnicity divided by the population, multiplied by 100,000. Lower ratios of observed to expected rates represent better results.

Diabetes Chronic Conditions In Tug Hill Seaway region’s Medicaid only population, St. Lawrence County has the highest observed to expected ratios for diabetes short-term complications (172/126) and Jefferson County has the highest ratio for diabetes long-term complications (138/101) (Table 4a). Lewis County has the lowest observed to expected ratios for both diabetes short-term (100/120) and long-term (67/96) complications.

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Table 4a. Tug Hill Seaway Region: Diabetes Short and Long-Term Complications Inpatient Prevention Quality Indicators by Medicaid Eligibility Diabetes Short-term Complications Diabetes Long-term Complications Dual Medicaid Dual Medicaid Medicaid Only Medicaid Only County and Medicare and Medicare Rates per 100,000 Observed Expected Observed Expected Observed Expected Observed Expected Jefferson 138 125 111 89 138 101 356 242 Lewis 100 120 0 88 67 96 86 233 St. Lawrence 172 126 122 93 115 109 261 250 Totals 137 124 78 90 107 102 234 242 Notes and Data Sources: Data is from the NYS Department of Health Quality Prevention Quality Indicators – Adult (AHRQ PQI) for Medicaid Enrollees database, discharge year 2014 data. Retrieved May 6, 2016 from https://health.data.ny.gov/Health/Medicaid-Inpatient-Prevention-Quality-Indicators-P/6kjt-7svn Similarly, in the dual population St. Lawrence County has the highest observed to expected ratios for diabetes short-term complications (122/93) and Jefferson County has the highest ratio for long-term complications (356/242). Lewis County has the lowest observed to expected ratios for both diabetes short-term (zero) and long-term (86/233) complications in this population.

Table 4b describes uncontrolled diabetes and lower-extremity amputation rates among patients with diabetes. In the Medicaid only population, Lewis County has the highest observed to expected ratio for uncontrolled diabetes (33/15) and St. Lawrence County has the lowest (19/17). Among all DSRIP regions, the Tug Hill Seaway region has the highest observed to expected ratio for uncontrolled diabetes in the Medicaid only population (27/16).

For lower-extremity amputations in this population, Jefferson County has the highest observed to expected ratio (14/11) and Lewis County has the lowest (zero).

Table 4b.Tug Hill Region: Diabetes Chronic Conditions Inpatient Prevention Quality Indicators by Medicaid Eligibility Lower-Extremity Amputation Uncontrolled Diabetes among Patients with Diabetes Dual Medicaid Dual Medicaid Medicaid Only Medicaid Only County and Medicare and Medicare Rates per 100,000 Observed Expected Observed Expected Observed Expected Observed Expected Jefferson 28 17 45 34 14 11 45 39 Lewis 33 15 0 33 0 11 0 40 St. Lawrence 1917 52 35 13 13 35 41 Totals27 16 32 34 912 26 40 Notes and Data Sources: Data is from the NYS Department of Health Quality Prevention Quality Indicators – Adult (AHRQ PQI) for Medicaid Enrollees database, discharge year 2014 data. Retrieved May 6, 2016 from https://health.data.ny.gov/Health/Medicaid-Inpatient-Prevention-Quality-Indicators-P/6kjt-7svn

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In the dual population, St. Lawrence County has the highest observed to expected ratio for uncontrolled diabetes (52/35) and Lewis County has the lowest (zero). Jefferson County also has the highest ratio for lower-extremity amputation among patients with diabetes (45/39) in the dual population and Lewis County has the lowest (zero).

Cardiac Chronic Conditions In the Tug Hill Seaway region (Table 5a), all counties have lower observed than expected rates for hypertension in both the Medicaid only and dual populations.

In the Medicaid only population St. Lawrence County has the highest ratio for heart failure (166/104) and Lewis has the lowest (zero). In this population, Lewis County has the highest ratio for angina without procedure (33/11, the highest ratio in any NYS county) and Jefferson County has the lowest (7/11).

In the dual Medicaid and Medicare population, Jefferson County has the highest observed to expected ratio for heart failure (846/618) and Lewis County has the lowest ratio (343/641). In this population, all counties have zero rates for angina without procedure. Among all DSRIP regions, the Tug Hill Seaway region has the lowest observed to expected ratio (zero) for angina without procedure in the dual population.

Table 5a. Tug Hill Seaway Region: Cardiac Chronic Conditions Inpatient Prevention Quality Indicators by Medicaid Eligibility Hypertension Heart Failure Angina Without Procedure Dual Medicaid Dual Medicaid Dual Medicaid Medicaid Only Medicaid Only Medicaid Only County and Medicare and Medicare and Medicare Rate per 100,000 Observed Expected Observed Expected Observed Expected Observed Expected Observed Expected Observed Expected Jefferson 28 37 67 78 90 93 846 618 7 11 0 23 Lewis 33 34 0 76 0 87 343 641 33 11 0 22 St. Lawrence 32 39 52 73 166 104 627 583 19 13 0 23 Total31 37 40 76 85 94605 614 20 12 023 Notes and Data Sources: Data is from the NYS Department of Health Quality Prevention Quality Indicators – Adult (AHRQ PQI) for Medicaid Enrollees database, discharge year 2014 data. Retrieved May 6, 2016 from https://health.data.ny.gov/Health/Medicaid-Inpatient-Prevention-Quality-Indicators-P/6kjt-7svn

Asthma Chronic Conditions Asthma chronic conditions are described in Table 5b. St. Lawrence County has the highest observed to expected ratio for asthma in younger adults in the Medicaid only population (81/77) and Jefferson has the lowest (32/81).

In the dual population all counties have zero rates for asthma in younger adults. Among all DSRIP regions, the Tug Hill Seaway region has the lowest observed to expected ratio (zero) for asthma in the dual population.

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Table 5b. Tug Hill Seaway Region: Asthma Chronic Conditions Inpatient Prevention Quality Indicators by

Medicaid Eligibility

Asthma in Younger Adults Dual Medicaid Medicaid Only and Medicare County Rate per 100,000

Observed Expected Observed Expected Jefferson 32 81 0 126 Lewis 51 76 0 108 St. Lawrence 81 77 0 117 Total 55 78 0 117 Notes and Data Sources: Data is from the NYS Department of Health Quality Prevention Quality Indicators – Adult (AHRQ PQI) for Medicaid Enrollees database, discharge year 2014 data. Retrieved May 6, 2016 from https://health.data.ny.gov/Health/Medicaid- Inpatient-Prevention-Quality-Indicators-P/6kjt-7svn

Composite PQIs Tables 6 and 7 report observed and expected composite PQIs by county in the Tug Hill Seaway region.

 The Chronic Composite PQI includes: Diabetes Short-Term and Long-Term Complications Admission Rates, the Asthma in Younger and Older Adults Admission Rates, the Hypertension Admission Rate, the Congestive Heart Failure (CHF) Admission Rate, the Angina without Procedure Admission Rate, the Uncontrolled Diabetes Admission Rate, and the Rate of Lower-Extremity Amputation among Patients with Diabetes.  The Acute Composite includes: the Dehydration Admission Rate, the Bacterial Pneumonia Admission Rate, and the Urinary Tract Infection Admission Rate.  The Overall Composite PQI refers to all PQI measures within the Chronic and Acute Composites.

In the Tug Hill Seaway region’s Medicaid only population, St. Lawrence County has the highest observed to expected ratios for the overall composite (1,300/981), acute composite (357/271) and chronic composite (943/710) indicators. The lowest ratios for these indicators are in Lewis County (overall composite, 865/915, acute composite, 233/263 and chronic composite, 632/652). Among all DSRIP regions, the Tug Hill Seaway region has the highest chronic composite ratio (781/678) for the Medicaid only population.

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Table 6. Tug Hill Seaway Region: Prevention Quality Overall, Acute, and Chronic Composite Indicators by Medicaid Eligibility Overall Composite Acute Composite Chronic Composite Dual Medicaid Dual Medicaid Dual Medicaid Medicaid Only Medicaid Only Medicaid Only County and Medicare and Medicare and Medicare Rate per 100,000 Observed Expected Observed Expected Observed Expected Observed Expected Observed Expected Observed Expected Jefferson 1,003 931 3,316 3,142 235 261 1,180 1,217 768 670 2,137 1,925 Lewis 865 915 1,715 3,160 233 263 686 1,249 632 652 1,029 1,911 St. Lawrence 1,300 981 3,674 3,077 357 271 1,289 1,172 943 710 2,386 1,906 Totals 1,056 943 2,902 3,126 275 265 1,051 1,213 781 678 1,850 1,914 Notes and Data Source: Data is from the NYS Department of Health Quality Prevention Quality Indicators – Adult (AHRQ PQI) for Medicaid Enrollees database, discharge year 2014 data. Retrieved May 6, 2016 from https://health.data.ny.gov/Health/Medicaid-Inpatient-Prevention-Quality-Indicators-P/6kjt-7svn

In the Tug Hill Seaway region’s dual population, St. Lawrence County also has the highest observed to expected ratios for these indicators: overall composite (3,674/3,077), acute composite (1,289/1,172) and chronic composite (2,386/1,906). The lowest ratios for these indicators are also in Lewis County (overall composite, 1,715/3,160, acute composite, 686/1,249 and chronic composite, 1,029/1,911).

Table 7 describes the all diabetes, circulatory and respiratory composite indicators. In the Tug Hill Seaway region’s Medicaid only population, Jefferson County has the highest observed to expected ratio for the all diabetes composite (318/253), and St. Lawrence has the highest ratios for the all circulatory composite (217/155) and all respiratory composite (414/295) indicators. The lowest ratios for the all diabetes (200/242) and all circulatory (67/132) composite indicators are in Lewis County, and Jefferson County has the lowest ratio for the all respiratory composite indicator (332/280).

Table 7. Tug Hill Seaway Region: Prevention Quality All Diabetes, Circulatory, and Respiratory Composite Indicators by Medicaid Eligibility All Diabetes Composite All Circulatory Composite All Respiratory Composite Dual Medicaid Dual Medicaid Dual Medicaid Medicaid Only Medicaid Only Medicaid Only County and Medicare and Medicare and Medicare Rate per 100,000 Observed Expected Observed Expected Observed Expected Observed Expected Observed Expected Observed Expected Jefferson 318 253 556 405 125 141 913 719 332 280 690 816 Lewis 200 242 86 395 67 132 343 740 366 282 600 792 St. Lawrence 319 265 470 418 217 155 679 679 414 295 1,254 825 Total 279 254 371 406 136 143 645 713 371 286 848 811 Notes and Data Sources: Data is from the NYS Department of Health Quality Prevention Quality Indicators – Adult (AHRQ PQI) for Medicaid Enrollees database, discharge year 2014 data. Retrieved May 6, 2016 from https://health.data.ny.gov/Health/Medicaid-Inpatient-Prevention-Quality-Indicators-P/6kjt-7svn

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In the region’s dual population, Jefferson County has the highest observed to expected ratios for the all diabetes composite (556/405) and all circulatory composite (913/719) indicators, and Lewis County has the lowest ratios for these indicators (86/395 and 343/740 respectively). In this population, St. Lawrence County has the highest ratio for the all respiratory composite indicator (1,254/825) and Lewis County has the lowest (600/792).

3. Potentially Avoidable Emergency Room Visits In the Tug Hill Seaway region, St. Lawrence County has the highest observed to expected ratio (40/19, the highest ratio in any NYS county) of potentially preventable ER visits, and Lewis has the lowest (7/17) (Table 8).

Table 8. Tug Hill Seaway Region: All Payers Potentially Preventable Emergency Room Visits ER Discharges 2013: Rate per 100,000 County Observed Expected

Jefferson 34 20 Lewis 7 17 St. Lawrence 40 19 Total 27 19 Notes and Data Sources: Data is from the NYS Department of Health All Payer Potentially Preventable Emergency Visit (PPV) database. Rates by patient county, SPARCS data 2013. Retrieved May 6, 2016 from https://health.data.ny.gov/Health/All-Payer-Potentially-Preventable- Emergency-Visit-/f8ue-xzy3#About

Among all DSRIP regions, the Tug Hill Seaway region has the highest observed to expected ratio (27/19) for potentially preventable ER visits.

4. Local Assessment of Need by Tug Hill Seaway Region Counties

New York State Mental Hygiene Law requires the Office of Mental Health (OMH) and the Office of Alcoholism and Substance Abuse Services (OASAS) to guide and facilitate the process of local planning. As part of the planning process, New York State counties and New York City (local governmental units [LGUs]) conduct a needs assessment of local issues impacting populations with mental illness and chemical dependency. These issues include prevention, treatment, and recovery support service needs, including other individualized person-centered supports and services. The issues of workforce retention and recruitment and coordination/integration with other systems are also included.

Table 9 summarizes the results of the LGUs’ needs assessments for the Tug Hill Seaway region. The data were collected from LGUs from March 1, 2015 through June 1, 2015. For each need issue listed, the LGUs indicated the extent to which it is an area of need at the local level for each population by identifying high, moderate or low need.

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Table 9. Tug Hill Seaway Region: Assessment of Needs by Population and Issue Assessment of Local Need (N=3 Counties) Youth (<21) Adults (21+) High Moderate High Moderate Low Need Missing Low Need Missing Need Need Need Need Selected Issues Mental Illness Population Access to Prevention Services 0% 0% 100% 0% 0% 0% 100% 0% Access to Crisis Services 67% 0% 33% 0% 67% 0% 33% 0% Access to Treatment Services 33% 67% 0% 0% 67% 33% 0% 0% Access to Supported Housing 0% 0% 100% 0% 33% 0% 67% 0% Access to Transportation 0% 100% 0% 0% 33% 67% 0% 0% Access to Home/Community-based Services 0% 0% 100% 0% 33% 0% 67% 0% Access to Other Support Services 0% 33% 67% 0% 0% 0% 100% 0% Workforce Recruitment and Retention 0% 67% 33% 0% 0% 67% 33% 0% Coordination/Integration with Other Systems 0% 33% 67% 0% 0% 67% 33% 0% Selected Issues Chemical Dependency Population Access to Prevention Services 0% 0% 100% 0% 0% 0% 100% 0% Access to Crisis Services 33% 33% 33% 0% 33% 33% 33% 0% Access to Treatment Services 0% 33% 67% 0% 33% 33% 33% 0% Access to Supported Housing 0% 0% 100% 0% 33% 0% 67% 0% Access to Transportation 0% 100% 0% 0% 33% 33% 33% 0% Access to Home/Community-based Services 0% 0% 100% 0% 0% 33% 67% 0% Access to Other Support Services 0% 0% 100% 0% 0% 0% 100% 0% Workforce Recruitment and Retention 0% 67% 33% 0% 0% 67% 33% 0% Coordination/Integration with Other Systems 0% 33% 67% 0% 0% 67% 33% 0%

Mental Illness Population High Needs In the Tug Hill Seaway region mental illness population, for population 21 and under, the area of highest need is access to crisis services. For adults (21+) the area of highest need is access to both crisis and treatment services

Chemical Dependency Population High Needs In the Tug Hill Seaway region chemical dependency population, for population 21 and under, the area of highest need is access to crisis services. For adults (21+) the areas of highest need are access to crisis and treatment services, supported housing and transportation.

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VI. Consumer and Provider Input

This section summarizes the Tug Hill Seaway region’s consumer and provider input regarding community behavioral health needs. Input for this region was collected by two clinics (Table 1). In the region, North Star serves rural areas of St. Lawrence County and SBH serves Lewis County.

Table 1. Tug Hill Seaway Region: Clinics that Submitted Consumer and Provider Input Counties Served in Clinic Region Citizen Advocates, Inc., North Star Behavioral Rural areas of St. Health Services (North Star) Lawrence Syracuse Brick House, Inc. d/b/a Syracuse Behavioral Healthcare (SBH) Lewis

Methods To collect data, clinics used focus group templates and/or anonymous surveys created by NYSOMH. These instruments are included in Appendix IV. Collectively, these data collection instruments focus on behavioral health concerns, available programming and services, potential disparities in service access and use, evidence-based practices, trauma-informed services, and recommendations regarding strategies to promote improved community health.

Participating clinics utilized the instruments to collect consumer, family, caregiver and provider input. Once collected, the clinics aggregated and submitted the consumer and provider input to NYSOMH. The consumer survey was made available in English and Spanish.

Participating clinics were asked to gather input from consumers and providers in and outside of the clinic, including:

 Clinic consumers ages 15 and older; parents or guardians of consumers younger than 15; and family members or caregivers of consumers. Consumer information was also collected from Veterans and individuals in foster care or homeless shelters who receive services from secondary related agencies that make referrals to behavioral health services.

 Provider surveys were administered to and focus groups were conducted with both participating clinics and secondary related agency providers.

When reporting survey multiple choice item results to NYSOMH, participating clinics recorded the frequency for each response option. The percentages reported in the tables below are based on those numbers as indicated. For open-ended questions, the clinics recorded the most frequently occurring responses or “themes”. All responses to

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open-ended survey questions are stated as they were submitted to NYSOMH by the clinics, and include response frequencies.

Participant Descriptions and Demographics Demographics and information about participating consumers and providers are reported in Tables 2a and 2b respectively. North Star surveyed 208 consumer and 39 providers. A majority of consumer respondents were ages 18-64 (80%), 18% were under age 18, and 1% were adults age 65 and older. Eighteen percent are not patients at North Star. More than a quarter (26%) of provider respondents do not practice at North Star.

SBH surveyed 370 consumers and three providers. All SBH consumer respondents were ages 18-64. All SBH provider respondents practice at SBH and all consumer respondents are patients there.

Table 2a. Tug Hill Seaway Region: Consumer Input – Table 2b. Tug Hill Seaway Region: Provider Input North Star SBH Consumer Demographics Provider Information (n=39) (n=3) North Star SBH % (n=208) (n=370) Survey Participants 100% 100% Participant Information % Focus Group Participants 0% 0% Survey Participants 100% 100% Do not practice at the Clinic 26% 0% Focus Group Participants 0% 0% Practice within the Clinic county 100% 100% Not patients at the Clinic 18% 0% Have a Master’s degree or higher 82% 33% Live in the Clinic county 75% 100% Age n=202

Under 18 18% 0% 18-64 80% 100% 65 or older 1% 0% Gender n=204 Male 38% 67% Female 61% 33% Race/Ethnicity* n=208 n=342

White 94% 73%

Black/African-American 1% 24% Asian 0% 0% Native-American 5% 0% Other Race 2% 0% Hispanic/Latino Ethnicity 3% 3% *The race/ethnicity question was asked only in the survey, not in the focus groups. Participants were instructed to select all that apply. Percentage is the number within each group divided by the number who responded to the question.

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Findings The consumer and provider input is organized into four domains: 1. Service Utilization, Perceived Service Needs, Barriers to Access, and Disparities in Access 2. Scope of Services in Treatment 3. Provider Training Needs 4. Participants Feel Welcome where they Receive Services

1. Service Utilization, Perceived Service Needs, Barriers to Access, and Disparities in Access

A. Service Utilization Table 3 shows the distribution of behavioral health services that respondents reported using (question 6, consumer survey).

Table 3. Tug Hill Seaway Region: Consumer Survey Input – Behavioral Health Services Used Service Category North Star SBH (n=208) (n=370) Mental Health Services % a. Outpatient mental health services - (e.g., outpatient clinic) 60% 9% b. Inpatient treatment 31% 6% c. Medication for mental health problems 59% 6% d. Residential treatment 18% 5% Substance Use Disorder Services e. Outpatient substance use disorder services (e.g., outpatient clinic) 25% 9% f. Inpatient rehabilitation 12% 4% g. Detoxification 9% 4% h. Residential treatment 7% 5% i. Medication for substance use problems (e.g., methadone or buprenorphine to treat opioid addiction) 15% 4% Other Services j. Case managers or providers who will meet individuals outside of an agency setting (e.g., in the home, church, school, homeless shelter, foster care setting, ER, recreational facility, jail) if necessary 38% 5% k. Providers who will meet with patients via phone or webcam 17% 2% l. Help with finding or maintaining employment 13% 2% m. Help with advancing education or seeking job training 11% 2% n. Help with finding, maintaining, or improving housing 15% 3% o. Education about mental health and substance use issues 24% 6% p. 24-hour crisis phone line 22% 3% q. 24-hour mobile crisis teams 11% 1% r. Peer delivered services (services provided by people who have experienced behavioral health problems and who work to help others with behavioral health problems; e.g., self-help groups, warmlines, and peer specialist services) 12% 4% s. Education and supports (e.g., support groups) for families of individuals in behavioral health treatment 18% 2% *These service categories are not mutually exclusive; one individual could be receiving more than one service.

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North Star For North Star, the most frequently reported services received include outpatient mental health services (60%), medication for mental health problems (59%), and case managers or providers who will meet individuals outside of an agency setting (38%). At least 25% of consumers reported receiving some form of SUD service. The least frequently received services include SUD residential treatment (7%) and detox (9%), and help with advancing education and seeking job training and 24-hour mobile crisis teams (11% each).

SBH For SBH, the most frequently reported services received include outpatient mental health services and outpatient substance use disorder services (9% each). The least frequently reported services are 24-hour mobile crisis teams (1%) and providers who will meet with patients via phone or webcam, help with finding or maintaining employment, help with advancing education or seeking job training, and education and support for families (2% each).

B. Perceived Service Needs

North Star North Star consumer respondents reported the following unmet service needs (consumer survey, question 9).

 Anger management for children  I live in southern St. Lawrence County and it is over an hour away from mental health

North Star provider respondents reported the following types of behavioral health services that they thought would be beneficial in their communities, but are currently unavailable (provider survey, question 7).

 Most respondents left this blank.  Ambulatory detox (n=4)  Inpatient mental health (n=4)  Housing (n=4)  Intensive day programs (n=2)  Inpatient detox; More social activities for clients; Children’s Day Treatment - used to have it; Mobile Crisis Team; Crisis for DD/MH clients for ER diversion; Transportation in rural area with few population centers; Services and program specifically for pregnant teens; Continue to grow integration of behavioral health into primary care practices; The crisis stabilization project/ambulatory detox that is in process (n=1 each)

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SBH At SBH, consumers did not report any unmet service needs (consumer survey, question 9). SBH provider respondents reported the following types of behavioral health services that they thought would be beneficial in their communities, but are currently unavailable (provider survey, question 7).  Onondaga County needs more residential services for women/children for both mental health and SUD (n=1)  Residential stabilization and rehabilitation for SUD (n=1)

C. Perceived Barriers Table 4a presents the percentages of consumers and providers that reported barriers to accessing behavioral health treatment (consumer survey, question 7; provider survey, question 4).

Table 4a. Tug Hill Seaway Region: Consumer and Provider Input -- Barriers to Accessing Behavioral Health Treatment North Star SBH Consumers Providers Consumers Providers Perceived Barrier (n=208) (n=39) (n=370) (n=3) Percentage that selected barrier Problems with transportation 11% 100% 7% 67% Took too long to get an appointment 7% 79% 0% 67% Problems paying for services 6% 31% 1% 67% Provider hours are not convenient 4% 10% 0% 0% No service provider in the area 3% 5% 0% 33% Service providers are not sensitive to other cultures 1% 10% 0% 0% Nearest service provider is too far away 2% 5% 0% 0% Services were not accessible to people with disabilities 1% 3% 0% 0% Service providers don’t speak my (or the patient’s) preferred language 0% 0% 0% 33% Services were not available to Veterans or members of the armed forces 0% * 0% * Services were not available to children or the elderly 1% * 0% * Local provider does not serve individuals with these particular problems 1% * 0% * Other 3% 5% 0% 0% *Provider responses to questions about access for particular demographic groups are reported in Table 4b North Star At North Star, problems with transportation, having to wait too long to get an appointment, problems paying for services, and inconvenient provider hours are the barriers most frequently reported by both providers and consumers. The survey administrators noted that “many” North Star providers clarified that "takes too long to get appointment" refers specifically to psychiatrists. North Star providers also reported that service providers are not sensitive to other cultures (10%).

SBH At SBH, the two barriers most frequently reported by both providers and consumers are problems with transportation and problems paying for services. Other barriers reported

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by providers include too long to get an appointment (67%) and no service provider in this area and service providers don’t speak patient’s preferred language (33% each).

D. Access Disparities Table 4b describes disparities in access to behavioral health services reported by providers (provider survey, question 5).

Table 4b. Tug Hill Seaway Region: Providers Input -- Access to Behavioral Health Services by Special Populations North Star SBH Total # % Answered Total # % Answered Special Population Respondents "No"* Respondents "No"* Veterans or members of the armed forces 30 3% 3 0% Children 39 0% 3 33% Children in foster care 37 0% 3 33% Elderly 30 3% 3 0% Homeless 33 3% 3 0% Incarcerated 33 0% 3 33% *Percentage is the number who responded "No" divided by the total number of respondents.

Three percent of North Star provider respondents stated that services are not available to Veterans, the elderly, and homeless individuals. One of three SBH providers reported that services are not available to incarcerated individuals, children, and children in foster care.

2. Scope of Services in Treatment Table 5 describes consumers’ experiences with evidence-based services, care coordination, and integrated care while receiving care from behavioral or physical health providers (consumer survey, question 8).

North Star At North Star, the most frequently provided services are: screen for depression, anxiety, substance abuse or another behavioral health problem; and information about how to get treatment for mental health and substance use issues (82% each). The least frequently provided services are: talk with other providers about your care (62%); and screen for a history of traumatic life events or abuse (64%).

SBH At SBH, the most frequently provided services are: screen for history of traumatic life events or abuse; screen for physical health problems; assess strengths, abilities, preferences, and goals; provision of clear information about crisis management or how to cope with mental health and substance use issues (100% each).

The least frequently provided services are: screen for depression, anxiety, substance abuse or another behavioral health problem; talk to you about the relationship between

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thoughts, behaviors, and feelings; and information about how to get treatment for mental health and substance use issues (30% each).

Table 5. Tug Hill Seaway Region: Consumer Input -- Scope of Services in Treatment North Star SBH Provider Service Total # % Answered Total # % Answered Respondents "Yes"* Respondents "Yes"* a. Screen for history of traumatic life events or abuse? 160 64% 370 100% b. Screen for depression, anxiety, substance abuse, or another behavioral health problem? 169 82% 10 30% c. Screen for physical health problems? 154 77% 370 100% d. Assess your strengths, abilities, preferences, and goals? 156 77% 370 100% e. Talk with other providers about your care? 150 62% 370 71% f. Talk to you about the relationship between thoughts, behaviors, and feelings? 140 81% 10 30% g. Provide clear information about: i. How to get treatment for mental health and substance use issues? 158 82% 10 30% ii. How to cope with mental health and substance use issues? 146 79% 370 100% iii. Crisis management? 153 76% 370 100% h. Met all of your health care needs? 160 77% 370 81% *Percentage is the number that responded "Yes" divided by the total number of respondents.

3. Provider Training Needs

North Star providers reported the following training needs (provider survey, question 6).

 All respondents said yes, additional training is always beneficial  Clinicians mentioned the challenge with trainings not being available in the north country and the inconvenience and cost associated with traveling downstate for specialized training (n=10)  Cultural Competency training needed (n=4) o One respondent from reservation stated providers could benefit from training on cultural sensitivity and treatment for Native Americans  While providers and several schools have done trauma informed care training, the community could benefit from education on trauma (n=3)  LGBT training (n=2)

SBH providers reported the following training needs.

 Trauma-informed care (n=3)  Traumatic Brain Injury screenings, Medication Assisted Therapies, and Grief/loss services (n=1 each).

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4. Participants Feel Welcome where they Receive Services As shown in Table 6, 3% of North Star consumers and 13% of SBH consumers reported not feeling welcome (consumer survey, question 10).

Table 6. Tug Hill Seaway Region: Consumer Input - Feeling Welcome where you Receive Behavioral Health Services North Star SBH Total # % Answered Total # % Answered Respondents "No"* Respondents "No"* 160 3% 370 13% *Percentage is the number who responded "No" divided by the total number of respondents.

Things that make North Star consumers feel welcome are listed below.  Friendly staff (n=42)  Smiles (n=9)  Helpful (n=6)  Comfortable environment (n=4)  Privacy (n=3)  Feel welcome, Professional, Respected, Wonderful customer service (n=2 for each response)  Someone is always available to see you, Good listeners, Easy to understand, Relaxing waiting area, More toys, Shorter wait time (n=1 each)

SBH reported that 87% of consumers report that “friendly and welcoming staff” are what makes them feel welcome.

Summary North Star surveyed 208 consumers and 39 providers. Syracuse Behavioral Healthcare (SBH) surveyed 370 consumers and three providers. Across both clinics, the most frequently reported needs among consumers and providers included:

 Transportation to health care services  Assistance with paying for services  Reduced wait times for an appointment  Behavioral health services for children  Local clinical training  Ambulatory detox  Inpatient mental health  Housing  Convenient provider hours (evenings and weekends)

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 575 New York State Office of Mental Health

Appendix A. Highlights of Tug Hill Seaway Region Needs Assessment Findings

Appendix A summarizes needs assessment findings that may impact providers meeting the health care service needs of the target consumer population in the Tug Hill Seaway region.

I. Population Characteristics Summary Highlights

Tug Hill Seaway Region: Population Characteristics Characteristic Region Region/County Comparison Median household $44,953  The Tug Hill Seaway region’s median household income income is below the state median of $58,687 and has the lowest median household income of any DSRIP region. Education 13% of adults in region are  Compared to DSRIP regions, the Tug Hill Seaway without a high school diploma region has the smallest percentage of adults with a and 18% have a bachelor’s bachelor’s degree or higher. degree or higher. Poverty 17% of region’s population live  Region has the 2nd highest percentage living below below poverty level the poverty level of any DSRIP region.  3% of the region’s population are on cash public assistance and 14% receive food stamps/SNAP benefits (the 2nd highest percentage in any DSRIP region). Public Health Insurance/ 35% of region’s population are  The Tug Hill Seaway population percentage on Medicaid/ Beneficiaries/ on public health insurance, 23% some type of public health insurance is 3rd highest No Health Insurance are Medicaid beneficiaries and across DSRIP regions. 10% have no health insurance. Special Populations 14% of the region’s population  The Tug Hill Seaway region has the highest are disabled and 12% are percentage of Veterans in any DSRIP region and Veterans. the 2nd highest percentage of disabled. Foreign Born 4% of the population are foreign  The Tug Hill Seaway percentage of foreign born is born. the smallest percentage of any DSRIP region. Primary Language other 7% of the region’s population  The Tug Hill Seaway percentage of those with a than English speak a primary language other primary language other than English is the smallest than English. percentage of any DSRIP region.  2% speak English less than “very well” (the lowest percentage in any DSRIP region).

II. Health Care Resources Summary Highlights A. Tug Hill Seaway Region: Health Care Professional Supply and Shortages Domain Region/County Region/County Comparison Supply of Primary 1. The region has 552 primary care 1. Lowest rate in any NYS DSRIP region (see Health Care Providers providers or 21 per 10,000 HPSAs below). population. Supply of Physical 1. The region has 225 physical 1. The 2nd lowest concentration of any DSRIP Health Care Specialists medical health specialists or 9 region. providers per 10,000 population. Supply of Licensed 1. The region has 437 licensed MH 1. This is the 2nd lowest rate in any DSRIP Mental Health (MH) professionals or 17 per 10,000 region. There is a mal-distribution of these Professionals population. providers (see HPSAs below). Substance Use Disorder 1. The region has a total of 134 1. In the Tug Hill Seaway region there is one (SUD) Professionals certified and credentialed physician certified in addiction medicine, the

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 1 New York State Office of Mental Health

Appendix A. Highlights of Tug Hill Seaway Region Needs Assessment Findings A. Tug Hill Seaway Region: Health Care Professional Supply and Shortages Domain Region/County Region/County Comparison SUD professionals or five per lowest number in any NYS DSRIP region. 10,000 population. Region’s HPSA County Designations Federal Health Primary Health Care: Professional Shortage All counties in the region have primary care Medically Underserved Area/Populations Areas (HPSAs) (MUA/Ps). In addition, all of the counties’ Medicaid eligible populations have been designated primary care MUPs. Mental Health Professionals: In the region all counties have a whole county MH professional shortage designation. All of the counties in the region also have a MH Medically Underserved Area/Population (MUA/P) designations. Jefferson and St. Lawrence counties’ Medicaid eligible populations have also been designated MH MUPs.

B. Tug Hill Seaway Region: Facility- and Program-based Health Care Supply, Service Rates and Constraints Facility/Program Region Region/County Comparison Physical Health Acute 1. The region’s nursing homes have no Care Hospitals behavioral health intervention beds. Mental Health Inpatient 1. Total psychiatric bed capacity in the 1. Psychiatric bed capacity for adults is 3rd Facilities region is 63 per 100,000 adults and 39 highest among all DSRIP regions. per 100,000 children. 2. In the region the total ADC per 100,000 adults is 49, which is the 2nd highest rate in any DSRIP region. The total ADC per 100,000 children is also 49, which is the highest rate in any DSRIP region. Substance Use Disorder 1. In the Tug Hill Seaway region there is 1. The total capacity per 10,000 for all (SUD) Inpatient one SUD inpatient crisis program and SUD inpatient programs is 7, the 3rd Programs two inpatient rehabilitation programs highest rate in NYS DSRIP regions. located in St. Lawrence County. The 2. The total ADE per 10,000 for these region’s six residential programs are programs is six, the 3rd highest rate in located in Jefferson (n=4) and St. NYS DSRIP regions. Lawrence counties. Mental Health Outpatient 1. Outpatient programs (other than clinic) 1. This is the lowest rate in any NYS and Clinic Programs are located in St. Lawrence County. DSRIP region There are a total of 48 non-clinic 2. In the region 3,019 adults received outpatient program slots in the region clinic treatment per 100,000 adults, the or 26 slots per 100,000 adults. 2nd highest rate in any NYS DSRIP 2. In addition to locally-operated clinics in region. all counties, the region has state- 3. In the region 2,871 children received operated clinics in St. Lawrence clinic treatment per 100,000 children, County serving adults and children. which is the 3rd highest rate in any NYS 3. There are child outpatient programs DSRIP region. St. Lawrence County’s other than clinic in Jefferson and St. rate of 4,368 children per 100,000 Lawrence counties. There are a total of children is the 3rd highest in any NYS 36 non-clinic outpatient program slots county. in the region or 52 slots per 100,000 children. MH Emergency and 1. In the region emergency programs are 1. The adult emergency services rate is Community Support located in St. Lawrence. In the region, the lowest in any DSRIP region. Programs 1 adult received emergency services per 100,000 adults. 2. The region has no emergency programs for children.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 2 New York State Office of Mental Health

Appendix A. Highlights of Tug Hill Seaway Region Needs Assessment Findings B. Tug Hill Seaway Region: Facility- and Program-based Health Care Supply, Service Rates and Constraints Facility/Program Region Region/County Comparison 3. In the region, 179 adults per 100,000 received services from community support programs located in all 3 counties. 4. Community support programs in the region served 162 children per 100,000. SUD Outpatient 1. In the region all counties except Lewis 1. The region’s SUD ADE rate is the 2nd Programs have SUD outpatient programs. The lowest in any NYS DSRIP region. average daily enrollment (ADE) is 24 per 10,000. 2. The region has no opioid treatment programs. It is the only DSRIP region without opioid treatment programs.

III. Health Status Tug Hill Seaway Region: Health Status Challenges/Strengths Domain Region/County Comparison Disease Prevalence  Among all DSRIP regions, the Tug Hill Seaway region has the highest average Chronic Health percentages of adults with diabetes (11%) and that are overweight or obese (68%) and Conditions the 2nd highest average percentage of adults with high blood pressure (30%).  Compared to all DSRIP regions, the Tug Hill Seaway has the lowest average case rates per 100,000 of both HIV and AIDS. Health Behaviors and  Among all DSRIP regions the region has the highest average rate of binge drinking Risk Factors (21%).  Jefferson and St. Lawrence Counties have the highest percentages of adults that report binge drinking (26% each, the highest rate in any NYS county). Premature  Among all NYS DSRIP regions, the region has the highest average rate per 100,000 of Deaths/Mortality premature death from stroke and the rate in Lewis County (n=24) is the 2nd highest in any NYS county.  Among all DSRIP regions, the region has the highest average death rate per 100,000 from cirrhosis of the liver (n=12) and the 2nd highest from suicide (n=14).  The Lewis County death rate from suicide is the highest of any NYS county. Patients in the Public Chronic Health Conditions: Among all DSRIP regions, the Tug Hill Seaway region has the Mental Health System highest percentages of patients that are smokers (33%), obese (20%) and that have hyperlipidemia (16%), and the 2nd highest percentage of those with high blood pressure (20%). Behavioral Health Diagnoses: Among all DSRIP regions, the region has the highest percentages of patients served with anxiety disorder (11%) and neurodevelopmental disorders (9%), the 2nd highest percentage with depressive disorders (29%), and the lowest percentage with schizophrenia and other psychotic disorders (14%). .

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 3 New York State Office of Mental Health

Appendix A. Highlights of Tug Hill Seaway Region Needs Assessment Findings

IV. Behavioral Health Care Utilization A. Tug Hill Seaway Region: Medicaid Beneficiary Health Care Utilization by Behavioral Health Diagnosis Domain Utilization by Diagnosis Region Mental Health Diagnosis Region-wide, the largest percentages of Medicaid beneficiaries with a mental health inpatient hospital admission had depressive disorders (47%), followed by other mental health diagnoses (17%), chronic stress and anxiety diagnoses Medicaid Inpatient (13%), schizophrenia (12%), bi-polar Admissions disorder (8%), and PTSD (3%). Substance Use Disorder Compared to all other DSRIP regions, the Tug Region-wide, the largest percentages of Hill Seaway region had the largest Medicaid beneficiaries with a SUD percentages of Medicaid beneficiaries inpatient hospital admission had alcohol hospitalized with alcohol use disorder, drug use disorder (27%), followed by drug abuse: cannabis/NOS/NEC, and other SUD abuse: cannabis/NOS/NEC (26%), opioid diagnoses. use disorder (22%), other SUD diagnoses (17%), and cocaine use disorder (8%). Mental Health Diagnosis Region-wide by diagnosis, the largest percentages of Medicaid beneficiaries with a mental health ER visit were for depressive disorders (41%), followed by other mental health diagnoses (23%), chronic stress and anxiety diagnoses Medicaid Emergency (14%), schizophrenia (11%), bi-polar Room Visits disorder (7%), and PTSD (4%). Substance Use Disorder Compared to all other DSRIP regions, the Tug Region-wide, the largest percentages of Hill Seaway region had the largest percentage Medicaid beneficiaries with a SUD ER visit of Medicaid beneficiaries with ER visits for were for cocaine use disorder (26%), other SUD diagnoses. followed by opioid use disorder (23%), drug abuse: cannabis/NOS/NEC (22%), other SUD diagnoses (21%), and alcohol use disorder (8%).

B. Tug Hill Seaway Region: Medicaid Mental Health and Substance Use Disorder Beneficiaries Compared to All Medicaid Beneficiaries Domain Utilization MH Medicaid In the region, 8% of all Medicaid beneficiaries had a mental health inpatient hospital admission and 19% had a mental health ER visit. SUD Medicaid In the region, 3% of all Medicaid beneficiaries had a SUD inpatient hospital admission and 6% had a SUD ER visit.

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 4 New York State Office of Mental Health

Appendix A. Highlights of Tug Hill Seaway Region Needs Assessment Findings C. Tug Hill Seaway Region: Medicaid Beneficiary Health Care Utilization by Eligibility Type Domain Utilization by Eligibility Region Medicaid Inpatient In the region 11% of Medicaid only Admissions beneficiaries and 14% of Medicaid/Medicare dual-eligible beneficiaries experienced at least one hospital inpatient admission. Medicaid Emergency In the region 37% of Medicaid only Compared to all other DSRIP regions, the Tug Hill Room Visits beneficiaries and 17% of Seaway had the highest percentage of Medicaid Medicaid/Medicare dual-eligible only beneficiaries with ER visits. beneficiaries experienced at least one ER visit.

V. Unmet Service Needs Tug Hill Seaway Region: Summary Highlights of Unmet Service Needs in Behavioral Health Treatment Domain Measure Region/County 1. Adherence to antipsychotic 1. Region-wide 60% of adults with schizophrenia medications for individuals adhere to their medications (40% do not). with schizophrenia for at least 80% of their treatment period. Mental Health

Medication 2. Antidepressant medication 2. Region-wide 55% of individuals remain on their Adherence and management effective acute medication during the entire acute treatment phase.  Management phase treatment. Among all DSRIP regions, the Tug Hill Seaway region has the highest adherence to antidepressants for the acute phase. 3. Antidepressant medication 3. Region-wide 37% of individuals remain on their management effective medication during continuation phase treatment continuation phase treatment. (63% do not). 1. Follow-up care after 1. Region-wide 32% of individuals have follow-up care hospitalization for mental within 7 days (68% do not) and 46% follow-up within illness within 7 or 30 days of 30 days of discharge (54% do not). hospital discharge.  Among all DSRIP regions, the region has the lowest percentages of both seven day and 30 day follow-up care after hospitalization for mental illness. Mental Health Follow- 2. Follow-up care for children 2. Region-wide 59% of children prescribed ADHD up Care prescribed ADHD medication medication have one follow-up visit with a initiation phase. practitioner within 30 days after starting the medication. 3. Follow-up care for children 3. Region-wide 61% of children with a new prescription prescribed ADHD medication for ADHD medication remain on the medication for 7 continuation and months and/or have at least 2 follow-up visits in the maintenance phase. 9-month period after the initiation phase. Alcohol and other 1. AOD Initiation 1. Region-wide 48% of individuals initiate AOD Drug Dependence treatment within 14 days of diagnosis. (AOD) Initiation and 2. AOD Engagement 2. Region-wide 24% of individuals engage in AOD Engagement treatment within 30 days after initiation (76% do not). Treatment Potentially Avoidable 1. Chronic Composite PQI 1. Among all DSRIP regions, the Tug Hill Seaway Hospitalizations region has the highest chronic composite ratio (Conditions for which (781/678) for the Medicaid only population. good outpatient care can potentially prevent the need for hospitalization or for which early intervention can prevent

Tug Hill Seaway DSRIP Region Needs Assessment – December 2016 5 New York State Office of Mental Health

Appendix A. Highlights of Tug Hill Seaway Region Needs Assessment Findings Tug Hill Seaway Region: Summary Highlights of Unmet Service Needs in Behavioral Health Treatment Domain Measure Region/County complications)

Potentially Avoidable 1. Potentially avoidable ER 1. Among all DSRIP regions, the Tug Hill Seaway ER Visits visits region has the highest observed to expected ratio (27/19) for potentially preventable ER visits.

VI. Consumer and Provider Input Tug Hill Seaway region counties’ surveys of consumer and provider stakeholders to assess local needs indicate that access to crisis services and treatment services are issues that need attention for the populations with mental health and/or chemical dependency concerns.

Clinics in the Tug Hill Seaway region surveyed a total of 578 consumers and 42 providers. The needs most frequently reported by both consumers and providers include: transportation to health care services; assistance with paying for services; reduced wait times for an appointment; convenient provider hours (evenings and weekends); behavioral health services for children; and local clinical training.

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