Delaware County, NY Community Health Assessment Community Health Improvement Plan Community Service Plans 2019-2021 This page was intentionally left blank. 1 | P a g e Delaware County 2019-2021 Community Health Assessment and Improvement Plan and Community Service Plans Local Health Department: Delaware County Public Health Amanda Walsh, MPH, Public Health Director 99 Main Street, Delhi, NY 13856 607-832-5200 [email protected] Heather Warner, Public Health Programs Manager 99 Main Street, Delhi, NY 13856 607-832-5200 [email protected] Hospitals: UHS Delaware Valley Hospital Dotti Kruppo, Community Relations Director 1 Titus Place Walton, NY 13856 607-865-2409 [email protected] Margaretville Memorial Hospital Marilyn Donnelly, RN 42084 NY Route 28, Margaretville, NY 12455 845-338-2500 [email protected] O’Connor Hospital Amy Beveridge, MBA, Director of Operational Support 460 Andes Road, Delhi, NY 13753 607-746-0331 [email protected] Community Health Assessment update completed with the assistance of the Southern Tier regional Population Health Improvement Program (PHIP). Support provided by Mary Maruscak, Evan Heaney, and Stephanie Wright. 2 | P a g e 2019-2021 Community Health Assessment and Improvement Plan for Delaware County Table of Contents Executive Summary 4-7 Acknowledgements 8 Introduction 8-9 Mission 8 Vision 8 Core Values 8 Background and Purpose 9 Community Health Assessment Update I. Data Mining and Review 9-10 II. Identification and Review of Primary and Secondary Data 10-11 Section I: 12-46 a. Geography and Demography 12-20 b. Socioeconomics 20-38 c. Morbidity and Mortality 38-46 Section II: New York State Prevention Agenda Priority Areas a. Prevent Chronic Diseases 47-62 b. Promote Well-Being and Prevent Mental and Substance Use Disorders 63-80 c. Promote a Healthy and Safe Environment 81-83 d. Prevent Communicable Diseases 84-88 e. Promote Healthy Women, Infants, and Children 89-94 Section III: County Health Rankings 95-100 a. Social Determinants of Health 100-103 III. Community Partner Involvement & Process a. Population Health Improvement Program (PHIP) Regional Assessment 103-107 b. Delivery System Reform Incentive Payment (DSRIP) Program 107-119 c. Delaware County Coalitions, Task Forces, and Work Groups 119-122 IV. Conclusions 123 Community Health Improvement Plan 124-131 Prevent Chronic Disease 127-128 Promote Well-Being and Prevent Mental and Substance Use Disorders 128-130 Community Engagement Strategy 131 Dissemination Plan 131 Appendices: Appendix A: Summary of Assets and Resources 132-149 Appendix B: Social Determinants of Health 150 Appendix C: Delaware Valley Hospital Community Services Plan 151-180 Appendix D: Margaretville Memorial Hospital Community Services Plan 181-193 3 | P a g e Appendix E: O’Connor Hospital Community Services Plan 194-217 Executive Summary Delaware County’s Community Health Assessment and Improvement Plan and three Community Service Plans represent a collaborative work process to bring unity to public health and population health activities within the county. This document includes information from a variety of data sources including community surveys, roundtable discussions, updates on the work of the three Performing Provider Systems (PPSs) which intersect in Delaware County, data from the New York State Department of Health’s Prevention Agenda dashboard, information from the County Health Rankings, and other local datasets. The participating organizations, Delaware County Public Health (DCPH) and the three hospitals within the county: Delaware Valley Hospital (DVH), an affiliate of United Health Services (UHS) system; Margaretville Memorial Hospital (MMH), which is a part of the Health Alliance of the Hudson Valley and a member of the Westchester Medical Center Health Network; and O’Connor Hospital (OCH), of the Bassett Healthcare Network, selected the Prevention Agenda priority areas of Prevent Chronic Diseases and Promote Well-Being and Prevent Mental and Substance Use Disorders. Based on the available demographic and health indicator data, the disparate population to be addressed throughout these plans is low income residents living in rural areas of Delaware County. These priority areas represent a continuation of the 2013-2017 full Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP), and the 2016-2018 updated assessment and plan. However, changes have been made to the specific activities selected. Notably, the four entities working to support the CHIP and the three Community Service Plans (CSPs) modified each of their plans to work collectively to impact specific issues, work within each organization’s resources, and by utilizing 4 | P a g e evidence-based practices. Additional partnering entities have been and will continue to be engaged through community coalitions, work groups, and task forces. Prevent Chronic Disease: DCPH will promote physical activity by mapping the walking and biking trails in Delaware County in order to make the numerous trails more accessible and identifiable to everyone. Continuation of Complete Streets policies and design elements remains prominent in the plans for OCH, with modifications to include age friendly community design elements. Initial work completed during the last two CHIP and CSP timeframes laid the groundwork for objectives outlined in the 2019- 2021 time period. All three hospitals seek to expand access to self-management tools for those with chronic disease, and will work in coordination with the PPSs active in the county to provide support for Chronic Disease Self-Management Program (CDSMP) activities for the region’s residents. Additionally, OCH, DVH, and DCPH will promote preventive care and management through increasing cancer screening rates, the former for breast and respiratory cancers, and the latter two for colorectal cancer. Both MMH and OCH have identified a need for tobacco use cessation initiatives through messaging and communications, and to promote healthy eating and food insecurity. MMH and OCH will promote food security among inpatients through evidence-based screening tools and facilitating referrals. Additionally, OCH will seek to increase employee access to fresh fruit and vegetables and increase employee physical activity through evidence-based worksite wellness programs. Promote Well-Being and Prevent Mental and Substance Use Disorders: Delaware Valley Hospital will work to build resilience across the lifespan by convening a coalition of stakeholders to begin to incorporate the eight domains of livability and age friendly principles. Delaware 5 | P a g e County is the fourth largest of 62 counties in New York State, and the fifth most rural. Coupled with the aging trend throughout Delaware County, accessing necessary services and remaining in one’s community poses a challenge to a significant proportion of the population. These difficulties are augmented by other social determinants of health, such as the absence of a public transit system and the fact that most older adults eventually age out of driving. In order to increase support for older adults in Delaware County to age in place and remain involved in their community, DVH will disseminate information on the eight domains of livability through a workshop series to be held in Walton, follow up with participants, and establish committees to work towards each domain through community initiatives. Age friendly principles will also be integrated into existing initiatives, such as Complete Streets, which is support by OCH under the priority area Prevent Chronic Disease, and the Transportation Committee. DCPH will support the age friendly initiative by attending the age friendly workshops conducted by DVH with the goal of increasing the proportion of adults who report an inclusive social environment. A focal point across the CHIP and CSPs are suicide prevention and substance use prevention. O’Connor will continue to address substance use disorder by strengthening interventions and support systems for opioid users, increasing referrals to treatment, and increasing the availability of and access to Naloxone. This also includes participating in the Delaware County Opioid Task Force and Catskills Addiction Coalition, and sharing data with Delaware County Public Health. MMH will similarly reduce opioid overdose by building and participating in collaborative community support systems to care for opioid users and those at risk of overdosing. MMH will also prevent and address adverse childhood experiences (ACEs) through engaging the community with free trainings for staff and community partners. DCPH, MMH, and OCH seek to reduce suicide mortality by identifying and supporting people at risk, including treatment for those who have previously attempted suicide and offering annual gatekeeper trainings such as question, persuade, refer (QPR). Additionally, DCPH will introduce a means reduction 6 | P a g e initiative in the community with the measurable goals of forming a workgroup, forming partnerships with gun owner groups, and offer a means reduction awareness conference in the community. Environmental Changes Over the last decade, New York State has created a healthcare alignment model with the goal of improving population health, transforming healthcare delivery and eliminating health disparities centered on the “Triple Aim” for all New Yorkers: improved health, better healthcare quality and consumer experience, and lower costs. This includes the State Health Innovation Plan