Allegany County Department of Health Community Health Assessment 2014-2017 and Community Health Improvement Plan 2014-2017

Lori Ballengee, M.S. Public Health Director

Thomas E. Hull, M.S. Deputy Public Health Director

Laurie Hennessy, RN, BSN Director of Patient Services

The 2014-2017 Community Health Assessment was compiled and written by Theresa Moore Supervising Public Health Educator

County Office Building 7 Court Street Belmont, New York 14813 Tel: 716-268-9250 Fax: (716)-268-9264

Table of Contents

A. Community Health Assessment (CHA) 1. A description of Allegany County a. Demographics of the population served b. Health status of the population served 2. Main health challenges for Allegany County and contributing causes of health challenges 3. Summary of assets and resources to address health issues 4. Process and methods used to conduct the assessment B. Community Health Improvement Plan (CHIP) 1. Identification of priorities from the Prevention Agenda 2013 2-6 are included in CHIP grid 2. Goals and objectives 3. Individuals and organizations implementing strategies 4. Outcome and process measures 5. Description of strategies and best practice or evidence-based practices 6. Description of process for maintaining, tracking, and making changes to CHIP

Attachments:  Allegany County Community Health Assessment Survey  Allegany County Integrated Health Plan 2013-2014 Report (summary of survey and focus groups)  Allegany County Data 2013-Community Health Assessment (Power point)  Allegany County Obesity Related Services-provider survey results  Allegany County Obesity tables  Allegany County Child Psychiatric Services-Provider Survey results  Allegany County Department of Health Organizational Chart

COVER PAGE

Local Health Department/Unit Address: Allegany County Health Department

7 Court Street, Belmont, New York 14813

Telephone: (585) 268-9250 Fax: (585) 268-9264

Submitted by: Theresa Moore E-MAIL: [email protected]

Prepared by: Theresa Moore, Supervising Public Health Educator

GENERAL COUNTY INFORMATION

Health Department Type (please check one):

XX Full Service Less than Full Service

Organization Type (please check one):

XX Single Agency _____ Multiple Agency, (Health Only) please list: ______

Sources of Data Information on the demographic and population characteristics of Allegany County were obtained from the following:  2010 U.S. Census Data  2007-2011 American Community Survey 5 year Estimates (U.S. Census)  People Quick-facts for the U.S. Census  New York State Vital Statistics  New York State Expanded Behavioral Risk Factor Surveillance System (BRFSS) July 2008-June 2009  New York State District Report Card Comprehensive Information Report  National Center for children in Poverty  New York Makes Work Pay (NYMWP) project  United States Bureau of Labor  Uniform Crime Reporting Program  Allegany County Indicators for tracking Public Health Priority Areas, 2013-2017-various data sources

A. Community Health Assessment (CHA)

1.Description of Allegany County Allegany County is a rural county located along the Southern Tier of Upstate New York, with an Area of 1,030 square miles. It is bordered by Cattaraugus, Wyoming, Livingston, and Steuben Counties in New York State, and by McKean and Potter counties in Pennsylvania.

a.Demographics of population served The 2010 U.S. Census data shows Allegany County population at 48,949, a decrease of 1.96% from the 2000 U.S. Census (see line graph below). The average births from 2008-2011 for Allegany County was 511 per year. The population density is 47.6 people per square mile. The county has 12 public school districts, 29 townships and 10 villages. Population concentrations are in Wellsville, Alfred, Cuba, Bolivar and Andover.

Allegany County Population * Census data ** Census estimate

55000 50000 45000

40000

1960 1970 1980 1990 2000 2010

2012**

Gender, Race and Age The 2010 U.S. Census showed the median age of Allegany County residents to be 37.8 years, with 50.5% male to 49.5% female ratio, slightly less than 1:1. Caucasians comprise the vast majority of county residents, making up 96.2% of the population. African Americans, 1.1%; American Native/Alaska Native, 0.2%; Asians, 0.9% and 1.2% other racial groups total the remaining 3.8%. Allegany County percentages of Racial group

Caucasian

Africian American

Asian

American Native/ Alaska Native Other

Census data also shows that 27.71% of the population is 19 years of age or younger. From 1970 to present, there has been little change in the composition of this age group. A little over 57.09% of the population is age 20-64 and 15.21% is age 65 or older. The data also indicate that the county’s population is living longer. In 1970, the population age 65 and over totaled 5,113. By 1994, this number had increased 40%, to 7,159, in 2000 it increased to 7,000, and in 2010 it increased to 7,443 (an increase of 6.3%) (See chart below)

Age Distribution of Residents of Allegany County, New York: 2010 U.S. Census Age Group Number of Percent of Number of Percent of Difference Persons Population persons 2000 Population percentage 2010 2010 2000 of population < 5 years 2,667 5.4% 2,798 5.6% -0.2 5-9 years 2,895 5.9% 3,267 6.5% -0.6 10-14 years 3,048 6.2% 3,866 7.7% -1.5 15-19 years 4,953 10.1% 5,250 10.5% -0.4 20-24 years 4,761 9.7% 4,737 9.5% +0.2 25-34 years 4,866 9.9% 5,040 10.1% -0.2 35-44 years 5,203 10.6% 6,902 13.8% -3.2 45-54 years 6,832 14% 6,505 13.0% +1.0 55-59 years 3,295 6.7% 2,431 4.9% +1.8 60-64 years 2,983 6.1% 2,131 4.3% +1.8 65-74 years 3,931 8.0% 3,748 7.5% +0.5 75-84 years 2,503 5.1% 2,328 4.7% +0.4 >85 years 1,009 2.1% 924 1.9% +0.2 Totals 48,946 100% 49,927 100% -1.97%

Income Income levels in Allegany County are among the lowest in the state. The 2010 census shows the county’s per capita income as $26,953, with median household income at $41,900. The New York State median household income was $56,951 in 2010, while the 2010 national figure was $52,762.

Allegany County New York State United States 2010 Median Household income $41,900 $56,951 $52,762 2010 Annual Per Capita Income $26,953 $48,596 $39,937 2007-2011 per capita money income (2011 dollars) $20,047 $31,796 $27,915

The 2010 percentage of residents living below 100% of poverty is 17.2%, up from 15.5% in the 2000 Census. A total of 15% of New Yorkers live at or below the poverty level while 15.3% nationally live at or below poverty level.

In the table below the 2005-2007 estimates U.S. Census are compared to 2007-2011 estimates U.S. Census for the numbers and percentage of Allegany County Residents living below the Federal Poverty Level Standards. The 2007-2011 data shows Allegany County at 16.6% for all persons living below poverty, a slight decrease from 2005-2007 and above NYS at 14.5%. In 2007-2011 the percentage of families with children under 5 years living in poverty is 22.6%, an increase from 2005-2007 which was 21.3%. The 2007-2011 percentage families with a female householder and no male present and related children under 5 years, living under poverty is 49.6% a decrease from 61.8% in 2005-2007. 6

Population Group Allegany County Percent Below Poverty Percent Below Poverty Level 2005-2007 Level 2007-2011 All persons 16.7 16.6 Persons 18 years and over 15.2 14.7 Persons 65 years and over 8.2 9.3 All Families 11.0 11.6 Families with children under 5 years of age 21.3 22.6 Female Head of Household Families 38.3 37.3 Female Head of Household families, no 61.8 49.6 male present and related children under age 5 years

The American Community Survey 5 year estimates of U.S. Census data provided the following income data for Allegany County inflation adjusted dollars.

American Community Survey (U.S. Census) 1998 2000 2007 2011 % of households with income less than $10,000 17.2 12.1 8.8 7.8 % of households with income of $50,000+ 13.7 27.1 36.5 40.7 % of households receiving public assistance 10.2 4.4 3.4 3.9

The National Center for Children in Poverty shows in 2011 40% of the children in New York State were living in low-income families, 43% in rural areas. County specific percentages were not available from this source, Allegany County falls into the rural percentages for New York State with 43% rural low-income.

Income status of children under age 18, by residential area, 2011 50 state data 2011 American Community Survey Urban Rural Low income Above low income Low income Above low income National 43% 57% 52% 48% New York 40% 60% 43% 57% Definitions: Low Income-Families and children are defined as low income if the family income is less than twice the federal poverty threshold. Poor-Families and children are defined as poor if family income is below the federal poverty threshold. The federal poverty for a family of four with two children was $22,350 in 2011 and $22,050 in 2010. Rural- An area that is not in a metropolitan statistical area (MSA), as defined by the U.S. Census Bureau.

According to the New York State Department of Health in 2011, Allegany County’s Medicaid/Family Health Plus/Self-Pay Labor and Delivery rate continues to increase, 57.42% and continues to be higher than the NYS rate of 50.21%. In 2007 Community Health Data Set, our Medicaid and Self-pay Delivery rate was 46.7% while the NYS excluding NYC percent is 33.8.

According to the New York State District Report Card Comprehensive Information Report Alfred-Almond also had the least number of children eligible for the Free Lunch Program in

2011-2012 with 21%, and 10% of their population received free lunches. In the same school year Friendship School had the most students eligible for Free lunches at 61% of their population, while only 10% of their students actually receive them. Please see Table below for a complete listing of eligibility and usage by school district.

School District % % % Eligible % % Eligible % Receiving Eligible Receiving for Free Receiving for Free Free/Reduce for Free Free/Reduce Lunch Free/Reduc Lunch Lunch Program Lunch Lunch Program in e Lunch Program in in 2011-2012 Program Program in 2010-2011 Program in 2011-2012 in 2009- 2009-2010 2010-2011 2010 Alfred-Almond 19 11 23 7 21 10

Andover 33 13 25 17 38 15 Belfast 31 16 36 13 37 15 Bolivar- 44 15 45 11 42 15 Richburg Canaseraga 32 13 36 11 40 10 Cuba-Rushford 32 9 40 11 44 10 Fillmore 36 14 37 9 35 9 Friendship 53 13 58 12 61 10 Genesee Valley 35 10 29 18 39 8

Scio 42 16 48 13 51 14 Wellsville 32 12 36 11 36 12 Whitesville 19 13 27 6 22 8 Source: New York State Education Department-NYS District Report Card

Disabilities According to the New York Makes Work Pay (NYMWP) project and the American Community Survey (ACS) for 2008-2010 focusing on working-age population 18-64 years old, Allegany County has 12% of women and 10.3% of men reporting a disability in comparison with 8.5% and 8.6%, respectively, in New York State. The working-age population of Allegany County is estimated to be 31,000 with 11.1%, 3,500 individuals having reported one or more disabilities. The prevalence of disabilities in Allegany County is greater than the statewide average of 8.5% and the national average of 10%. Allegany County ranked 27th highest in or disabilities prevalence among the 60 counties in this report of New York State counties. Some estimates of the “Disability and Employment Status Report for Allegany County” are based on data specifically for Allegany County while others are based on a larger geographic area called a Public Use Microdata Area (PUMA) which include Allegany and Cattaraugus County. In this larger area PUMA Allegany County accounts for 38.8% of the working-age population. Working people in the PUMA with Allegany County disability types are reported: 5.9% ambulatory disability, 4.7% cognitive disability, 3.4% independent living disability, 1.7% self-

8 care disability, 1.9% visual disability and 2.6% hearing disability. 5.1% of individuals reported two or more disabilities included in these six types. In the PUMA containing Allegany County, there are 4,600 civilian veterans 18 years and older, 12.5% reported a service-connected disability. The employment rate for working age individuals with disabilities is 27.4% and 72.2% for individuals without a disability. New York State’s employment rates, in comparison, are 27.4% and 73.9%. In the larger PUMA area that contains Allegany County, working-age individuals with disabilities that did not graduate from high school was 20.4% compared to 7.8% of individuals without disabilities. In Allegany County 36.2% of working-age people with disabilities live below the federal poverty level which is three times the poverty rate for people without disabilities.

Mobility

Access Allegany has been working to improve transit service to the people of Allegany County since 2007. The service area includes most of the communities in Allegany County. The bus routes connect townships across the region, major employment centers, shopping areas, and healthcare facility in the county. The service offers five bus routes, an express route in Wellsville and seven supplemental flex routes. Allegany County residents have consistently increased their ridership each year. Mass transit is not as accepted in rural Allegany County as in urban areas of New York State. The 2007-2011 American Community Survey 5-year Estimates for Allegany County workers 16 years and over total 20,851 and the table below is a breakdown of how they commute to work. Their mean travel time to work is 21.3 minutes.

2007-2011 Allegany County Commute to work for workers 16 years and over

worked at home

Other means

Walked

Public Transportation (Excluding taxicab)

Car, Truck, or van (carpooled)

Car, Truck or van (drove alone)

0 5,000 10,000 15,000 20,000

Educational attainment The 2010 U.S. Census showed that 30,495 Allegany County residents 25 years of age and older 9

who had ever been enrolled in school (see table below) 8.6% have less than a high school diploma or equivalency degree; 3.5% having less than a 9th grade education; and 41.4% have a high school diploma or equivalency degree. 29.8% have an advanced degree with the following breakdown, 12.4% have an Associate’s Degree, 8.7% have a Bachelor’s Degree and 8.7% hold a Graduate or Professional Degree. In comparison the 2005-2007 U.S. Census showed that educational attainment status was available on 30,010 people, 25 years and over, who had ever been enrolled in school. Of these, 11.6% have less than a high school diploma or equivalency degree, with 3.7% having less than a 9th grade education. Of those ever-enrolled in school, 31.2% have an advanced degree with the following breakdown, 12.6% have an Associate’s Degree, 8.8% have a Bachelor’s Degree and 9.8% hold a Graduate or Professional Degree.

Allegany County residents 25 years of age and older who had ever been enrolled in school 2010 U. S. Census

3.5% 8.7% < 9th Grade 8.6% Education 8.7% < High School Diploma

High School Graduate

2 Year Degree 12.4%

41.4% 4 Year Degree

Post-Graduate

Allegany County School Enrollment 2007-2011 U.S. Census 2005-2007 U.S. Census Population 3 years & over enrolled in school 14,815 14,727 Preschool 3.65% 4.4% Kindergarten through 12th grade 53.63% 59.2% College 42.74% 40.8%

The New York State Department of Health reports the school dropout rate for Allegany County over the three year period of 2008-2010 was 1.8 compared to New York State’s rate of 2.8 and NYS excluding NYC’s rate of 2.0.

There are 12 Public School Districts in Allegany County. According to the New York State District Report Card Comprehensive Information Report, 11 of the 12 districts are Category 4 Schools, which means they are rural schools with high student needs in relation to district resource capacity. Only Alfred-Almond School District is a Category 5, which denotes average student needs in relation to district resource capacity.

Home ownership The People Quick-facts for the U.S. Census identified in 2010, 26,140, total housing units within the county and 18,208 are occupied housing units. Of these housing units 41% were built before 1940. Of the 18,208 occupied housing units, .8% lack complete plumbing facilities, 1.4% lack complete kitchen facilities, and 2.5% have no telephone service available. According to Allegany County Environmental Health statistics for 2013, approximately 50% obtained their water from a public water supply, while the remaining 50% had private water sources such as wells and springs, while 35% were connected to a public sewer, with 65% having individual sewage disposal systems, such as septic systems, cesspools, etc. Median monthly mortgage payments for owner-occupied housing units (with a mortgage 7,476) were $1,007 (a 9% increase from 2005-2007), with 32.1% of homes valued at less than $50.000. Another 42.8% of these homes are valued at $50,000 to $99,000, for a total of 79.9% of the homes in Allegany County valued at less than $100,000. The median monthly rent for occupied units was $584 (38% increase from 2005-2007). In 2007-2011 the total number of households within the county, 18,936; 74.4% is the homeownership rate; the average number of persons per household is 2.32; and the median value of owner-occupied housing units is $66,800. Of these, 69.8% moved into their housing unit in 1990 or later, 13.1% moved into their housing unit between 1980-1989, 8.5 % had moved between 1970-1979, and 8.7% had moved in during 1969 or earlier. The 2007-2011 Census data shows an average owner occupied household size is 2.39 (renter occupied units is 2.10) and the average family size is 2.79. The majority of households in Allegany County (67%) are family households, while 11.5% are householder 65 years and over. Additional data showed that 2.5% of the occupied units had no telephone, 7.3% had no vehicle, and 92.8% had one or more vehicles.

Employment status According to the U.S. Census Bureau, 2007-2001 American Community Survey, Allegany County had an estimated 21, 595 civilian employed population 16 years and over. Management, professional and related occupations remains the number one occupational category and sales and office occupations is still number two. Construction/extraction/maintenance occupations and farming/forestry/fishing occupations were not in the top five occupations in 2007-201. Natural resources/construction/maintenance moved into the top five in 2007-2011.

Occupational Status of Labor Force, by Percent, Allegany County, New York: 2007-2011 U.S. Census

Occupational Category Percent of Labor Percent of Labor Force 2007-2011 Force 2005-2007 Management, professional, and related 31.7 30.9 Occupations Sales and Office Occupations 20.6 20.3 Service Occupations 19.5 19.5 Production, transportation and material moving 15.8 16.6 Occupations Construction, extraction and maintenance Not in top 5 10.8 Occupations Farming, Forestry, and Fishing Occupations Not in top 5 1.9 Natural resources, construction and maintenance 12.3 Not in top 6 occupations

For the industrial occupational status of the labor force by percentage, educational services/health care/social assistance remains number one and manufacturing increases the percentage and remains number two. Industrial Occupational Status of Labor Force, by Percent, Allegany County, New York: 2007-2011 U.S. Census Rank Industry Estimated Percentage Percentage number 2007-2011 2005-2007 individuals 1 Educational services, and health care and social 7,481 34.65 34.8 assistance 2 Manufacturing 3,458 16.02 14.9 3 Retail Trade 2,231 10.34 9.7 4 Construction 1,590 7.37 7.7 5 Arts, entertainment and recreation, and 1,407 6.52 6.6 accommodation and food services 6 Other services, except public administration 949 4.40 4.3 7 Public Administration 919 4.26 3.6 8 Transportation and warehousing, and utilities 865 4.01 4.0 9 Professional, scientific, and health care and social 851 3.94 4.9 assistance 10 Agriculture, forestry, fishing and hunting, and 743 3.44 3.7 mining 11 Finance and insurance, and real estate and rental 465 2.16 2.2 and leasing 12 Wholesale trade 318 1.48 2.0 12 Information 318 1.48 1.6 12

TOTAL 21,595 100 100

According to the 1990 U.S. Census, Allegany County’s labor force population (individuals > age 16) was 38,889. The 2000 US Census shows a slight increase to 39,335. The 2005-2007 census estimates show an increase to 40, 751. In the 2005-2007 census estimates, 25,102 (50.5%) represented the civilian labor force, of which 22,485 were employed. By worker class, 73.8% were private wage and salary workers, 18.4% were local, state, or federal government workers, and 7.5% were self-employed. By occupational category, most employees worked in professional specialty occupations, administrative support occupations, service occupations, or sales and office occupations. By specific industrial category, educational, health and social service workers comprised the largest group, followed by those manufacturing durable goods, retail trade, construction, and arts, entertainment, recreation, accommodation and food services. The county has few industrial employers of any size.

Allegany County Business Location Product type Number of employees Dresser Rand Co. Wellsville, NY Steam Turbines, Generators 700 Otis Easter, Inc Wellsville, NY Pipe line Construction 50 (NY) & 645 (NY & PA) Allegany County Belmont, NY Government 540 Alfred State College Alfred, NY Education 537 Alfred University Alfred, NY Education 518 Alstrom Power, Inc Wellsville, NY Air Heaters/Oxidizers 500 Allegany ARC Wellsville, NY Services for Developmentally disabled 383 Jones Memorial Hospital Wellsville, NY Medical Services 348 Swain Ski and Snowboard Center Swain, NY Ski Resort 340 (winter) Houghton College Houghton, NY Education 300 Friendship Dairies Friendship, NY Dairy products 265 Cuba Memorial Hospital Cuba, NY Medical Services 222 Empire Cheese Cuba, NY Cheese products 220 L.C. Whiford Co, Inc. Wellsville, NY Construction 200

According to the United States Bureau of Labor, the June 2013 unemployment rate (not seasonal adjusted) for Allegany County was 7.8%, New York State’s rate was 7.6% and the national rate was 7.8%. This is down from the June 2009 unemployment rate for Allegany County of 9.7%, (New York State’s rate was 8.6% and the national rate was 9.5%). The 2005-2007 estimates for the US Census shows an unemployment rate of 6.4% for Allegany County. The NYSDOH County Health Indicator Profile (2004-2006) showed an unemployment rate of 5.7% for Allegany County, while the state rate (excluding New York City) was 4.6%. Allegany County consistently has unemployment rates higher than the state.

Health insurance status and Access to a regular source of care The New York State (NYS) socio-economic status and general health indicators for Allegany County for 2008-2010 show 93.8% of children ages less than 19 with health insurance in 2010 compared to NYS with 94.9 %. The same data set showed adults, ages 18-64 years with health insurance in 2010 was 85.3% in comparison to NYS with 83.1 percent. This data also showed an age-adjusted 13.3% of adults in Allegany County, 13.8 % in NYS and 12% in NYS excluding

New York City (NYC), who did not receive medical care because of the cost in 2008-2009. The NYS data also showed age-adjusted 83.6% of adults with a regular health care provider in 2008- 2009 in Allegany County, in NYS 83% and in NYS excluding NYC 87.1%. For the 3 year period 2008-2010 the total emergency department visit rate per 10,000 for Allegany County was 3,660.2, NYS 3821.2 and NYS excluding NYC 3,544.4. In comparison the age adjusted total emergency department visit rate per 10,000 was 3,716.4 for Allegany County, 3,8121.2 for NYS, and 3,556.7 for NYS excluding NYC. The total hospitalization rate per 10,000 for Allegany County was 1,196.1, for NYS 1,290.5 and NYS excluding NYC 1,223.2. Age adjusted total hospitalization rates per 10,000 were 1,155.2 for Allegany County, 1,242.5 for NYS, and 1,167.6 for NYS excluding NYC.

In Allegany County the ratio of 18 physicians to population is physicians to 48,949 residents in 2010, 2,719.4 residents to each physician. In Allegany County the ratio of dentists to population is 11 dentists to 48,949 residents in 2010, 4449.9 residents to each dentist.

New York State Expanded Behavioral Risk Factor Surveillance System in 2008-2009 reported for Allegany County the:  Age adjusted percentage of adults who did not receive medical care because of the cost in 2008-2009 was 13.3 compared to NYS at 13.8 and NYS excluding NYC at 12.  Age adjusted percentage of adults with regular health care provider in 2008-2009 was 83.6, NYS 83 and NYS excluding NYC was 87.1 Vital Records NYSDOH Bureau of Biometrics and Health Statistics reports for Allegany County in 2008-2010 the  Age adjusted total emergency department visit rate per 10,000 is 3,716.4 compared to NYS 3,819.5 and NYS excluding NYC is 3,556.7  Age adjusted total hospitalization rate per 10,000 is 1,155.2 compared to NYS 1,242.5 and NYS excluding NYC is 1,167.6.

Immigrant/migrant status According to the U.S. 2010 Census for Allegany County, 670 individuals or 1.4% reported they were Hispanic or Latino. Immigrant, migrant residents or seasonal workers may not consistently complete documents like the U. S. Census. Several agencies working within Allegany County have reported in increase in the number of year round and seasonal migrant farm workers. Statistics for either group is unavailable or unstable. Cornell Cooperative Extension of Allegany and Cattaraugus Counties reported 12-15 year round immigrant employees on four farms in Allegany County in the townships of Rushford, Angelica, Scio and Wellsville. They do not know of any migrant, seasonal employees working in Allegany County for agricultural production.

Other Relevant Characteristics and Demographic Data

According to New York State Vital Statistics Data from 2009-2011, there were an average 264 marriages in Allegany County, which outweighed the 2009-2011 average of 166.67 for divorces.

Data collected for 2007, 2008, 2010, and 2011 by the FBI as part of the Uniform Crime

Reporting Program illustrates offenses reported to and arrests made by State and Local law enforcement that report data to the FBI. These data do not include Federal law enforcement activity. Data indicates that in 2011 69% of the reported crimes committed were larceny – thefts, while 21% were burglaries and 5.26% were aggravated assaults.

Crime 2007 2008 2010 2011 Total 707 649 841 895 Murder 1 0 0 0 Rape 10 10 11 13 Robbery 2 4 6 4 Aggravated Assault 73 77 72 47 Burglary 195 174 161 190 Larceny-Theft 410 366 577 621 Motor vehicle thefts 16 18 14 20

According to 2012 Kid’s Well-Being Indicators Clearinghouse (KWIC) data, the rate of Persons in Need of Supervision (PINS) cases opened in Allegany County was 10.2 per 1,000 7-17 year olds compared to the base year of 2005 rate, 16.8 per 1,000.

According to New York State Department of Health Community Health Indicator Profile Data for 2008-2010, the overall adolescent pregnancy rate for Allegany County is 17.5 per 1,000 females age 15-17 (in 2004-2006 the adolescent pregnancy rate for Allegany County was 24.8 per 1,000 females age 15-19, and the Western New York regional rate is 49.9) compared to 31.1 for New York State. Our adolescent pregnancy rates continue to be lower than New York State and the Western New York region, as they have been for more than eleven years.

Total Births for the 29 townships and 11 villages in Allegany County using 2002-2011 New York State Vital Statistics Live Births by Minor Civil Division Table 55 are in the table below. The townships with the highest live birth averages are Wellsville, Cuba, Hume, Friendship, and Bolivar. The Villages with the highest live birth averages are Wellsville, Cuba and Andover.

29 Townships Total live births from 10 year 11 Villages Total live births 10 year 2002-2011 average from 2002-2011 average Alfred 160 16 Alfred 50 5 Allen 41 4.1 Almond 49 4.9 Alma 97 9.7 Belmont 118 11.8 Almond 181 18.1 Andover 136 13.6 Amity 275 27.5 Angelica 114 11.4 Andover 250 25 Bolivar 150 15 Angelica 159 15.9 Richburg 36 3.6 Belfast 228 22.8 Canaseraga 59 5.9 Birdsall 25 2.5 Cuba 241 24.1 Bolivar 288 28.8 Wellsville 614 61.4 Burns 116 11.6 Richburg 52 5.2 Caneadea 187 18.7 Centerville 128 12.8 Clarksville 122 12.2 Cuba 348 34.8 Friendship 294 29.4 Genesee 176 17.6 Granger 45 4.5 Grove 40 4 Hume 298 29.8 Independence 154 15.4 New Hudson 106 10.6 Oil Springs 2 0.2 Rushford 120 12 Scio 186 18.6 Ward 33 3.3 Wellsville 896 89.6 West Almond 21 2.1 Willing 118 11.8 Wirt 128 12.8 Allegany County is an extremely poor county that is extremely rural. The county has a large geographic area, but public transportation is limited, which can make it difficult to access services. The county is one and a half to two and a half hours from a large, metropolitan area. We have a high unemployment, high percentage of students eligible for free/reduced lunch and high Medicaid/Family Health Plus/Self-pay delivery rate compared to the rest of the state. All of these factors contribute to the poor health of Allegany County, and public health services are an important part of the health of the county.

b. Health status of the population served Information about the health status of the residents of Allegany County begins with a section entitled Improve Health Status and Reduce Health Disparities. Other sections are organized using the five prevention agenda priorities for 2013-2017: Prevent Chronic Diseases; Promote a Healthy and Safe environment; Promote Healthy Women, Infants, and Children; Promote Mental Health and Prevent Substance Abuse; and Prevent HIV, STDs, Vaccine Preventable Diseases and Healthcare Associated Infections. The topics included in the five prevention agenda priorities for 2013-2017 were included in the community assessment survey. See the attached copy of the survey and the summary of the survey results. Also see the summary of the focus group discussions in the attached document.

Improve health status and reduce health disparities The health indicators for health status and disparities are shown in the table below. Allegany County is not very racially diverse and premature death ratios showing black non-Hispanic and white non-Hispanic are unstable. The disparities indicators for Allegany County are less than, in line with or slightly above the New York State (NYS) rates.

Improve Health Status and Reduce Health Data Allegany New York NYS 2017 Disparities Indicators years County State Objective % premature death (before age 65) 2008-2010 2008-10 19 24.2 21.8 Premature Death ratio black non-Hispanics to 2008-10 Unstable* 2.12 1.87 white non-Hispanics Premature Death ratio of Hispanics to white 2008-10 Unstable* 2.14 1.86 non-Hispanics Age adjusted preventable hospitalizations rate 2008-10 151.6 155 133.3 per 10,000 ages 18+ ratio black non-Hispanics to white non- 2008-10 0.86 2.09 1.85 Hispanics ratio of Hispanics to White non-Hispanics 2008-10 0.1 1.5 1.38 % Adults with health insurance ages 18-64 2010 85.3 83 100 Age adjusted % of adults who have a regular 2008-09 83.6 83 90.8 health care provider, ages 18+ *Fewer than 10 events in one or both rate numerators, therefore the ratio is unstable

Promote a Healthy and Safe environment

The table below includes the indicators for a healthy and safe environment including fall injuries, assault, occupational injuries and illness attributed to exposures at work, fluoridation of public water supplies, access to grocery stores and transportation. To note fall hospitalization rate per 10,000 for children less than 10 years of age and 10-14 years were both higher than the NYS 17

excluding NYC rate, in the 4th quartile and statistically significant. The percentage of commuters who use alternate modes of transportation is very low compared to NYS. This low number may be attributed to the limited access to public transportation and lack of knowledge and confidence in the new bus system. The percentage of residents served by community water systems with optimally fluoridated water is very low compared to NYS. Fluoridation of the community water supplies in Allegany County is in most cases not cost effective when comparing the cost of the equipment and supplies with the number of residents using the water supply. Allegany County has two public water supplies with fluoridation and about 50% of the total county residents have private water sources.

In comparison to the data from 2006-2008 the rate of hospitalizations due to falls per 10,000 shows:  Ages 65+ in 2008-2010 is 187.8 for AC and in 2006-2008 for ages 65-74 was 64.7, ages 75-84 was 253.6, and ages 85+ was 542.6. In AC, great strides have been made with fall prevention in the elderly and was chosen a priority in the last CHA.  Ages less than 10 years in 2008-2010 is 31.7 for AC and in 2006-2008 was 11.7 (unstable number due to fewer than 20 events in the numerator)  Ages 10-14 years in 2008-2010 is 31.3 and in 2006-2008 was 15.2 (unstable number due to fewer than 20 events in the numerator)

Promote a Healthy Data years Alleg. NYS NYS Quartile Yes or No and Safe Environment Co. ex Statistical Indicators NYC Significance Rate of hospitalizations due to falls per 10,000- 2008-10 187.8 204.6 ages 65+ years Rate of ED visits due to falls per 10,000-ages 1- 2008-10 519.6 476.8 4 years th Fall hospitalization rate per 10,000-less than 10 2008-10 31.7 26.2 22 4 Yes-NYS excl years NYC th Fall hospitalization rate per 10,000-10-14 years 2008-10 31.3 21.1 19.3 4 Yes-NYS excl NYC Assault-related hospitalization rate per 10,000 2008-10 1.1 4.8 Rate of occupational injures treated in ED per 2008-10 40.2 36.7 10,000 adolescents-ages 15-19 years Work related hospitalizations per 100,000 2008-10 278.4 168.4 210.9 employed persons ages 16 years and older Elevated Blood Lead Levels per 100,000 2008-10 60.5 23.2 24 employed persons ages 16 years and older Hospitalization rate per 100,000 persons ages 15 2008-10 71.1 24.5 32.8 years and older-Pneumoconiosis Hospitalization rate per 100,000 persons ages 15 2008-10 57.5 22.2 36 years and older-Asbestosis % of commuters who use alternate modes of 2007-11 27.6 44.6 transportation % of population with low-income and low 2010 2.9 2.5 access to a supermarket or large grocery store

% of residents served by community water 2012 22.5 71.4 systems with optimally fluoridated water Prevent Chronic Diseases The following table gives the prevention of chronic diseases indicators for Allegany County (AC) in comparison to New York State (NYS) and NYS excluding New York City (NYC); the ranking quartile with the rest of New York State; and yes or no was it statistically significant in comparison to NYS and NYS excluding NYC. The Age adjusted percentage of adults who were obese (BMI of 30 or higher) was in the 4th quartile and statistically significant compared to NYS (2008-2009 NYS Expanded Behavioral Risk Factor Surveillance System). The age-adjusted percentage of adults who smoke cigarettes; The age-adjusted percentage of adults living in homes where smoking is prohibited; and the age adjusted percentage of adults eating 5 or more fruits or vegetables per day (2008-2009 NYS Expanded Behavioral Risk Factor Surveillance System) were all in the 4th quartile and statistically significant compared to NYS and NYS excluding NYC.

Prevention Chronic Diseases Data Allegany NYS NYS Quartile Yes or No Indicators years County (ex Statistical NYC) Significance % of adults who are obese 2008-09 29.9 23.2 th Age adjusted % of adults obese (BMI 30 2008-09 30.5 23.1 24.3 4 Yes-NYS or higher) % of children and adolescents who are 2010-12 14.7 17.6 obese % of cigarette smoking among adults 2008-09 24.6 16.8 th Age-Adjusted % of adults who smoke 2008-09 25.5 17 18.9 4 Yes-NYS & NYS cigarettes excluding NYC th Age-Adjusted % of adults living in 2008-09 71.2 80.9 79.3 4 Yes-NYS & NYS homes where smoking is prohibited excluding NYC Age adjusted % of adults eating 5 or 2008-09 21.2 27.1 27.7 4th Yes- NYS more fruits or vegetables per day excluding NYC rd % of children in WIC viewing TV 2 2008-10 83.3 78.6 80.7 3 Yes-NYS hours or less per day (ages 0-4 years)

Incidence (morbidity) rates for 2008-2010 for pneumonia, chronic lower respiratory disease, and asthma are AC in comparison to NYS and NYS excluding NYC are shown in the chart below. The pneumonia hospitalizations per 10,000 for ages 0-4 years were in the 4th quartile and statistically significant for AC compared to NYS and NYS excluding NYC. AC is 83.7, NYS is 44.6 and NYS excluding NYC is 37.5. The Chronic Lower Respiratory Disease CLRD) hospitalization rate per 10,000-age adjusted is in the 3rd quartile and statically significant compared to NYS excluding NYC, AC is 38.4, NYS is 37.5 and NYS excluding NYC is 31.7.

Incidence/Morbidity Data years Allegany NYS NYS Quartile Yes or No Pneumonia, Chronic Lower County ex Statistical Respiratory Disease, Asthma NYC Significance th Pneumonia hospitalization rate per 10,000- 2008-10 83.7 44.6 37.5 4 Yes-NYS & NYS ages 0-4 years excluding NYC rh Chronic Lower Respiratory Disease 2008-10 38.4 37.5 31.7 3 Yes-NYS excluding Hospitalization rate per 10,000-age NYC adjusted Asthma ED visit rate per 10,000 2008-10 31.7 83.7 Asthma ED visit rate per 10,000-ages 0-4 2008-10 58.3 221.4 years Adults told by a healthcare provider they 2008-09 16.1 15.2 have Asthma from BRFSS expanded county data ER visit rate due to Adult Asthma in all 2007-09 36.4 83.7 ages from NYSDOH Hospitalization rate due to Adult Asthma 2007-09 7.6 14.8 per 10,000 in ages 18-64 from NYSDOH Hospitalization rate due to Asthma per 2007-09 11.6 20.3 12.4 10,000 from NYSDOH Asthma hospitalization rate per 10,000- 2008-10 29.2 58.8 36.1 ages 0-4 years Asthma hospitalization rate per 10,000- 2008-10 13.7 20.9 11.2 ages 5-14 years Asthma hospitalization rate per 10,000- 2008-10 15.6 29 16.1 ages 0-17 years Rate of hospitalizations for short-term 2008-10 3.3 3.2 complications of diabetes per 10,000- unstable ages 6-17 years Rate of hospitalizations for short-term 2008-10 5.6 5.6 complications of diabetes per 10,000- ages 18+ years Department of Health and Human Services 2009 9.5% 8.9 CDC National Diabetes surveillance system % adult population estimate NYSDOH vital statistics Age Adjusted 2010 10.6 16.2 death rate per 100,000, BRFSS percentage age 18+ reported they 2004-10 12.4% 8.2 have diabetes % Medicare enrollees receiving HbA1c 2003-06 85.9% 79.6 test (County Health Rankings)

Incidence (morbidity) rates for 2008-2010 for diabetes are AC in comparison to NYS and NYS excluding NYC are shown in the chart below. AC age adjusted diabetes hospitalization rate per 10,000 with diabetes as the primary diagnosis for the years 2008-2010 was 16.9. This is the 4th quartile in comparison to NYS excluding NYC which is 14.3 and below the NYS rate of 19. AC 20

age adjusted diabetes hospitalization rate per 10,000 with any diagnosis for the years 2008-2010 was 228.2. This is in the 3rd quartile compared to NYS excluding NYC which is 198.2 and above the NYS rate of 226.1.

In comparison to past indicators:  Diabetes hospitalization rate per 10,000 (primary diagnosis)-age adj. in 2008-2010 is 16.9 and was 15.2 in 2004-06  Diabetes hospitalization rate per 10,000 (any diagnosis)-age adj. in 2008-2010 is 228.2 and was 217.1 in 2004-06

Incidence/Morbidity Data years Allegany NYS NYS Quartile Yes or No Statistical Diabetes County ex Significance NYC Rate of hospitalizations for short-term 2008-10 3.3 3.2 complications of diabetes per 10,000- unstable ages 6-17 years Rate of hospitalizations for short-term 2008-10 5.6 5.6 complications of diabetes per 10,000- ages 18+ years Department of Health and Human 2009 9.5% 8.9% Services CDC National Diabetes surveillance system % adult population estimate NYSDOH vital statistics Age Adjusted 2010 10.6 16.2 death rate per 100,000, BRFSS percentage age 18+ reported they 2004-10 12.4% 8.2% have diabetes % Medicare enrollees receiving HbA1c 2003-06 85.9% 79.6 test (County Health Rankings) % th Diabetes hospitalization rate per 10,000 2008-10 16.9 19 14.3 4 Yes NYS excluding (primary diagnosis)-age adj. NYC 226.1 rd Yes NYS excluding Diabetes hospitalization rate per 10,000 2008-10 228.2 198. 3 (any diagnosis)-age adj. 2 NYC

Incidence (morbidity) rates for 2008-2010 for cardiovascular disease, disease of the heart, and coronary heart disease hospitalizations are in the 4th quartile and statistically significant when comparing AC to NYS and NYS excluding NYC are shown in the chart below. Congestive heart failure mortality, congestive heart failure and stroke pre transport mortality are in the 4th quartile and statistically significant when comparing AC to NYS and NYS excluding NYC.

Incidence/Morbidity Data years Allegany NYS NYS ex Quartile Yes or No Statistical Stroke, Heart Disease County NYC Significance

Age adjusted heart attack 2010 25.1 15.5 hospitalization rate per 10,000 Cardiovascular disease 2008-10 173.4 165.6 157.5 4th, Y, Y Yes-NYS & NYS hospitalization rate per 10,000- excluding NYC age adjusted Disease of the heart 2008-10 129.7 113.3 109.2 4th, Y, Y Yes-NYS & NYS hospitalization rate per 10,000 – excluding NYC age adjusted Heart Disease deaths per 100,000 2003-09 221.9 234.1 from NVS Coronary Heart Disease mortality 2008-10 148.3 169.4 145.1 3rd, Y, N Yes-NYS rate per 100,000- age adjusted Coronary Heart Disease 2008-10 57.7 46.9 43.7 4th, Y, Y Yes-NYS & NYS hospitalization rate per 10,000- excluding NYC age adjusted Age Adjusted death rate per 2008 149.5 193.4 100,000 from Coronary Heart Disease from HIW Coronary Health Disease Deaths 2003-09 158 182.5 per 100,000 from NVS Congestive heart failure mortality 2008-10 28.4 13.3 19.8 4th, Y, Y Yes-NYS & NYS rate per 100,000, crude excluding NYC Congestive heart failure mortality 2008-10 22.4 11.3 15.5 4th Y, N Yes-NYS rate per 100,000, age adjusted Congestive heart failure mortality 2008-10 18.3 7.2 10.9 4th, Y, Y Yes-NYS & NYS rate per 100,000- pre-transport excluding NYC mortality Congestive heart failure 2008-10 29.9 28.9 26.9 4th,N, Y Yes-NYS excluding hospitalization rate per 10,000 – NYC age adjusted rd Stroke mortality rate per 100,000- 2008-10 37.4 26.7 31.9 3 ,Y, N Yes-NYS age adjusted th Stroke mortality rate per 100,000- 2008-10 27.1 10.9 16.5 4 ,Y, Y Yes-NYS & NYS pre-transport mortality excluding NYC Stroke Deaths per 100,000 from 2003-09 41.1 30.1 NVS Age Adjusted death rate per 100,000 2008 35 31.5 from Cerebrovascular (stroke) from Health Indicators Warehouse

According to the NYS Vital Statistics for 2007-2009, the following are incidence rates (per 100,000 population and age adjusted incidence) for AC and NYS respectively. The data illustrates that our lung and female breast cancer incidence rates are slightly higher than the state rate and slightly below the NYS excluding NYC rate. Our female breast, colorectal and cervical (although cervical is unstable due to low number of events) rates are elevated in comparison to NYS and NYS excluding NYC. The colorectal and cervical rates may be attributed to the increased activity of our Cancer Services Program of Allegany and Cattaraugus Counties; more people are being screened now because of the education and screenings provided by this program. AC’s melanoma Cancer incidence rates are above the NYS rate. Our overall cancer incidence rate is in line with the NYS rate and below the NYS excluding NYC rate.

Cancer Allegany County age New York State age NYS excluding NYC incidence adjusted rate per adjusted rate per age adjusted rate per 100,000 100,000 100,000 Lung 69.9 63.8 72.2 Female Breast 132.0 126.9 136.1 Cervical 13.7* 8.3 7.4 Colorectal 54.5 45.8 46.2 Lip, Oral, 15.6 10.4 10.8 Pharynx Ovarian 12.8 12.9 13.5 Prostate 135.9 166.9 171.3 Melanoma 20.0 17.0 All Cancers 489.1 489.6 520.0 *Fewer than 10 events in the numerator, therefor the rate is unstable

Mortality According to 2010 and 2011 New York State Vital Statistics, the leading causes of death in Allegany County, and New York State, by rank and total number of deaths are in the below chart. Heart disease was the leading cause of death in 2010 and 2011 for Allegany County and New York State. Cancer is number two for both AC and NYS in 2010 and 2011. Stroke rates are decreasing from 2010 to 2011 in AC and Chronic Lower Respiratory Disease (CLRD) rates are increasing.

Select Causes Allegany New Allegany New Rank for Cause of Allegany of Death County York County York AC for premature death County deaths in Allegany 2008-10 2010 State 2011 State # of deaths County (number Premature 2010 2011 in 2008-10 of deaths) Death Rate 100,000 Heart Disease 235 229.9 272.7 225.9 1 160 448 Cancer 190 181.1 217.3 180 2 107 229 Stroke 51.1 31.6 32.8 31.6 Pneumonia 34.7 23.6 45.1 24.7 Chronic Lower 67.4 35 75.9 35.5 4 33 60 Respiratory D. Total Accidents 49 24.4 43.1 27 3 34 78 Diabetes 14.3 18.6 36.9 20.1 5 15 44 Liver Disease 14.3 7.3 8.2 7.6 5 15 34 Suicide 4.1 7.8 10.3 8.3 5 15 34

The data illustrates that our lung cancer morbidity rate is slightly higher than the state rate and below the NYS excluding NYC rate. Our female breast mortality rate is slightly elevated in comparison to NYS and NYS excluding NYC. The Lip, Oral, Pharynx rates for Allegany County are higher than the NYS and NYS excluding NYC rates.

Cancer Allegany County age New York State age NYS excluding NYC mortality adjusted rate per adjusted rate per age adjusted rate per 100,000 100,000 100,000 Lung 44.0 42.8 49.0 Female Breast 23.9 21.7 22.2 Cervical 2.4* 2.3 1.9 Colorectal 15.5 15.7 15.7 Lip, Oral, 15.6 10.4 10.8 Pharynx Ovarian 11.6 7.8 8.5 Prostate 17.8 21.6 20.8 Melanoma 1.3* 2.1 2.7 All cancers 175.9 163.0 173.9 *Fewer than 10 events in the numerator, therefor the rate is unstable

Chronic lower respiratory disease (CLRD) age adjusted mortality rate per 100,000 is in the 3rd quartile and statistically significant compared to the NYS rate and the NYS excluding NYC rate. Death rates due to pneumonia in 2010 and 2011 are slightly higher than the state rate.

Mortality Data Allegany NYS NYS ex Quartile Yes or No Pneumonia, Chronic Lower years County NYC Statistical Respiratory Disease Significance Age Adjusted death rate due 2010 26 19.8 to Pneumonia per 100,000 from NYS vital statistics Age Adjusted death rate due 2011 34.9 20.3 to Pneumonia per 100,000 from NYS vital statistics rd Chronic Lower Respiratory 2008-10 52.1 31.1 38.5 3 Yes-NYS & Disease mortality rate per NYS 100,000-age adjusted excluding NYC

For 2011, the Vital Statistics also revealed the following mortality data, by age group, for Allegany County and the ranking for these deaths by age group for Allegany County and New York State provided the following results:

Number of Deaths in 2011 Allegany County New York State 189 85+ 85+ 125 75-84 75-84 67 65-74 65-74 53 55-64 55-64 20 45-54 45-54 14 35-44 35-44 10 25-34 25-34 3 0-9 0-9 2 20-24 20-24 2 10-19 10-19

The leading age group for death in Allegany County in 2007 was the same as 2011and the same as NYS, age 85+. The rank order for Allegany County and New York State remains the same as in 2007 and 2000. The ranking for deaths by age group for Allegany County was the same order as New York State for the year 2007. This was not true in 2000, Allegany County’s top group was 75-84 year olds and 0-9 year olds were 7th, 10-19 year olds were 8th, and 25-34 year olds were last.

According to the New York State 2011 Vital Statistics compared to the 2007 NYS Vital Statistics, the first and second leading causes of death for Caucasians in each age group in New York State are as follows:

Age Number 1 Cause of Number 2 Cause Number 1 Cause Number 2 Cause Group Death 2011 of Death 2011 of Death 2007 of Death 2007 <1 Conditions Congenital Conditions Congenital Originating in the Anomalies Originating in the Anomalies Perinatal Period Perinatal Period 1-9 Malignant Accidents Malignant Accidents Neoplasms Neoplasms 10-19 Accidents Suicide Accidents Malignant Neoplasms 20-24 Accidents Suicide Accidents Suicide 25-44 Accidents Malignant Accidents Malignant Neoplasms Neoplasms 45-64 Malignant Diseases of the Malignant Diseases of the Neoplasms Heart Neoplasms Heart 65+ Diseases of the Malignant Diseases of the Malignant Heart Neoplasms Heart Neoplasms

Prevent HIV, STDs, Vaccine Preventable Diseases and Healthcare Associated Infections The health indicators for this prevention agenda category are listed in the chart below. The Allegany County pertussis incidence per 100,000 for the years 2008-2010 was in the 4th quartile and statistically significant in comparison to New York State. Allegany County’s rate was 8.1 more than double the New York State rate at 3.0. The Allegany County pneumonia/flu hospitalization rate (ages 65 years +) per 10,000 was 179.3, in the 3rd quartile and statistically significant compared to NYS at 127.9 and NYS excluding NYC at 140.1.

According to the New York State Department of Health statistics for 2008-2010, most of the communicable disease incidence (morbidity) rates per 100,000 population for Allegany County are either non-existent, less than, or consistent with New York State (NYS) and NYS excluding New York City (NYC). This is consistent with the last assessment from 2010-2013.

Vaccine Preventable Diseases Data Allegany NYS NYS Quartile Yes or No and Healthcare-Associated years County ex Statistical Infections Indicators NYC Significance % of children with 2011 60.4 47.6 4:3:1:3:3:1:4 immunization series-ages 19-35 months th Pertussis incidence per 100,000 2008-10 8.1 3.0 4.3 4 Yes-NYS % of adolescent females with 2011 25.2 26 3-dose HPV immunization – ages 13-17 years Age-adjusted % of adults with 2008-09 70.7 75 flu immunization-ages 65+ years rd Pneumonia/flu hospitalization 2008-10 179.3 127.9 140.1 3 Yes-NYS rate (ages 65 years +) per and NYS 10,000 excl. NYC H. influenza incidence per 2008- 0.7* 1.3 1.5 100,000 2010 Hepatitis A incidence per 2008- 0.0* 0.8 0.5 100,00 2010 Hepatitis B Acute incidence 2008- 0.0* 0.8 0.6 per 100,000 2010 Tuberculosis incidence per 2008- 1.4* 5.4 2.4 100,000 2010 E.Coli 0157 incidence per 2008- 2.0* 0.6 0.8 100,000 2010 Salmonella incidence per 2008- 6.8 13.9 12.9 100,000 2010 Shigella incidence per 100,000 2008-10 0.0* 4.4 3.2 Lyme disease incidence per 2008- 9.5 42.4 66.2 100,000 2010 % of adults 65 years and older 2008- 70.7 75.0 76.0 with flu shot in last year 2010 % of adults 65 years and older 2008- 63.0 64.0 71.2 who ever received pneumonia 2010 shot Mumps incidence per 100,000 2008-10 0.0* 5.5 4.0 Meningococcal incidence per 2008- 63.0 64.7 71.2 100,000 2010 *Fewer than 10 events in the numerator, therefore the rate is unstable

Our AIDS case rate, per 100,000 population, for 2008-2010 is 2.7* and the New York State rate is 17.6, and NYS excluding New York City is 5.6, according to the Bureau of HIV/AIDS Epidemiology data. Incidence rates for Allegany County for HIV, syphilis, gonorrhea, and chlamydia are so low they are unstable or below the NYS and NYS excluding NYC rates.

Prevent HIV/STDS Data Allegany NYS NYS Quartile Yes or No Indicators years County ex Statistical NYC Significance HIV case rate per 100,000 2008-10 2.0* 21.4 7.4 AIDS case rate per 100,000 2008-10 2.7* 17.6 5.6 AIDS age adjusted mortality 2008-10 0.0* 5.3 1.6 rate per 100,000 Primary and secondary syphilis 2010 0 11.2 case rate per 100,000 males unstable Primary and secondary syphilis 2010 0 0.5 case rate per 100,000 females unstable Syphilis Early 2008-10 1.4* 12.8 2.5 Gonorrhea case rate per 2008-10 5.4* 89.7 55.7 100,000 for all ages Gonorrhea case rate per 2008-10 25.5* 335.5 210.3 100,000 for ages 15-19 Gonorrhea case rate per 2010 10.5 203.4 100,000 women – ages 15-44 unstable years Gonorrhea case rate per 2010 9.8 221.7 100,000 men – ages 15-44 unstable years Chlamydia case rate per 2008-10 65.8 305.1 178.9 100,000 males of all ages Chlamydia case rate per 2008-10 197.9 644.6 426.2 100,000 females of all ages Chlamydia case rate per 2010 523.8 1,619.8 100,000 women – ages 15-44 years PID hospitalization rates per 2008-10 1.7* 3.7 10,000 females ages 15-44 *Fewer than 10 events in the numerator, therefore the rate is unstable

Promote Healthy Women, Infants, and Children

According to 2008-2010 New York State Vital Statistics, the pregnancies for Allegany County females age 15-44 for 3 years total was 1,837, while there were 1,534 births. A cumulative rate of pregnancies per 1,000 females age 15-44 for 2008-2010 for Allegany County is 61.0 while the New York rate is 93.6. The cumulative birth rate per 1,000 females age 15-44 for Allegany County from 2008-2010 is 50.9 while the New York birth rate is 60.9.

The indicators for the prevention agenda item Promote Healthy Women, Infants and Children shows Allegany County is above NYS in the percentage of infants exclusively breastfed in the hospital in 2008-2010. The percentage of children ages with the recommended number of well child visits in government sponsored insurance programs is below the NYS percentage, as is the percentage for each of the year categories (1-15 months, 3-6 years, 12-21 years). This shows the lack of prevention knowledge, attitude and behavior of the parents to take their children to regular physical appointments. Access to physician may also play a role in these numbers being below the state percentages.

Promote Healthy Women, Infants, and Children Data Alleg. NYS NYS Indicators years Co. 2017 Obj.

% of preterm births 2008-10 11.8 12 10.2

% of preterm births ratio of Medicaid births to non- 2008-10 1.18 1.10 1.00 Medicaid births % of infants exclusively breastfed in the hospital 2008-10 64.7 42.5 48.1

% of infants exclusively breastfed in the hospital 2008-10 1.17 .5 .57 ratio of Black non-Hispanics to White non- (unstable) Hispanics % of infants exclusively breastfed in the hospital 2008-10 1.24 .55 .64 ratio of Hispanics to white non-Hispanics % of infants exclusively breastfed in the hospital 2008-10 .72 .57 .66 ratio of Medicaid births to non-Medicaid births Maternal mortality rate per 100,000 births 2008-10 Unstable 23.3 21 Medicaid/Family Health Plus/Self-Pay Labor and 2011 57.42 50.21 Delivery rate continues to increase % of children with recommended number of well 2011 52.4 69.9 76.9 child visits in government sponsored insurance programs % of children ages 0-15 months who have had the 2011 78.8 82.8 91.3 recommended number of well child visits in government sponsored insurance programs % of children ages 3-6 years with recommended 2011 65.7 82.8 91.3 number of well child visits in government sponsored insurance programs % of children ages 12-21 years with recommended 2011 41.3 61 67.1 number of well child visits in government sponsored insurance programs % of children with any kind of health insurance- 2010 93.8 94.9 100 ages 0-19 years

The table below illustrates data on dental health for children and adults. From the 3rd grade study children in Allegany County have more caries, evidence of untreated tooth decay, dental sealants, at least one dental visit in the last year and take fluoride tablets than 3rd graders in NYS excluding NYC. For adults, the age adjusted percentage who had a dentist visit in the last year was below the NYS and NYS excluding NYC percentages, ranking in the 4th quartile. Emergency department visit rate per 10,000 was also in the 4th quartile and statistically 30

significant. These statistics show adults do not have the knowledge, attitudes or behaviors that model good dental hygiene and preventative care. Parents have made positive changes from the 2002-2004 3rd grade study. A survey of third grade children in 6 schools in the county, conducted in 2002-2004 and reported by the New York State Department of Health, reported a rate of 64% of county third graders studied, had caries experience. Of those, 43.7% had untreated caries. Only 36.3% had received dental sealants. An impressive 77.1% had a dental visit within the last 12 months, while 63.2% are covered by dental insurance. Additionally, 44.6% of Allegany County third graders received fluoride supplements. Only 14% of the Allegany County population on public water systems (approximately 50% of the homes are on a public water supply) receives fluoridated water.

Promote Healthy Women, Infants, and Data Alleg. NYS NYS Quartile Yes or No Children Indicators years Co. ex Statistical Dental NYC Significance rd 2009-11 51.7 NA 45.4 rd Yes-NYS % of 3 grade children with caries experience 3 excluding NYC rd 2009-11 25.4 NA 24 rd Yes-NYS % of 3 grade children with evidence of 3 excluding NYC untreated tooth decay rd 2009-11 53.6 NA 41.9 rd Yes-NYS % of 3 grade children with dental sealants 3 excluding NYC rd 2009-11 87.8 NA 83.4 th Yes-NYS % of 3 grade children with at least one dental 4 excluding NYC visit in last year rd 2009-11 63.3 NA 41.9 rd Yes-NYS % of 3 grade children with reported taking 3 excluding NYC fluoride tablets regularly th Age adjusted % of adults who had a dentist visit 2008-09 63 71.1 72.7 4 Yes-NYS & within the past year NYS excl. NYC th Caries emergency department visit rate per 2008-10 280.6 65.8 69.9 4 Yes-NYS & 10,000 NYS excl. NYC rd % Medicaid enrollees with at least one dental 2008-10 26.6 31.3 29.4 3 Yes-NYS & visit within the last year NYS excl. NYC rd % Medicaid enrollees with at least one preventive 2008-10 19.9 25.9 23.4 3 Yes-NYS & dental visit within the last year NYS excl. NYC rd % Medicaid enrollees (ages 2-20 years) who had 2008-10 38 40.8 40.5 3 Yes-NYS & at least one dental visit within the last year NYS excl. NYC rd % of 3 grade children ratio of low –income 2009-11 1.2 2.5 children to non-low income children

The following statistics include adolescent pregnancy rates, pregnancy data and lead screening. The 2008-2010 adolescent pregnancy rates per 1,000 females ages 15-17 years is almost half the NYS rate. The 2008-2010 percentage of births to teens ages 15-19 years is over the NYS and NYS excluding NYC rates, in the 3rd quartile and statistically significant. The percentage of unintended pregnancy among live births is above the state. The difference in the 15-17 and 15- 19 age ranges may be attributed to 18 and 19 year olds who were pregnant in 2008-2010. The percentage of pregnant women in WIC who were pre-pregnancy obese (BMI 30 or higher) is in the 3rd quartile (above the state). The percentage of births within 24 months of previous pregnancy for Allegany County is 26.7 and NYS is 18, AC is in the 4th quartile. The percentage of children born 2008 with a lead screening by 18 months and children born in 2008 with at least two lead screenings by 36 months are both below the state. Children with at least two lead screenings by 36 months, is in the 4th quartile. This may be attributed to physicians in Allegany County completing the lead test by 18 months for the first year and not rescreening the child by 36 months for the second year. Many physicians do not see the large number of children with extremely high blood lead levels and do not feel it is necessary to retest each child. The ACDOH has been working with the physicians in Allegany County to have them test children at age one and age two. Parents also do not feel it is necessary or convenient to take their child to the laboratory after the doctor’s appointment to have blood drawn. ACDOH is working with physicians to do lead testing in their offices to overcome this barrier.

Promote Healthy Women, Infants, and Data Alleg. NYS NYS Quartile Yes or No Children Indicators (con.) years Co. ex Statistical NYC Significance Adolescent pregnancy rate per 1,000 2008-10 17.5 31.1 females-ages 15-17 years rd % of births to teens ages 15-19 years 2008-10 9.2 6.6 6.8 3 Yes-NYS & NYS exc NYC % of unintended pregnancy among live 2011 35.2 26.7 births % of unintended pregnancy among live 2011 2.19 2.09 births ratio of Black non-Hispanics to (unstable) White non-Hispanics % of unintended pregnancy among live 2011 2.08 1.58 births ratio of Hispanics to White non- (unstable) Hispanics % of unintended pregnancy among live 2011 1.62 1.69 births ratio of Medicaid births to non- Medicaid births % of women with health coverage-ages 18- 2010 87.4 86.1 64 yrs % of live births that occur within 24 2008-10 26.7 18 months of previous pregnancy rd % of births to women 25 years & older 2008-10 11.5 14.8 10.3 3 Yes-NYS without a high school education rd % of pregnant women in WIC who were 2008-10 29.4 23.4 26.7 3 Yes-NYS pre-pregnancy obese (BMI 30 or higher)

rd % of WIC mothers breastfeeding at least 6 2008-10 18.5 39.7 28.7 3 Yes-NYS & months NYS exc NYC rd % of births delivered by cesarean section 2008-10 33 34.4 36.1 3 Yes- NYS excl NYC th % of births within 24 months of previous 2008-10 26.7 18 21.1 4 Yes-NYS & pregnancy NYS excl NYC th % children born in 2008 with lead 2008-10 0.2 6.8 2.9 4 Yes-NYS & screening by 9 months unstable NYS exc NYC rd % children born 2008 with a lead screening 2008-10 56.2 69.5 65.4 3 Yes-NYS & by 18 months NYS exc NYC th % children born in 2008 with at least two 2008-10 28.6 52.9 45.2 4 Yes-NYS & lead screenings by 36 months NYS exc NYC

Promote Mental Health and Prevent Substance Abuse Alcohol related motor vehicle injuries and deaths per 100,000 for the 2008-2010 timeframe was in the 4th quartile for Allegany County, more than two times the NYS percentage. The age adjusted suicide death rate per 100,000 for AC is above the NYS rate. The numbers for mental health consumers are below the NYS numbers. This may be attributed to the limited access to mental health providers, lack of knowledge of the benefits of mental health services and lack of insurances that pay for mental health services. Mental health outpatient services available in AC are similar to the rest of NYS. Outpatient services are the primary source of services offered for adults and children. Support is second for children in AC with no emergency, inpatient, or residential services for children in AC. Residential is second and support is third for adults in AC with not emergency or inpatient services. In comparison to the previous indicators for AC  Age-adjusted suicide death rate per 100,000 in 2008-10 is 11.5 and in 2006-08 was 15.5  Alcohol related motor vehicle injuries and deaths per 100,000 in 2008-210 is 76.5 and in 2007-09 was 82.6

Promote Mental Health and Data Alleg. Co. NYS NYS Quartile Yes or No Prevention Substance Abuse years ex Statistical Indicators NYC Significance

Age-adjusted % of adults with poor 2008-09 8.6 10.2 mental health for 14 or more days in the last month Age-Adjusted % adults binge 2008-09 19.4 18.1 drinking during the past month th Alcohol related motor vehicle 2008-10 76.5 36.2 50.0 4 Yes-NYS & injuries and deaths per 100,000 NYS excl NYC Age-adjusted suicide death rate per 2008-10 11.5 7.1 100,000 Office of Mental Health-mental 2005-07 .84% (409) .92% health consumers (178,272) Office of Mental Health-mental 2005-07 1.08% (124) % 20.6% health consumers-youth (0-17) of youth pop (36,739) 30.3% of total MHC Office of Mental Health-mental 2005-07 .89% (271) % of 72.4% health consumers-adults (18-64) adult pop (129,052) 66.3% of total MHC Office of Mental Health-mental 2005-07 .20 (14) % of 7% health consumers-adults (65+) older adult pop (12,413) 3.4% of total MHC

2. Main health challenges for Allegany County and contributing causes of health challenges

Allegany County has long had the designation as a Health Professional Shortage Area (HPSA) for Dental, Mental Health and Primary Care. The extreme rural nature and poverty of the county make it difficult to recruit and retain physicians and other health professionals. This contributes to an inconsistency in health care as professionals come and go. Allegany County has an increasingly aged population, as do most areas of the nation, yet there are no geriatric specialists in Allegany County.

The geographic vastness of the county also makes health care difficult. The county is 1,030 square miles; it takes well over an hour to travel from one end of the county to the other by car. With a population of 48,949 in 2010 U.S. Census, there are 47.6 people per square mile in the county. There are several villages that have no physicians or health care facilities and there are portions of the Northern Central County (Fillmore, Hume) that have a half-hour drive time to an Emergency facility. Larger villages contain Ambulance Corps and/or Fire Departments that rely largely on volunteers; the county is covered by a comprehensive 911 Emergency system located just outside the Village of Belmont in the Town of Amity in the Allegany County Jail and Public Safety Facility.

The social environment in Allegany County tends to be one of close-knit extended families that typically stay within close proximity of the county. Residents, especially the elderly, are slow to change, which makes the frequent change in health professionals, especially specialists, difficult. Residents typically rely on family and close friends for medical and health care advice. This stems from a lack of access to providers as well as the inability to afford health care.

Allegany County consistently ranks in the poorest counties in New York State with a Medicaid/Family Health Plus and Self-Pay delivery rate that is higher than New York State. It is a one and a half to two hour drive to the nearest Medical Centers and certain types of specialists. Even if residents could afford the care, many are unable to access it due to the distance and/or inability to travel, either locally or regionally. Another economic concern is the lack of providers (especially specialists, such as dentists) that accept Medicaid. Medicaid is traditionally a cumbersome system that offers substandard reimbursements for physicians.

Several problems in Allegany County impact negatively on the health of county residents by serving as barriers to timely and affective health care. These barriers are primarily financial, educational, transportation, and logistical in nature.

Families living at or below standardized poverty levels (11.6% of Allegany County), tend to neglect or ignore health care because they lack the ability to pay for these services, or because they do not recognize or understand the seriousness of problems for which they should seek timely medical care for themselves or family members. In Allegany County, this problem is compounded by the fact that a majority of dentists and some medical specialists in the county will not accept Medicaid patients or allow patients to have time-based payment plans. In 2011, the Medicaid/Family Health Plus and Self-Pay delivery rate in Allegany County (57.42%) was more than the New York State rate (50.21%). Over half (57.42%) of deliveries were 35

Medicaid/Family Health Plus or Self-Pay. This tells us that almost half of county residents use Medicaid or have no health insurance and must self-pay. Yet, with limited Medicaid providers, this becomes a major barrier to access to care.

From a transportation standpoint, many low-income people cannot afford or do not have access to a vehicle in which they could travel to receive needed medical care. The fact that the county has a limited public transportation services greatly exacerbates this problem. County logistics makes this problem even worse. The majority of health care providers and facilities are located in the villages of Alfred, Cuba, or Wellsville, the three largest communities in the county. However, a substantial number of residents are located across large sections of the county, and accessing these areas for medical care can be extremely difficult as a result. An unfortunate consequence of these factors is that by the time many county residents seek out and access health care, it is often late in the course of their disease, when outcomes are less favorable and longer, more costly care may be necessary.

Since more than 96.2% of Allegany County residents are white, English-speaking, there are few cultural and/or linguistic barriers to health care. The small non-English speaking populations exist primarily in the college/university areas. The county does have an Amish population, but there is a physician in the county that they utilize for prenatal visits, deliveries, and pediatric visits. They also attend immunization clinics at the LHU.

People of diminished means, particularly those living below established poverty levels, or of low socioeconomic status, are more prone to engage in unhealthful habits such as excessive tobacco and alcohol use. The county’s increased mortality rates for lung cancer and liver disease is evidence of this. Their lack of resources also make it difficult for them to purchase and prepare nutritionally sound meals that help to promote overall health and well-being, as our higher rates of diabetes mortality and hospitalizations show. Information obtained from the 2009 Expanded Behavioral Risk Factor Surveillance Surveys (BRFSS) showed that those people also typically lead sedentary lifestyles in which they participate in little or no beneficial physical activity. As mentioned previously, they also tend to neglect health care due to their inability to access and pay for these services. As such, they are impacted to a greater degree than people of greater economic means from the effects of acute and chronic disease conditions. Another key risk factor is the choice not to access care for a variety of reasons including the belief that health care is not important and/or will not affect significant change.

Because the county is so large geographically and public transportation is limited, residents must travel, sometimes great distances, for services that urban areas take for granted. This fact contributes to our increased motor vehicle accident and unintentional injury morbidity and mortality rates. The Department of Motor Vehicles shows the rates per 100,000 populations for 2008-2010 for alcohol-related motor vehicle injuries and deaths are double the state rate (36.2/100,000) at 76.5/100,000.

The above knowledge is important in an area such as Allegany County, which is one of the poorest counties in the state, generally ranking somewhere in the top three. In 2010, 11.6% of the county’s families were living below the federal poverty level. This signifies that 5,678 county residents are at high risk to poor health and the diminished quality of life that often coincides with it.

In Allegany County the main health challenges facing this community are Chronic Disease and Mental Health.

In the Chronic Disease priority, behavioral risk factors such as not eating 5 or more fruits or vegetables per day; eating a diet high in fat and calories; and lack of daily physical activity contribute to the level of obesity of Allegany County residents. The environmental risk factors also contribute to Obesity, i.e. rural communities are more dangerous to walk or ride a bicycle along road ways, have less outdoor space that is developed for physical exercise, less access to gyms, etc. Socioeconomic factors include the cost of healthy foods; the community’s access to stores with healthier options; lack of income to join a gym for physical exercise. In Allegany County there is a lack of policy environments such as zoning for walkable communities and menu labeling in restaurants, although Allegany County does have smoke free parks. In the community survey, lack of motivation was mention as a reason why they did not exercise more often. Allegany County does have 12 school districts, with exercise/weight rooms, hallways for inside walking in winter weather, tennis courts, outdoor basketball courts, tracks and paved areas for walking/running and some have swimming pools. There is a disconnect between the school districts and county residents, they do not know how or when to access the facilities in their own school district. Many communities have parks, playgrounds and a few have walking trails for community members to access, although usage is low. Obesity is a risk factor for all chronic diseases including diabetes, heart disease, stroke, and cancers.

In the Mental Health priority, behavioral risk factors include not accessing health care for physical health, mental, emotional or behavioral health where problems can be identified and managed. Additionally, Allegany County includes a population that does not have enough knowledge or positive attitude about preventing/managing mental health problems to access what assistance is available. Socioeconomic factors include lack of funds or insurance to access services; high economic stresses including unemployment; difficulty in recruiting and retaining mental health practitioners; lack of paid time from work to access needed services and lack of transportation to services offering within Allegany County and in Western New York.

Allegany County is a very poor, rural county with many broad determinants of health including behavioral risk factors, environmental risk factors, socioeconomic factors, policy environment and other unique characteristics. All of these factors contribute to the health status of the residents of this county, as well as the knowledge, attitudes and behaviors of the county residents in working toward preventing the main health challenges surrounding preventing chronic diseases and promoting better mental health.

3. Assets and Resources in Allegany County There are 12 public school districts in Allegany County, two private schools, Immaculate Conception School of Allegany County that educates students Pre-K through 8th grade and Houghton Academy that educates students 6th through 12th grade, and includes the Cattaraugus Allegany BOCES center at Belmont and a BOCES administered alternative school in Cuba. The schools are mandated to provide health education and the health department is a part of that education, to some degree, in most districts. Allegany County is home to Alfred State College, Alfred University and Houghton College. The Health Department attends health fairs offered by worksites, colleges and community agencies.

The Environmental Division of the Health Department addresses the physical environment and issues that deal with indoor air, food, water and septic/sewer system safety, inspection and installation. They are the regulatory agency for enforcement of public health laws and regulations. The county has little or no incidence of food-borne diseases and very infrequent outbreaks.

The following are media sources used by the Allegany County Department of Health for public service announcements, clinic schedules, emergency notification to the public and advertisements. Local media outlets include Wellsville Daily Reporter and Pennysaver; Spectator Sunday paper from Hornell, NY; WLSV/WJQZ radio; WPIG/WHDL radio; WMXO/WOEN radio; Time Warner TV community bill board; WZKZ radio; WDNY radio; Patriot weekly paper; Alfred Sun weekly paper; Hornell Tribune daily paper; Olean Times Herald daily paper; WKPQ/WHHO radio; Angelia Booster News monthly paper; college newspapers Tor Echo and Fiat Lux; Pennysaver for Cuba/Franklinville; and WGRZ channel 2 Buffalo; WIVB channel 4 Buffalo and WKBW channel 7 Buffalo.

Health Department The Allegany County Department of Health has been in operation since the early 1920's, when home care services, well baby visits, and tuberculosis care were first provided. Since that time, services were increased and expanded so that by 1975, the department functioned as a full service health department, providing both public health nursing and environmental health programs. The health department has approximately 36 people in its employ including administrative staff, nursing, health educators, public health sanitarians, clerical support, and grant funded subcontracted staff. A Board of Health that meets on a quarterly basis governs the Health Department. There are Management level employees that provide oversight of staff and programs and reports to board of health.

Administration and Management Five employees of the health department serve in administrative or managerial capacities. This includes the Public Health Director that holds a Master’s Degree in Public Health and Physical Education, the Deputy Public Health Director who holds a Master’s Degree in Epidemiology, the Director of Patient Services who holds a Bachelor’s Degree in Nursing, the Supervising Public Health Educator who holds a Bachelor’s Degree in Community and School Health Education, and Accountant who holds a bachelor’s degree in Business Administration with a concentration in accounting. 38

Nursing Services Division The Nursing Division is comprised of a Director of Nursing, one Public Health Nurse, one Registered Nurse and a Nurse Practitioner for the Family Planning Program. The Department of Health also has responsibility for the provision of traditional Community Health Services to the Allegany County residents. The services provided are inclusive of but certainly not limited to the prevention of and follow up of communicable disease. We owe many of our successes in the prevention of and follow up of communicable disease to the fine working relationship we enjoy with our community partners. Direct clinic services are also provided under community Health. A sample of the clinic services provided to the community is Family Planning, Immunization and Blood Pressure Screening.

Children’s Services Division This division oversees the administration of the Early Intervention Program (EIP), the Child Find Program, the Physically Handicapped Children’s Program (PHCP), Preschool Special Education Program and the Children with Special Health Care Needs Program. The Early Intervention Service Coordinator who holds two Associate’s Degrees conducts day to day activity within the EIP and Child Find. The PHCP and Children with Special Health Care Needs Program operate under the direction of the Physically Handicapped Children’s Program Coordinator who also holds a Bachelor’s Degree. The budget for the Children’s Services Division is adequate to meet its needs. Funds are available as needed for any specialized care, medical supplies, or equipment a child may require. The program coordinators have adequate clerical and billing support, and each has their own computer.

Child Find Children between 0-3 years who are or may be at risk for developmental problems are monitored at periodic intervals by the health department so that timely intervention strategies, where needed, can be implemented.

Early Intervention Program (EIP) A child between the ages of 0-3 diagnosed with a developmental disorder or delay is determined eligible for EIP and if requested by parent, the family will receive services in accordance with an Individualized Family Services Plan (IFSP). EIP services are provided by NYSDOH approved providers the county’s EI official is responsible to ensure that EIP services contained in the IFSP are provided.

Children with Special Health Care Needs (CSHCN) CSHCN is an informational, referral and advocacy program for children from birth to 21 years of age who may require health or related service of a type or amount beyond that typically required by children. This program encompasses the Physically Handicapped Children’s Program and Preschool School Special Education Program.

Preschool Special Education Program (PSEP) Children age 3-5 with disabilities may receive special education services through the PSEP. In 2012, over 195, children were enrolled in this program.

Physically Handicapped Children’s Program (PHCP) The PHCP provides financial assistance and case management to children between the ages of 0-21 with handicapping conditions that would otherwise be unable to afford such care. This program has a medical treatment component, and an orthodontia component. As of August 2012 there are 17 children currently receiving PHCP services.

Environmental Health Division The Environmental Health Division (EHD) provides a full range of services focused on community sanitation, food safety, and regulation of public water systems, disease control, and correcting public health hazards. The division is composed of the Deputy Public Health Director/Director for Environmental Health, four full-time public health sanitarians, and one public health technician. The Deputy Public Health Director/Director of Environmental Health holds a Master’s Degree in Environmental Health with a major in Epidemiology. Each of the Public Health Sanitarians (PHS) holds a Bachelor’s Degree in a science or environmental health related major, and one is also a registered nurse. The Public Health Technician (PHT) holds a Bachelor of Arts Degree in Biology.

Each PHS is provided with a county vehicle to use on the job. Each PHS also “specializes” in at least one or more environmental health program areas (e.g., public water supply, food safety, children’s camps, and lead poisoning prevention). In the general areas they all inspect the:  Installation of new and replacement septic systems for compliance with State Rules and Regulations.  Inspect food service establishments, mobile home parks, campgrounds, hotels, motels, swimming pools, bathing beaches for compliance with the New York State Sanitary Code and advise operators on how to maintain compliance with Code requirements.  Provide water sampling, inspections and oversight of over 100 public water systems located within the county.  Conduct compliance checks relative to the Adolescent Tobacco Use Prevention Act (ATUPA) and investigate complaints regarding possible violations of the New York State Clean Indoor Air Act (CIAA).  Investigate nuisance complaints and determine if they constitute public health hazards, then advise the responsible individual (landowner/facility owner or operator, etc.) on how to correct the problem to protect the public health.  Conduct sanitary surveys of private septic systems and water supplies as required at the transfer of ownership of houses.  Investigate animal bites to prevent the possibility of the patient from contracting rabies.  Inspects children’s camps and reviews their safety plans.  Conduct site visits at households of children with Elevated Blood Lead Levels 15 ug/dL and above and conduct comprehensive lead assessment surveys of dwellings occupied by children considered to be lead poisoned.

All Environmental Health Division work is conducted by a small but well-trained staff. The EHD budget has been sufficient to meet its needs, including the completion of routine work, special or emergency studies (e.g., food or water testing in cases of possible contamination or illness), vehicle maintenance, office and field supplies, conferences, training, and environmental health related publications, subscriptions and memberships. Computer support to the division to monitor program activity, track data, and generate reports, etc., has been adequate. There is no supplemental funding for CIAA activities or enforcement, other than what is contained within the annual ATUPA grant.

Health Education Division The department has one full-time Supervising Public Health Educator (SPHE) who holds a Bachelor’s degree and 21 years’ experience in health education at the health department. The SPHE is the Public Information Officer for the health department, Program Director for the CSPACC, writes grants for the health department, supervises the Community Health Educator and the coordinator for the CSPACC, writes the Community Health Assessment, and the Community Health Improvement Plan (CHIP). The Community Health Educator is a subcontractor, holds a Master’s degree in Adult Education, provides education and outreach for the Family Planning Program 70% of his time, education and outreach for the Lead Poisoning Prevention Program 4% of time and provides general public health education program activities including dental health, work with local coalitions on physical activity and nutrition for youth and elderly; injury control; advertising and marketing for health department programs; and other grants activities.

Clerical support within the health department includes the Secretary to the Public Health Director, a Medical Records Computer Operator, a Clinic Secretary and a two typists (one acts as receptionist). The number of clerical staff, when all positions are filled, is sufficient to meet departmental needs. Cross training is conducted to allow continuation of support to all program areas when clerical staff is deficient. Also, many perform the same general job duties despite supporting separate areas of the department, so moving individuals as needed to cover personnel shortfalls has generally not been a problem. Each clerical staff member has their own computer and receives training on the software used in their primary program support areas.

Subcontracted Staff WIC Program WIC Program Director holds a Bachelor’s degree and is a registered nurse who is Internationally Board Certified as a Lactation Consultant (IBCLC). She supervises one full-time registered nurse, 1 nutritionist with BA in Nutrition and three full-time clerical and program support staff that provide nutritional screening and education to pregnant, breastfeeding and postpartum women, infants and children up to age five. She manages a client-driven budget that is currently serving approximately 1250. The WIC Breastfeeding Coordinator has an Associate’s Degree in Nursing from Alfred State and is a registered nurse who is a Certified Lactation Consultant (CLC). In May 2007 she was promoted to Assistant Program Coordinator and in May 2008 became certified as lactation consultant. The Nutrition Coordinator has a Bachelor’s Degree in Nutrition from Mansfield University. The Nutrition Educator and Outreach Coordinator have an Associate’s Degree in Human Services and a BA in management. WIC Clinic Specialist and 41

Vendor Manager has an Associate’s Degree and a certificate from BOCES for Medical Office Assisting, certification as a Lactation Consultant and her postpartum Doula certificate. WIC Administrative Assistant has a Bachelor’s Degree. She has a Certification as Lactation consultant.

The Cancer Services Program of Allegany and Cattaraugus Counties (CSPACC) provides comprehensive screening, case management, and diagnostic services with respect to colorectal, breast and cervical cancers. Prostate cancer services are educational and Medicaid Treatment Act only. The Medicaid Treatment Act provides Medicaid for breast, cervical, cervical pre- cancerous, colorectal, and prostate cancer patients receiving treatment for cancer, once eligibility is determined. The CSPACC now has three sub-contracted staff that works solely within this program: a Coordinator who holds a Bachelor’s degree and is a registered nurse; a Data Manager; and an Outreach Specialist who holds a Bachelor’s degree. The Supervising Public Health Educator is Program Director of the CSPACC grant and provides grant management. The screening numbers for the calendar year 2012 are: 375 mammograms, 323 clinical breast exams, 186 cervical screenings, and 144colorectal screening (FIT Kit). The grant in previous years has been able to provide screenings to all those eligible for the CSPACC and recruited into the partnership, due to budget cuts to the NYSDOH Cancer Services Program this grant must now stay within the contracted amount for screenings and diagnostic services. Eligibility guidelines of the program are women 40-64 without health insurance that pays for screenings are eligible for cervical and breast screening and diagnostic testing; women and men 50-64 without health insurance that pays for screenings are eligible for colorectal screening and diagnostic testing. This grant is currently in an extension period and will be reapplying for an additional four years at the end of 2013 or beginning of 2014.

Public Health Emergency Preparedness Coordinator has been with the health department for 7 years in this position. She prepares and monitors local emergency preparedness response plans through collaborations with local, state, regional, and federal entities to build an "all-hazards" approach to public health emergency response. She is responsible for the coordination of public health related exercises to ensure compliance with CDC, and US DHS Homeland Security Exercise and Evaluation Program (HSEEP) guidelines. She coordinates with local, state, and federal entities to ensure activities for the federally funded public health emergency preparedness initiatives comply with grant requirements.

Accounting Accountant monitors effectiveness of departmental fiscal systems by developing, revising and implementing accounting systems and procedures to provide complete and accurate accounting for the agency's financial transactions. He is responsible for aiding an outside accounting firm in completion of annual Medicaid and Medicare cost reports; prepares the annual State Aid application and quarterly claims, and compiles the department’s annual budget and maintains required financial records and reports throughout the year. He performs cost and budget analyses, financial forecasting feasibility studies and other accounting tasks to aid in program efficiency and effectiveness. He maintains ledger and journal accounts and balances and reconciles with the County Treasurer's office; prepares periodic fiscal and statistical statements and reports for agency use, and/or submission to State and/or Federal agencies; assists in the 42 completion/preparation of grant applications by compiling and analyzing financial data; and advises and consults with the County Treasurer and/or the Public Health Director and other staff as appropriate on current fiscal reporting requirements and control of expenditures.

County Coroners The county has four coroners who fall under the organizational umbrella of the health department. These individuals are salaried through health department which provides them with administrative support, along with needed supplies, reimbursement for travel, transportation, and telephone use, other related expenses, etc. The coroners are now included in the county’s Comprehensive Emergency Preparedness and Response Plan. Each coroner covers a general area of the county. As needed, they help one another to ensure countywide coroner services are available at all times. The coroners are assisted in simple cases by a doctor who acts as “Coroner’s Physician”. The county does not have a medical examiner for postmortem examinations in coroner case deaths. These services are obtained through contractual agreement with the Monroe County Medical Examiner’s Office in Rochester.

Community Resources A tremendous variety of community agencies serve as resources contributing to the social, mental, and physical well-being of Allegany County residents. While the following list of these agencies is quite comprehensive, it does not necessarily reflect all organizations that provide services aimed at protecting and promoting health in Allegany County. See attached Allegany County Obesity related services, Allegany County Child Psychiatric Services, and Allegany County Obesity services table.

Mental, Emotional, Behavioral Health services complete list on www.networkofcare.org (choose Mental Health/Behavioral Health then choose Allegany County)

Allegany County Mental Health Association Provides day treatment for adults with developmental disabilities, mentoring programs, crisis intervention and counseling services.

Milestone Psychiatric Services, Wellsville NY Psychological Services, a Medical Group Practice

Allegany County Community Services, Wellsville NY plans for, coordinates, provides services, and ensures quality of mental health, substance abuse, and developmental disabilities for residents of Allegany County.

Allegany Rehabilitation Association, Inc Offers mental health services, case management, chemical dependency, transportation, housing, education, and social and vocational rehabilitation.  PROS, Wellsville NY  The Counseling Center (TCC), Wellsville, NY  Senior Outreach Program

 Behavioral Health Clinician in Allegany County Jail

Alfred University-Powell Family and Child Counseling Services individual and family counseling for children, adolescents, and adults. We also offer psychoeducational assessments for children and adolescents from age three (3) through age twenty-one (21). The primary clinicians are advanced counseling and school psychology AU graduate students, and all sessions and treatments are supervised and observed by doctoral-level AU faculty psychologists.

ACCORD Adolescent and Youth Respite Program

Elmira Psychiatrist Center-outpatient Wellsville. NY

Youth for Christ-work with youth and families

Catholic Charities of Allegany & Cattaraugus County Provides counseling services and anger management instruction.

Southern Tier Environments for Living (STEL Inc.) Residential programs for adults with psychiatric illness. Programs provide rehabilitative services to assist residents with acquiring skills to live in more independent settings. STEL provides three levels of care in Wellsville. A 24 hour supervised group home setting scattered apartments with two to three staff visits a week. Our last program is single room occupancy. STEL has two locations in Wellsville, and individuals must possess independent living skills. This program is considered permanent housing.

Allegany County Counsel on Alcoholism and Substance Abuse, Wellsville, NY Allegany Council provides multidisciplinary treatment to any person either referred or self- directed who meets admission criteria. This program is certified by the State of New York Office of Alcoholism and Substance Abuse Services to deliver clinical treatment services to individuals and families whose lives have been affected by the disease of addiction. Full-time counselors are available to deliver a wide range of services. These include Information and Referrals, Evaluation/Assessments, Medical Assessment, Individual and Group Counseling, Child and Family Therapy, Family Intervention, Vocational/Educational Counseling, Clinical Consultation, and Adult MICA Programs.

Allegany County Mental Health Association | Youth/Adult Compeer Program Youth volunteer program designed to give adult role modeling to needy children. All volunteers undergo extensive background check and training. Activities are chosen by youth and adult jointly. In addition there are regularly scheduled outings for everyone involved in the program.

Alcohol Treatment Center, Buffalo, New York The Alcohol Treatment Center provides regional coverage in offering care for individuals and their families who are experiencing problems related to alcohol consumption and alcoholism. 44

The Center has a 24-hour help line available for use in crisis situations for those needing immediate intervention and treatment.

Allegany County School Districts The school districts within Allegany County, including the Allegany County BOCES, offer their students a vast array of health related programs, over and above the required school health curriculum. Often, these subjects are provided, upon request, by health department staff, or other individuals within the community. Topics presented include dental health, human sexuality, contraception, family planning, parenting skills, “Baby Think it Over”, prenatal care, nutrition, sexually transmitted disease, HIV/AIDS, alcohol and substance abuse, tobacco use, motor vehicle safety, etc. Another program available to the schools, that serves to promote child health include “Project KNOW”, a program designed to help prevent unplanned or unwanted teenage pregnancies, targeting grades five through twelve. School districts employ psychologists to work with children experiencing difficulties related to school, over concern for the mental health of the individual. Teachers and school nurses are trained to notice behaviors indicative of a child in need of help. As necessary, parents are advised of any problems, and referrals made to outside agencies or health care providers for more definitive care. School districts foster participation in physical activity programs at each grade level. Health classes and gym classes promote physical fitness in students. Extracurricular activities such as interscholastic and intramural sports also provide students the opportunity to participate in organized physical activities. All schools within the county call for their students to be up-to-date on required immunizations. Students are not allowed into school if they are not fully immunized. Students in need of immunizations are referred to the health department, local health care providers, or their personal physicians. County schools send letters home to parents when students are due for immunizations.

Elm Street Academy is a BOCES Big Picture School Program located in Cuba, NY in Allegany County and has students from Allegany, Cattaraugus and Steuben Counties. Big Picture Schools were created to address the problem of students dropping out of school. Big Picture Schools provide a unique learning opportunity for students who are at risk of dropping out of school. Under the Big Picture concept, students become immersed in areas they are passionate about, in particular through internships and real-world learning experiences.

Alzheimer’s Support Group of Allegany County, Wellsville, New York 14895 This group provides counseling and support to Alzheimer’s patient and their families, to help them cope with the difficulties encountered when affected by this disease.

American Lung Association, Buffalo, New York 14228 The American Lung Association provides services for persons suffering from asthma and other lung diseases, smoking cessation programs, and smoking prevention courses aimed at school children.

Andover Historic Preservation Corporation, 4 Main Street/Box 713, Andover, New York The Andover Historic Preservation Corporation provides affordable housing to low-income county residents. 45

Children’s Camps Each year, there are several children’s camps in the county that provide participants the opportunity to engage in various levels and types of physical activities. Several private camps and camps sponsored by local colleges and universities are also available.

Child Health Plus Child Health Plus is aimed at freeing children from common childhood diseases and protecting them from serious health threats posed by untreated illnesses. The program protects children with no health insurance or who are underinsured, through reduced rate or free medical care, by covering primary, outpatient, and preventive health services for all children meeting income guidelines.

Absolut Center for Nursing and Rehabilitation at Houghton; Houghton, New York 14744 The goal of this facility is to treat its patients with a focus on facilitating their return to home. Services include a planned recovery program that may consist of physical therapy, speech therapy, occupational therapy, nutrition, respiratory therapy, restorative nursing, case management, and outcome measurement.

Alfred State College and Alfred University, Alfred, NY, Houghton College, Houghton, NY Colleges and universities located within the county provide health related services to their students. Depending on the program, faculty members and the general public may also make use of these offerings. Various programs and services provided include treatment and counseling for sexually transmitted disease, contraception, psychological counseling, and counseling and referral for students experiencing problems related to drug and alcohol use. Facilities are set up to handle minor health care problems on an outpatient basis (colds, flu, minor injuries, etc.), followed by appropriate referral to higher-level care when warranted. To help control communicable disease, each facility requires entering students to be screened for tuberculosis and be up-to-date on all required immunizations before they can start classes. Students in need of these services can receive them from their personal health care provider, the school health center, or they may be referred to a local health care provider or the health department. Problems with drug and alcohol abuse at universities around the country, some of which were highly publicized, has led these facilities to develop harder stances on the use of drugs and alcohol by students, whether on or off-campus. These efforts include notification of parents when an underage student is caught drinking or drunk on campus, eliminating hazing activities involving fraternities and sororities, suspending students who are repeat offenders, and offering alcohol and drug-free social activities to their students. Alfred University has eliminated the Greek organizations altogether. Students, faculty, and members of the community can take part in exercise and physical activity through these schools. Houghton College, Alfred State College, and Alfred University hold summer camps for children from throughout the area in sports such as swimming, basketball, football, baseball, soccer, tennis, and horseback riding. Each facility also offers a wide range of interscholastic and intramural sports their students can participate in, and fitness centers and swimming pools for student, faculty, and community use.

Community Groups/Volunteers Community groups and individuals, who volunteer their time and effort as officials, coaches, etc., help promote physical fitness through a wide variety of organized team sports. These include participation in Little League baseball, tackle and flag football, golf, basketball, softball, and soccer, etc.

Developmental Disabilities Prevention Program, Williamsville, New York 14231 This program provides services to individuals with developmental disabilities designed to promote health practices and strategies that reduce the occurrence of mental retardation and developmental disabilities.

Dog Control Officers Most townships in the county have Dog Control Officers (DCO) who are responsible for ensuring that the dogs within their township are licensed and properly immunized against rabies. The DCOs assist the health department in locating and confining stray dogs involved in bite incidents so the animals can be observed for signs/symptoms of rabies. They may also seize and destroy, if necessary, dogs with multiple bite histories or those whose owners refuse to have them vaccinated against rabies.

Farmers Markets in Wellsville, Alfred and Belmont once a week between May and October.

Family Court, 7 Court Street, Belmont, New York 14813 Family court handles domestic violence and abuse petitions filed by or on behalf of victims. The Court adjudicates these cases to determine the appropriate course of action to take in resolving each case.

Hillside Children’s Center, Western Region Office, Warsaw and Cuba, New York The Hillside Children’s Center provides foster care for emotionally disturbed children in a home environment, as opposed to an institution or group home. Children receive treatment primarily within the foster home through social workers, sociotherapists, and education specialists. The primary focus of this program, whenever possible, is to reunite the child with his or her natural family.

Allegany County Sheriff’s Department, Belmont, New York 14813 New York State Police, Belmont, New York 14813 Local Town and Village Police Law enforcement agencies provide training on highway traffic safety. Presentations are available to all county residents, with focus on teenage drivers. The New York State Police are involved in the Child Safety Seat Program. These agencies also respond to calls of domestic violence and abuse, and alcohol and drug abuse, arresting and charging offenders while referring victims to the appropriate care and support facilities.

Randolph Children’s Home, Inc., 356 Main St. ER, Randolph, NY 14772 The Randolph Children’s Home provides supervision and confinement to children with behavioral or other problems. Children live within the home located in Randolph and attend school on the grounds at Randolph Academy. Individual foster homes are also available for the placement of these children.

Allegany Western Steuben Rural Health Network, Wellsville, NY This agency seeks to identify unmet health needs, develop and organize rural health delivery systems, provide shared services and resources, develop wellness programs, identify financial resources to support health services, identify strategies that focus on consumer health needs.

Southern Tier Health Care System, Inc., One Blue Bird Square, Olean, New York 14760 This agency seeks to identify unmet health needs, develop and organize rural health delivery systems, provide shared services and resources, develop wellness programs, identify financial resources to support health services, identify strategies that focus on consumer health needs. Child advocacy center for sexual abuse in Wellsville, NY

WNY Regional Office of Mental Health This office provides assistance to those in need of mental health services through counseling, referral, and patient care through contact and affiliation with regional health care providers.

Western New York Emergency Medical System (WNY-EMS) The WNY Emergency Medical System consists of 286 EMS agencies and 31 hospital-based emergency medicine departments. The Allegany County Office of Emergency Services is part of this system. The WNY-EMS is coordinated through the Western Region Emergency Medical System (WREMS), which is responsible for the development of the EMS System, medical control, quality improvement, education, and establishing regional communications. Services to the community include the development and advancement of a Regional EMS System that provides the emergency patient a continuum of care from an accident or injury scene, through transport and treatment at a hospital emergency medicine department or trauma center.

Western New York Regional Trauma System (WNY-RTS) The WNY-RTS is composed of two regional and one area trauma center. The Erie County Medical Center (ECMC), Buffalo Children’s Hospital, and the Women’s Christian Association Hospital provide regional trauma services to WNY, including helicopter support. WNY has approximately 28 referring hospitals that provide specialty services that support trauma patients. The activities of these facilities are as follows:

Regional Adult Trauma Center About 60% of trauma injuries in WNY are triaged to the regional adult center. This center provides all patients with immediate intervention, evaluation and care from pre-admission through home health and rehabilitation. The Trauma Center accepts any patient with a traumatic injury, and has a policy of accepting all referred patients. Patient care is provided by a multidisciplinary Trauma Team, assisted as necessary by consulting specialty medical and support services.

Regional Pediatric Trauma Center The Pediatric Trauma Center provides services similar to the Adult Trauma Center. Cases are accepted by the Center, including those referred from other facilities. A trauma team provides all patient care, with assistance from specialty medical and support services as needed.

Area Adult Trauma Center This center provides trauma care similar to that of the regional and pediatric trauma centers, with services managed by a Trauma Team, with assistance as needed from specialty medical and support services.

WNY Community Hospitals All community hospitals within WNY have the capacity to administer emergency and lifesaving procedures in the event of a trauma admission. Major trauma patients that these hospitals cannot provide definitive care to are sent to a regional trauma center for treatment.

Zafron Home for Parenting Teens The Zafron Home for Parenting Teens serves pregnant and parenting teenage mothers from Western and Central New York State. Residents are placed through their county’s DSS, or the State Office of Children and Family Services, and must be in the custody of one of those agencies. The home provides a supportive living arrangement for teenage mothers and their children, and offers support and assistance designed to develop and improve independent living skills. Eligibility requirements must be met in order to be placed in this facility.

Clinic Facilities The following clinics are available through the Allegany County Department of Health. If no insurance is available a sliding fee scale is available. These services afford the working poor and Medicaid population health-related services they may otherwise neglect to get. There are Family Planning/STD Clinics available in Wellsville, Alfred, and Belmont. These well utilized services are offered by appointment and walk in and have a high participant satisfaction rate. There are free blood pressure screenings open to the public held monthly in Alfred, Belmont, Fillmore, Whitesville, Cuba, Wellsville, Canaseraga, Bolivar and Friendship. Immunization clinics are open to the public several times a month by appointment in Belmont. There is a sliding scale fee based on household income for all vaccines if no insurance coverage. Allegany County Health Department continues to utilize the vaccine for children program. These clinics are very busy, especially before the start of the school and college year and during influenza season.

The Health Department offers free rabies clinics for dogs, cats and ferrets at least once every four months in accordance with New York Public Health Law and the New York State Sanitary Code. These clinics are generally held on Saturday’s at various times throughout the year, most often at the centrally-located County Office Building in Belmont, NY. These clinics are always very well attended and busy and overall feedback from the public is very positive. If/when enough funds are available; the Health Department also sponsors two-three additional free rabies clinics for local townships, upon request.

The WIC Program offers free services in Alfred Station, Angelica, Belfast, Bolivar, Canaseraga, Cuba, Fillmore, Friendship and Wellsville for eligible residents. Several office clinics are also held monthly in Wellsville for those who miss their appointments, are coming on new, and for recently delivered babies. Evening and lunch clinic hours are available as needed. These office clinics mean that participants do not wait for services. New participants typically receive an appointment within 2-7 working days to insure timely use of services. The WIC Program also has a free Electric Breast Pump Loaner Program for participants that wish to continue breastfeeding upon returning to work/school or for those who are separated from their babies. Hand and pedal pumps are also available upon request. Participants report staff to be extremely friendly and helpful. Current caseload is 1,250.

The following physicians accept Medicaid patients and provide primary care, obstetrical/gynecological, pediatric, ophthalmic and other services in Allegany County. Dr. Kurt Benham, ophthalmic, Wellsville Dr. David Brubaker, family medicine, Houghton Dr. Gary Cook, optometry, Wellsville Dr. James Rummel, family medicine, Andover Dr. Osborn, family medicine, Bolivar Dr. Leo Cusumano, pediatrics, Cuba Dr. Depner, family medicine, Wellsville Dr. Lu-Ann Kaye, family practice/OBG, Wellsville Dr. Zahi Kassas, pediatrics, Wellsville Dr. Kelvin Gold, family medicine, Cuba Dr. Robert Maiden, psychology, Wellsville Dr. F. Clifton Miller, obstetrics/gynecology and pediatrics, Wellsville Dr. M. Raqib Raja, psychiatry, Wellsville Dr. Calvin Schierer, family medicine, Houghton Dr. Heather Lanphere, obstetrics/gynecology, Wellsville Dr. Kenneth VanDine, ophthalmic, Wellsville Dr. Reed Haag, Internal Medicine, Wellsville Dr. Susan Mason, family practice, Alfred Dr. Steven Collins, family practice, Belmont Tri County Family Medicine, Canaseraga Cuba Dental Clinic Dr. Peter Hancher Dentist, Wellsville Dr. Robert Riley, Dentist, Wellsville

The Universal Primary Care: Southern Tier Community Health Center Network, Inc., a Federal Qualified Health Care Center with locations in Cuba and Houghton. Established in 2004, UPC specializes in family medicine, adult medicine, pediatrics, obstetrics and gynecology. Our Medical Staff consists of five physicians, two certified nurse midwives, one nurse practitioner and one physician assistant. As a teaching site of the Olean General Hospital/University of Buffalo Family Medicine department, UPC is proud to train medical students and medical residents in rural Family Medicine. UPC is a nationally designated Patient Centered Medical Home. UPC is a Federally Qualified Health Center. The Jones Memorial Hospital offers clinics 50 in Belmont, Wellsville, and Alfred that accept Medicaid patients. The Olean Medical Group has a satellite office in Cuba that accepts Medicaid patients for general practice and obstetrics and gynecology. The Urgent Care Center at Cuba Memorial Hospital and Jones Memorial Hospital Emergency Room in Wellsville also accept Medicaid patients.

As with many small rural counties in New York State, health resources and access to care in Allegany County is often inadequate or lacking, particularly in the areas of dental care and specialty medical services. Part of this stems from the fact that Allegany County has such a large proportion of its population enrolled in Medicaid, or who are under insured or have no health insurance at all. Few dentists in the county accept Medicaid patients due to the low reimbursement rates they receive for services rendered. Specialty medical providers are impacted by this same problem. Neither group recovers basic expenditures for the services they provide to Medicaid patients, and are therefore reluctant to care for these people.

Cuba Memorial Hospital, located on the eastern side of Allegany County, offers a combined urgent care, rehabilitation and long-term care facility. Jones Memorial Hospital, located on the western side of Allegany County, is the only general hospital within the county’s borders. Jones Memorial has a clinic centrally located in Belvidere and a Women’s Health Center in Wellsville. Among the counties, which flank Allegany County, are several hospitals available to county residents. These include Olean General Hospital (Cattaraugus County), St. James Hospital in Hornell, and Ira Davenport Memorial Hospital in Bath (both in Steuben County), Noyes Memorial Hospital in Dansville (Livingston County), Wyoming County Community Hospital in Warsaw (Wyoming County), and Charles Cole Memorial Hospital in Coudersport, Pennsylvania (Potter County). Specialty hospitalization or tertiary care is available through hospitals in Buffalo (e.g., Buffalo General Hospital; Erie County Medical Center; Roswell Park Cancer Institute), Rochester (Strong Memorial Hospital), and Sayre, Pennsylvania (Guthrie Clinic/Robert Packer Memorial Hospital).

Primary and Specialty Health Services Currently, there are approximately 12.5 primary care physicians providing adult and pediatric services (general/family practice), and approximately 12 specialty care physicians, with practices in Allegany County. Specialty physicians include obstetrician/gynecologists, internal medicine physicians, general surgeons, pediatricians, ophthalmologists, and podiatrist. Access to these physicians is limited to a degree for the following two reasons. First, the majority of them are located in Alfred, Cuba, Houghton, and Wellsville. This leaves them geographically removed from large segments of the county population. Also, many of these physicians only practice in the county on a part-time basis, as they have their primary practices located in adjacent counties. This further limits access to these individuals for county residents in need of medical care.

Aside from private practice physicians, there are also several clinics available to county residents for receiving primary, specialty, or preventive health care. Jones Memorial Hospital operates three satellite clinics in the county, with locations in Belvidere, a Veteran’s Health Care Center in Wellsville and a Women’s Health Care Center in Wellsville. In Cuba, the West Main Medical Center provides family practice and primary care services to its clientele. Also in Cuba, the UPC (Southern Tier Community Health Center Network) is a Federally Qualified Health Care Center 51 and provides general practice and gynecological services. The Allegany County Department of Health offers family planning clinics in 3 locations in Allegany County, blood pressure clinics in 9 locations in Allegany County, and immunization clinics at the Belmont site. However, despite this fact, the extreme rural nature of the county, particularly in the northeastern, northwestern, and south central portions of the county restricts easy access for a substantial proportion of the county’s population.

Dental Health Care In 2013 there are 11 licensed dentists in Allegany County. Cuba Dental Clinic is an Article 28 clinic is owned and operated by the Cuba Memorial Hospital. A two dentist practice in Wellsville accepts Medicaid (Hancher and Riley). We currently have 2 orthodontists who practice at sites in several counties. There are four dental practices in Wellsville, two and a dental clinic in Cuba, one in Alfred and two in Houghton. This leaves a large area of the county with inadequate dental coverage, requiring many county residents to travel significant distances for these services.

Cancer Treatment-Regional cancer treatment is available to patients through Southern Tier Oncology in Hornell; Wilmont Cancer Center, Rochester General Breast Center, Strong Memorial Hospital in Rochester, CCS Oncology Cancer Center of WNY and the Roswell Park Memorial Cancer Institute in the Buffalo area, Southern Tier Cancer Care, Mildred Milliman Radiation Center and Berry Street Health Center in Olean and Cancer Care of WNY in Jamestown. Roswell Park Cancer Institute was recently identified as one of the top 10 cancer centers in the United States. Patients may also receive care in the forms of surgery, radiation therapy and chemotherapy through local physicians and area health care centers.

Rehabilitation Services-County residents have access to rehabilitation services through a variety of sources including private contractors, therapist groups, clinics, and the health department. Individual therapists or therapy groups often contract with the health department to provide services to patients identified through the Children’s Services programs. These include such specialty providers as physical therapists, occupational therapists, speech therapists, and audiologists.

Nursing Homes, Geriatric Care Facilities, and Rest Homes There are several nursing home, geriatric care facilities, and rest homes within the county including the following: Centerville- Wolfer Family Type home for adults; Bolivar - Bolivar Manor; Cuba - Cuba Memorial Skilled Nursing Facility; Houghton – Absolut at Houghton; Scio - Mater Dei Home for Adults; Wellsville - Highland Health Care Center, Manor Hills, and the Wellsville Manor. Availability of rooms at these locations is at a premium. The result is that many patients often end up in facilities well away from their families, such as in Olean, New York, Hornell, New York, and Coudersport, Pennsylvania, until a bed in a county home is available.

Helping to alleviate this problem WillCare offers long-term home health care to county residents in their homes (“nursing home without walls”), as an alternative to nursing home placement. To be considered for this program, a patient must be under the direct care of a licensed physician, qualify for nursing home placement, and have only an informal support system at home.

4. Documentation on the process and methods used to conduct the assessment. The process and methods of conducting the Community Health Assessment (CHA) included researching the data, surveying the community and conducting focus groups in the community. The key stakeholder core group is made up of representatives from the Allegany County Department of Health, the Allegany Western Steuben Rural Health Network, the Cuba Memorial Hospital and the Jones Memorial Hospital. This core group has been meeting since January 2013; attending the webinars from the New York State Department of Health on the Community Health Assessment (CHA), the Community Health Improvement Plan (CHIP), and the Community Service Plan (CSP); developing the survey for the community and the list of groups that should be represented by the focus groups. The data that was researched included the 2010 U.S. Census, 2007-2011 American Community Survey 5 year Estimates (U.S. Census), People Quick-facts for the U.S. Census, New York State Vital Statistics, New York State Expanded Behavioral Risk Factor Surveillance System (BRFSS) July 2008-June 2009, National Center for children in Poverty, New York State District Report Card Comprehensive Information Report, New York Makes Work Pay (NYMWP) project, United States Bureau of Labor, Uniform Crime Reporting Program, and Allegany County Indicators for tracking Public Health Priority Areas, 2013-2017-various data sources.

See the attachments: Allegany County Community Health Assessment Survey, Allegany County Integrated Health Plan 2013-2017 Report, and Data 2013-Community Health Assessment (power point) used at the stakeholders meeting.

The vision of this group is to collaboratively build the infrastructure and capacity of our local healthcare delivery system to make Allegany County the healthiest community in New York State. This group was guided through the MAPP (Mobilizing for Action through Planning and Partnerships) process by the AWSRHN. MAPP is an evidence-based, community driven strategic planning tool for improving community health. The elements of MAPP include: Build LHD leadership, but also promote community responsibility for the health of the public; Assess capacity of entire local public health system; Strategic planning; Focus on health status, community perceptions, forces of change, and local public health system capacities; and Strategically match needs, resources, ideas, and actions. The MAPP process in Allegany County included: Identify Key Stakeholders-January 2013; Quantitative Data Gathering and Analysis- January through August 2013; 8 Focus Groups- 101 Participants (March 25, 2013- 19 Teens, April 10, 2013- 9 Faith Leaders, April 10, 2013- 7 Physicians, April 15, 2013- 7 Community Nurses, April 22, 2013- 11 Community Health Educators, April 25, 2013- 23 Jones Memorial Hospital Leadership Team, May 22, 2013- 10 Business Leaders, June 25, 2013- 15 Aging Service Providers); Community Health Assessment Survey- 408 Participants-February –July 2013; and a Key Stakeholders meeting August 14, 2013 which included a power point presentation of data, community survey, and focus groups and the exercise to choose priorities.

The priorities that were selected from the Allegany County Community Health Assessment for the Allegany County Community Health Improvement Plan are:  Priority #1: Prevent Chronic Disease Reduce Obesity in Children and Adults

Disparity - Socioeconomic  Priority #2: Promote Mental Health and Prevent Substance Abuse Promote Mental, Emotional and Behavioral Health Disparity - Socioeconomic, Disability

B. Community Health Improvement Plan (CHIP)

1. Identification of priorities from the Prevention Agenda 2013 In January 2013, the Allegany County Department of Health (ACDOH), Allegany/ Western Steuben Rural Health Network (AWSRHN), Cuba Memorial Hospital (CMH), and Jones Memorial Hospital (JMH) started meeting to discuss the Community Health Assessment (CHA), Community Health Improvement Plan (CHIP), and hospital Community Service Plan (CSP). These meetings were organized around the dates for the New York State Department of Health (NYSDOH) webinars on CHA/CHIP/CSP. The vision of this group is to collaboratively build the infrastructure and capacity of our local healthcare delivery system to make Allegany County the healthiest community in New York State. This group was guided through the MAPP (Mobilizing for Action through Planning and Partnerships) process by the AWSRHN. MAPP is an evidence- based, community driven strategic planning tool for improving community health. The elements of MAPP are: • Build LHD leadership, but also promote community responsibility for the health of the public • Assess capacity of entire local public health system • Strategic planning • Focus on health status, community perceptions, forces of change, and local public health system capacities • Strategically match needs, resources, ideas, and actions The MAPP process in Allegany County: o Identify Key Stakeholders-January 2013 o Quantitative Data Gathering and Analysis-January through August 2013 o 8 Focus Groups- 101 Participants o March 25, 2013- 19 Teens o April 10, 2013- 9 Faith Leaders o April 10, 2013- 7 Physicians o April 15, 2013- 7 Community Nurses o April 22, 2013- 11 Community Health Educators o April 25, 2013- 23 Jones Memorial Hospital Leadership Team o May 22, 2013- 10 Business Leaders o June 25, 2013- 15 Aging Service Providers o Community Health Assessment Survey- 408 Participants-February –July 2013 o Key Stakeholders met August 14, 2013- o Power point presentation of data, community survey, and focus groups (see attached power point) o Exercise to choose priorities

Allegany County Community Health Assessment- Priority Scoring System from the exercise to choose priorities from the key stakeholders meeting on August 14, 2013. Attendance Allegany/Western Steuben Rural Health Network, Inc. Carrie Whitwood, Executive Director and Helen Evans, Associate Director Allegany County Department of Health Lori Ballengee, Public Health Director, Theresa Moore, Supervising Public Health Educator, Linda Wilcox, Director Early Intervention, Madelyn Thornton, Coordinator CSPACC, Lauri Smith, WIC Program Coordinator, Laurie Hennessy, Director of Patient Services, Shaye Reagan, Intern with WIC Program, and Richard Reynolds, Children with Special Health Care Needs Jones Memorial Hospital Eva Benedict, Chief Executive Officer, Tracy Gates, Chief Financial Officer, Donna Bliven, Judy Burt, Julie Hart, Brenda Sobeck, and Brenda Szabo Cuba Memorial Hospital Norma Kerling, Director of Patient Services

Priorities Priority #1: Prevent Chronic Disease Reduce Obesity in Children and Adults- 30 Points Priority #2: Promote Mental Health and Prevent Substance Abuse Promote Mental, Emotional and Behavioral Health- 24 Points Priority #3: Prevent Chronic Disease Increase Access to High Quality Chronic Disease Preventative Care and management in Both Clinical and Community Settings- 20 Points

Exercise Scoring Promote Mental Health and Prevent Substance Abuse Promote Mental, Emotional and Behavioral Health- 24 Points (4 Green * 3 = 12, 4 Pink * 2 = 8, 4 Yellow * 1 = 4) Prevent Substance Abuse and Other Mental, Emotional and Behavioral Health Disorders- 4 Points (1 Yellow * 1 = 1) Strengthen Infrastructure across Systems- 1 Point (1 Yellow * 1 = 1) Promote Healthy Women, Infants and Children Maternal and Infant Health- 0 Points Child Health- 7 Points (1 Green * 3 = 3, 2 Pink * 2 = 4, 0 Yellow * 1 = 0) Preconception and Reproductive Health- 0 Points Prevent HIV, STDs, Vaccine Preventable Diseases and Healthcare Associated Infections Vaccine Preventable Disease- 8 Points (1 Green * 3 = 3, 2 Pink * 2 = 4, 1 Yellow * 1 = 1) HIV- 0 Points Sexually Transmitted Disease- 0 Points Hepatitis C Virus- 0 Points Healthcare Associated Infections- 0 Points Prevent Chronic Disease Reduce Obesity in Children and Adults- 30 Points (8 Green * 3 = 24, 2 Pink * 2 = 4, 2 Yellow * 56

1 = 2) Reduce Illness, Disability and Death Related to Tobacco Use and Second Hand Smoke Exposure- 3 Points (0 Green * 3 = 0, 0 Pink * 2 = 0, 3 Yellow * 1 = 3) Increase Access to High Quality Chronic Disease Preventative Care and management in Both Clinical and Community Settings- 20 Points (2 Green * 3 = 6, 6 Pink * 2 = 12, 2 Yellow * 1 = 2) Promote a Healthy and Safe Environment Injury, Violence and Occupational Health- 2 Points (0 Green * 3 = 0, 0 Pink * 2 = 0, 2 Yellow * 1 = 2) Outdoor Air Quality- 0 Points Built Environment- 0 Points Water Quality- 0 Points Healthcare Disparities Poverty Entitlement No Incentive to Improve Health Pertussis- Babies and Children Influenza- Decrease Hospitalizations in those >65 years of Age (6) Obesity- Poverty Level - Wellness Programs, Exercise Programs, Proper Food Choices, Culture Change toward Improved Nutrition, Financial Means to Purchase Fresh Fruits and Vegetables, Increase Weight Loss Opportunities among Low Income Women, Increase Nutrition Education among Children, Increase Education among Parents, Promote Healthy Eating in Low Income Families, and Increase Physical Activity in Low Income Families Access to Mental Health Care- Children Access to Mental Health Care- Adolescents Dental Health in Children - Early Education, including Parents, for Caries Prevention Suicide Prevention- Youth Access to High Quality Chronic Disease Prevention and Management- Poverty/Uninsured - Increase In-County Access The core committee of stakeholders continued to meet and discuss scoring and committees for the CHA and CHIP. After the scoring for the key stakeholders was complete, two committees were assembled one on obesity and one on mental health. The obesity committee has met four times, completed a survey for an asset map, and determined the CHIP for obesity. The mental health committee has met once with physical health providers to determine the asset map for Allegany County and the gaps in services. The committee met a second time to determine the CHIP for mental health. (see attached See the attachments: Allegany County Community Health Assessment Survey, Allegany County Integrated Health Plan 2013-2017 Report, and Data 2013- Community Health Assessment (power point) used at the stakeholders meeting)

The priorities that were selected from the Allegany County Community Health Assessment for the Allegany County Community Health Improvement Plan are:  Priority #1: Prevent Chronic Disease

Reduce Obesity in Children and Adults Disparity - Socioeconomic  Priority #2: Promote Mental Health and Prevent Substance Abuse Promote Mental, Emotional and Behavioral Health Disparity - Socioeconomic, Disability

2., 3., 4.,5., 6. Allegany County Community Health Improvement Plan

Date Created: November 5, 2013 Date Reviewed/Updated:

Prevention Agenda Priority for 2013-2017: Promote Mental Health and Prevent Substance Abuse

Focus Area: Strengthen Infrastructure Across Systems GOAL: Strengthen infrastructure for MEB health promotion and MEB disorder prevention.

PERFORMANCE MEASURES How We Will Know We are Making a Difference Short Term Indicators Source Frequency Identify and strengthen opportunities for sharing data on access to care, identifying Utilization Data Annual service gaps, studying cost-effectiveness strategies for integration and coordination, and the impact of interventions. Identify and strengthen opportunities for implementing MEB health promotion and Suicide Prevention Quarterly MEB disorder prevention with individuals. Coalition Collaborate with the physical health community to identify opportunities to provide Utilization Data Quarterly cross systems training. # of PCPs Trained # Positive Screens # of Referrals Long Term Indicators Source Frequency Reduce the age-adjusted suicide death rate per 100,000 by 10% (Baseline: 11.5 per NYSDOH Vital Annual 100,000, Year: 2008-2010) Statistics

Maintain the age-adjusted % of adults with poor mental health for 14 or more days in BRFSS Annual the last month by 10% (Baseline: 8.6 per 100,000, Year: 2008-2010)

OBJECTIVE #1: Identify and strengthen opportunities for sharing data on access to care, identifying service gaps, studying cost-effectiveness strategies for integration and coordination, and the impact of interventions.

BACKGROUND ON STRATEGY Source: Center for Integrated Health Solutions, 2013 Evidence Base: Model Program Policy Change (Y/N): Y Disparity (Y/N): Y, Socioeconomic, Disability Improvement Strategies Activity Target Resources Lead Person/ Anticipated Progress Date Required Organization Product or Result Notes Identify key leaders among BEM 3/2014 Key leaders Helen Evans, Baseline data Key leader Agencies in Allegany County to AWSRHN Training schedule group has form an Advisory Team, whose Evidence Based been 58 responsibilities are to prioritize Theresa Moore, Practices to be used organized needs related to data, training, ACDOH and meet 2 and evidence based practices times to that are necessary to promote J. Hart, JMH organize the MEB health and prevent MEB disorders. CHIP M. Conklin, CMH Facilitate quarterly Advisory Ongoing Site L. White, Community Improved Team meetings to monitor and Services Communication evaluate system changes, Participant Buy- appropriateness of service In Improved provisions and augment when necessary. Coordination of Care Explore improving care 6/2014 Article 28 Status J. Hart, JMH Define and monitor coordination for the Severely consumer Quality Mentally Ill and/or Addicted by co- W. Penman, ACASA Indicators in the locating Primary Care Services in target population local Behavioral Health Settings; including data collection M. Damiano, ARA using a structured consumer Decrease Non- survey, research on state and L. White, Community Emergent ED federal regulations, literature Services Utilization reviews, and completing a business feasibility plan. Achieve regulatory requirements 12/2014 Certificate of J. Hart Certificate Of Need necessary to implement a Need integrated model system Implement in one (1) MEB setting 12/2015- Funding J. Hart, JMH SMI and Addicted and monitor effectiveness for Ongoing Consumers will have potential spread into other Billing Services W. Penman, ACASA improved access to specialized populations primary care Shared M. Damiano, ARA Organizational Movement toward Structure- L. White, Community Level 6- Full Clerical Support Services Collaboration in Transformed/Merged Exam Room- R. Anderson, Integrated Practice Space Community Services Six Levels of Collaboration/ Practitioner(s) Integration Improve access to MEB Health 12/2015 Tele-psychiatry J. Hart, JMH Tele-psychiatry Services for children and consultant Services adolescents through the contract R. Anderson, Implemented recruitment and retention of a (equipment Community Services Child and Adolescent Psychiatrist and/or expand Tele-psychiatry acquired Improved Medication Services. previously) M. Damiano, Management and ARA/ARC Treatment for Agency/Hospital Children and Cost-Sharing Adolescents Formula Improve care coordination 12/2015 IT Support J. Hart Improve Care between Primary Care and MEB Coordination via: Care via improved Health Process for M. Damiano, - Medication Information Exchange; i.e. Consent ARA/ACR Reconciliation integrated EMR exchange and/or Regional Health Information - Shared Case Notes Organizations (RHIOs) C. Murphy, TCC

W. Penman, ACASA

The Counseling Center

D. Lewis, ACASA 59

OBJECTIVE #2: Identify and strengthen opportunities for implementing MEB health promotion and MEB disorder prevention with individuals.

BACKGROUND ON STRATEGY Source: NYS Office of Mental Health, Suicide Prevention Center Evidence Base: Yes Policy Change (Y/N): No

ACTION PLAN Activity Target Resources Lead Person/ Anticipated Progress Date Required Organization Product or Notes Result Support the Allegany County 3/2014 Expanded Grant Helen Evans, Print Advertising Suicide Prevention Coalition in its Funds; current Allegany/Western efforts to improve mental health funds include Steuben Rural Health Promotional Items awareness and acceptance through MHANYS and Network, Inc. a multipronged anti-stigma campaign; addressing institutional AC United Way Lindy White, Allegany Radio Advertising stigma, societal stigma and Funds County Community individual stigma. Services Support the Allegany County 12/2014 Expanded Grant Helen Evans, Increase Suicide Suicide Prevention Coalition in its Funds; current Allegany/Western First Aid in efforts to increase the number of funds include Steuben Rural Health Community-At- gatekeepers trained through the MHANYS and Network, Inc. Large evidence-based curriculum SafeTALK (Talk, Ask, Listen and AC United Way Lindy White, Allegany Keep Safe) Funds County Community Services Support the Allegany County 12/2014 Expanded Grant Helen Evans, Increase Suicide Suicide Prevention Coalition in its Funds; current Allegany/Western Intervention Skills efforts to increase the number of funds include Steuben Rural Health in the Professional professionals trained through the MHANYS and Network, Inc. Community evidence-based curriculum ASIST (Applied Suicide Intervention Skills AC United Way Lindy White, Allegany Training). Funds County Community Services

OBJECTIVE #3: Collaborate with the physical health community to identify opportunities to provide cross systems training

BACKGROUND ON STRATEGY Source: Office of Alcohol and Substance Abuse (NYS OASAS) and Department of Health and Human Services Evidence Base: Yes Policy Change (Y/N): Yes ACTION PLAN Activity Target Resources Lead Person/ Anticipated Progress Date Required Organization Product or Notes Result Standardize substance use 12/2015 Professional J. Hart, JMH will PCP’s trained to screening in the Primary Care Development for mandate the training use SBIRT Setting through the development of SBIRT for PCP’s after EMR is complete protocols using the Screening, employed by in Summer of 2014 Brief Intervention and Referral to Treatment (SBIRT) approach. JMH Protocols will comply with AMA and CMS Guidelines allow for 60 maximum billing under CPT codes 99408, 99409, CMS codes G0396, G0397, and SBI codes H0049 and 0050. Develop a Quick Reference Guide 12/2015 Personnel W. Penman, ACASA Quick Reference to enhance referral strategies for Printing/Copying Guide individuals screened positive in Primary Care Settings using the SBIRT. Implement SBIRT in one (1) PCP 3/2015- Integration of J. Hart, JMH Improve screening office for test-piloting with Ongoing SBIRT in EMR and referral for anticipating spread to additional M. Conklin substance use in sites. the PCP setting Standardize adult depression 12/2014 Professional J. Hart, JMH will PCP’s trained to screening in the Primary Care Development for mandate the training use PHQ-9 Setting through the development of PHQ-9 for PCP’s after EMR is complete protocols using the PHQ9 employed by in Summer of 2014 Depression Screening Tool. Protocols will comply with CMS JMH Guidelines to allow for maximum billing under G0444 “Annual depression screening, 15 minutes” code. Develop a Quick Reference Guide 12/2014 Personnel T. Moore, ACDOH Quick Reference to enhance referral strategies for Printing/Copying MEB committee Guide individuals screened positive in Primary Care Settings using the PHQ9 Depression Screening. Implement PHQ-9 in one (1) PCP 3/2014- Integration of J. Hart, JMH Improve screening office for test-piloting with Ongoing PHQ-9 in EMR and referral for anticipating spread to additional M. Conklin, CMH adult depression in sites. the PCP setting

ALIGNMENT WITH STATE/NATIONAL PRIORITIES Obj # NYSDOH Prevention Agenda Healthy People 2020 National Prevention Strategy 2013-2017 1 Strengthen infrastructure for MEB AHS-5.1 Increase the proportion of 3. Provide individuals and families health promotion and MEB adults age 18-64 who have a specific with the support necessary to disorder prevention. source of ongoing care. maintain positive mental well-being. 2 Strengthen infrastructure for MEB MHMD-1 Reduce the suicide rate. 3.Provide individuals and families health promotion and MEB with the support necessary to disorder prevention. maintain positive mental well-being.

3 Strengthen infrastructure for MEB SA-8 Increase the proportion of 4.Promote early identification of health promotion and MEB persons who need alcohol and/or mental health needs and access to disorder prevention. illicit drug treatment and received quality services specialty treatment for abuse or dependence in the past year)

MHMD-11.1 Increase the proportion of primary care physicians who screen adults aged 19 years and older for depression during office visits.

DESCRIBE PLANS FOR SUSTAINING ACTION The Mental, Emotional, and Behavioral Health Committee (MEB) will meet on a quarterly basis to plan, implement and evaluate activities. Sustainment will be completed by tracking progress and making midcourse corrections as needed.

Obj. 1 & 3 Sustainment will be dependent upon maximizing billable services to support the cost of the primary care delivery system. Obj. 2: Sustainment will be by training gatekeepers and professionals to carry out suicide prevention, intervention, and postvention strategies.

Prevention Agenda Priority for 2013-2017: Focus Area: Reduce Obesity in Children and Adults GOAL: Create community environments that promote and support healthy food and beverage choices and physical activity.

PERFORMANCE MEASURES How We Will Know We are Making a Difference Short Term Indicators Source Frequency OBJECTIVE #1: Improve “Girls on the Run” participants who demonstrate Pre & Post Test Before and favorable self-esteem, eating attitudes and behaviors, physical activity attitude, and after every body size satisfaction as measured in the pre-posttest surveys results. cohort OBJECTIVE #2: Individuals living with chronic illness who participate in the Pre & Post Test Before and Chronic disease Self-Management (CDSM) Program will demonstrate significant after every improvements in exercise, cognitive symptom management, communication with cohort physicians, self-reported general health, health distress, fatigue, disability, and social/role activities limitations. Graduates will spend fewer days in the hospital and decrease outpatient visits and hospitalizations. OBJECTIVE #3: Individuals diagnosed as Pre-Diabetic will increase awareness and Pre & Post Test Before and knowledge of the seriousness of diabetes, its risk factors, and effective strategies for after every (1) preventing complications associated with diabetes and (2) preventing type 2- cohort Diabetes. A minimum of 50% of DPP participants will increase and sustain effective lifestyle changes to prevent diabetes; including losing 7% of body weight through healthy eating and physical activity. Long Term Indicators Source Frequency OBJECTIVE #1: Increasing the number of participants in the program; increase the Girls on the Run Annually number of sites throughout Allegany County by 100% at the end of three years Council OBJECTIVE #2: Decrease hospital readmission rates JMH Data Annually Cuba Data OBJECTIVE #3: Maintain or decrease incidence of diabetes Department of 3 Years/as Health and Human available Services CDC National Diabetes surveillance system % adult population estimate

OBJECTIVE #1: Improve “Girls on the Run” participants who demonstrate favorable self-esteem, eating attitudes and behaviors, physical activity attitude, and body size satisfaction as measured in the pre-post test surveys results. BACKGROUND ON STRATEGY Source: Girls on the Run Evidence Base: Y Policy Change (Y/N): N Disparity (Y/N): Y, Socioeconomic Improvement Strategies Activity Target Resources Lead Person/ Anticipated Progress Date Required Organization Product or Result Notes Secure funding to establish an 6/2014 $7,500.00 H. Evans, AWSRHN Council successfully Allegany County “Girls on the chartered Run” Council B. Szabo, JMH

M. Conklin, CMH

T. Moore, ACDOH Continue to sponsor and support 6/2014 Coaches B. Szabo, JMH Promote running as a JMH has the Wellsville Girls on the Run Life Skill graduated its Program Grant Funding first Girls on Pre/Post Test the Run Safe Green Space group; and/or Trail Increase Self Esteem 11/2013

Meeting Space Improved Body Image Healthy Snack Expand reach annually with a 6/2015 – Additional B. Szabo, JMH Promote running as a minimum of one new “Girls on the Ongoing Coaches Life Skill Run” site/year T. Moore, ACDOH Scholarship Pre/Post Test Funds for Girls M. Conklin, CMH Increase Self Esteem Safe Green Space and/or Trails Improved Body Image Meeting Space

Healthy Snack Monitor pre-post test results to 11/2013- Pre-Post Test B. Szabo, JMH Program evaluation guide programming changes as Ongoing Analysis and outcomes needed Explore the potential expansion 6/2015 Additional B. Szabo, JMH Build on the age to include “Girls on Track” Coaches T. Moore, ACDOH continuum if grades 6-8. H. Evans, AWSRHN appropriate Additional M. Conklin, CMH Funding

OBJECTIVE #2: Individuals living with chronic illness who participate in the Chronic disease Self Management (CDSM) Program will demonstrate significant improvements in exercise, cognitive symptom management, communication with physicians, self-reported general health, health distress, fatigue, disability, and social/role activities limitations. Graduates will spend fewer days in the hospital and decrease outpatient visits and hospitalizations. BACKGROUND ON STRATEGY Source: Stanford School of Medicine- Stanford Patient Education Research Center Evidence Base: Y Policy Change (Y/N): N Disparity (Y/N): Y, Socioeconomic Improvement Strategies Activity Target Resources Lead Person/ Anticipated Progress Date Required Organization Product or Result Notes Coordinate Stanford University’s 1/2014- Print H. Evans, AWSRHN A minimum of ten Chronic Disease Self- Ongoing Advertising- (10) registrations/ Management (CDSM) Program Funding J. Hart, JMH quarter. marketing, registration and planning targeting individuals and caregivers living with a chronic Referrals (Self- M. Conklin, CMH illness, healthcare professionals, referrals/Medical health and human service Referrals) T. Moore, ACDOH organizations, media outlets, etc. Outreach to Healthcare Providers Expand the number of trained 6/2014 Volunteer H. Evans 10 CDSM Leaders local CDSM Leaders from the Leaders current census of six (6) to ten J. Hart, JMH (10). Master Trainers M. Conklin, CMH

T. Moore, ACDOH

P2 Collaborative of WNY

QTAC

Deliver quarterly Stanford 1/2014- CDSM Trained H. Evans, AWSRHN 100 CDSM graduates University’s Chronic Disease Ongoing Leaders will demonstrate Self-Management (CDSM) CDSM Leaders significant Program workshops consisting of Workshop Sites improvements in two and a half hours, once a week, for six weeks, in QTAC chronic illness self- community settings such as Workshop management skills senior centers, worksites, Materials churches, libraries and hospitals. Monitor and evaluate the 3/2014- Hospital-Based H. Evans, AWSRHN Reduction in effectiveness of CDSM in relation Ongoing data readmissions; to established Quality Indicators; J. Hart, JMH graduates will i.e. hospital admission rates, ER demonstrate utilization, self-reported chronic illness indicators. M. Conklin, CMH significant improvements in QTAC chronic illness self- management skills

OBJECTIVE #3: Individuals diagnosed as Pre-Diabetic will increase awareness and knowledge of the seriousness of diabetes, its risk factors, and effective strategies for (1) preventing complications associated with diabetes and (2) preventing type 2-Diabetes. A minimum of 50% of DPP participants will increase and sustain effective lifestyle changes to prevent diabetes; including losing 7% of body weight through healthy eating and physical activity. BACKGROUND ON STRATEGY Source: Center for Disease Control and National Institutes for Health Evidence Base: Y Policy Change (Y/N): N Disparity (Y/N): Y, Socioeconomic Improvement Strategies Activity Target Resources Lead Person/ Anticipated Progress Date Required Organization Product or Result Notes Complete DPP Recognition 3/2014 Application H. Evans, AWSRHN DPP Recognition Application with the Center for Disease Control. Coordinate the National Diabetes 1/2014- Print H. Evans, AWSRHN A minimum of ten AWSRHN Prevention Program for Ongoing Advertising- (10) registrations/ awarded a individuals diagnosed as Pre- Funding K. Dahlgren, NDEP quarter. grant via the Diabetic, conducting outreach Consultant NYS Health and marketing to healthcare professionals, health and human Referrals (Self- Foundation service organizations, worksite referrals/Medical to launch wellness programs, media Referrals) DPP outlets, etc. Outreach to K. Dahlgren Healthcare is currently a Providers and DPP Worksite Facilitator Wellness Coordinators Attend community-based health 1/2014- Computer based H. Evans, AWSRHN A minimum of five fairs and outreach events to Ongoing AMA Risk Test (5) events promote the American Diabetes or Paper Risk K. Dahlgren, NDEP Association Type 2 Diabetes Risk Test Consultant Test; enrolling anyone scoring at- risk or pre-diabetic into DPP. Recruit and retain a minimum of 3/2014 Volunteer H. Evans Four (4) DPP four (4) local DPP Volunteer Leaders Volunteer Lifestyle Lifestyle Coaches to deliver the J. Hart, JMH Coaches DPP Program. P2 Collaborative M. Conklin, CMH NYS Health Foundation T. Moore, ACDOH

P2 Collaborative of WNY Stagger quarterly Diabetes 1/2014- DPP Lifestyle H. Evans, AWSRHN 50 DPP graduates Prevention Program (DPP) Ongoing Coaches will demonstrate workshops in community settings DPP Lifestyle Coaches significant lifestyle such as senior centers, worksites, Workshop Sites changes; i.e. weight churches, libraries and hospitals. Participants will work with a ACDOH loss. lifestyle coach in a group setting Workshop Allegany County OFA to receive a 1-year lifestyle Materials change program that includes 16 core sessions (usually 1 per week) and 6 post-core sessions (1 per month).

Monitor and evaluate the 3/2014- Hospital-Based H. Evans, AWSRHN Improved Quality effectiveness of DPP in relation to Ongoing data Indicators 65 established Quality Indicators; i.e. J. Hart, JMH Glucose Levels, ER Utilizations, In-Patient Visits, number of M. Conklin, CMH participants, retention rates, etc.

ALIGNMENT WITH STATE/NATIONAL PRIORITIES NYSDOH Prevention Agenda Healthy People 2020 National Prevention Strategy 2013-2017 Create community environments PA-3 Increase the proportion of Healthy Eating 4.Help people recognize and that promote and support healthy adolescents who meet current make healthy food and beverage choices. food and beverage choices and Federal physical activity guidelines Active Living 2. Promote and strengthen physical activity. for aerobic physical activity and for school and early learning policies and muscle-strengthening activity. programs that increase physical activity. Improve health, fitness and quality of life through daily physical activity. Improve the health function and quality of life and wellbeing for all individuals.

Create community environments Promote health and reduce chronic Healthy Eating 4.Help people recognize and that promote and support healthy disease risk though the consumption make healthy food and beverage choices. food and beverage choices and of helpful diets and achievement and physical activity. maintenance of healthy body weights. Improve the health function and quality of life in older adults. Improve health related quality of life and wellbeing for all individuals.

Create community environments D-16 Increase prevention Healthy Eating 4. Help people recognize and that promote and support healthy behaviors in persons at high risk for make healthy food and beverage choices. food and beverage choices and diabetes with pre-diabetes. physical activity. Improve health related quality of life and wellbeing for all individuals.

DESCRIBE PLANS FOR SUSTAINING ACTION Health and Wellness Committee will meet on a quarterly basis to plan, implement and evaluate activities. Sustainment will be completed by tracking progress and making midcourse corrections as needed.

The Health and Wellness Committee will explore funding sources and use of trained volunteers wherever possible.