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Collaborative Community Health Needs Assessment

2019-2021 collaborative Community Health Needs Assessment (CHNA), Implementation Strategy (IS), Community Health Improvement Plan (CHIP), and Community Service Plan (CSP)
for Schenectady County
and its Hospitals
Submitted in fulfillment of the requirements of the New York State Department of Health Prevention Agenda by Schenectady County Public Health Services, Ellis Hospital (d/b/a Ellis Medicine), and Sunnyview Rehabilitation Hospital. Submitted in fulfillment of the requirements of the Internal Revenue Service (pursuant to the Patient Protection and Affordable Care Act of 2010) by Ellis Hospital (d/b/a Ellis Medicine). CHNA and Implementation Strategy adopted by vote of the Ellis Hospital Board of Trustees on October 1, 2019. Submitted November 15, 2019.
Schenectady Coalition

To comment in writing on this document pursuant to the Patient Protection and Affordable Care Act (PPACA) of 2010
please contact Ellis Hospital at
or write to Director of Community Relations, Ellis Hospital Administration, 1101 Nott Street, Schenectady, New York 12308

Volume One - Table of Contents

(Note: S = State mandated; F-x = federal mandated, where x = Form 990, Schedule H, Part V, Sec. B, Line 3 reference)
A. New York State Required Cover Page (S) 4
B. Executive Summary in State Required format 5
o 1. Prevention Agenda Priorities and Disparity (S)
o 2. Data Reviewed to Identify Priorities (S)
o 3. Partners and Roles, Engagement of Broad Community (S)
o 4. Evidence-Based Interventions – What Are They and How Selected (S)
o 5. Progress and Improvement Tracking, with Process Measures (S)
C. Community Health Needs Assessment (S) 9
o 1. Definition and Description of the Community Served (S, F-a)
 a. Demographics of Population Served (S, F-b)
 b. Health Status of the Population and Distribution of Health Issues (S)
 c. Current Data, and Changes Over Time (S)
 d. How the Data Were Obtained (F-d)
o 2. Identification of Significant Health Needs and Main Health Challenges (S, F-e)
 a. Discussion of Risk Factors (S)
 Behavioral, Environmental, and Socioeconomic Risk Factors (S)
 Primary/Chronic Disease Needs of Uninsured/Low-income/Minority(F-f)
 b. NYS Prevention Agenda Priority and Focus Areas (S)
 c. Policy Environment (S)
 d. Other Unique Community Characteristics (S)
o 3. Summary of Existing Health Care Assets, Facilities, and Resources (S, F-c)
D. Actions Taken to Address Significant Health Needs Identified in 2013/2016 with Impact (F-i) 38
E. Community Health Improvement Plan/Community Service Plan (S)/Implementation Strategy (F) 50
o 1. Identification of Two Priorities – Process, Criteria, Community Engagement (S, F-g, F-h)
o 2. Goals, Objectives, Intervention Strategies, Process Measures (S)
o 3. Work Plan (see also Appendix B) (S)
 a. Hospital Actions and Impact (S)
 b. Hospital Resources to be Committed (S)
 c. Local Health Department Actions and Impact (S)
 d. Local Health Department Resources to be Committed (S)
 e. Roles and Resources of Others (S)
 f. How Address a Disparity (S)
o 4. Process to Maintain Partner Engagement, Progress Tracking, & Mid-course Corrections(S)
o 5. Dissemination of Executive Summary (S)
Appendix A – Community meetings of the Schenectady Coalition for a Health Community 76
Appendix B – State Required Work Plan Spreadsheets 85

Volume Two - 2019 Capital Region Community Health Needs Assessment
Available at:


New York State 2019-2021 Community Health Needs Assessment, Community Health Improvement Plan and Community Service Plan

A. New York State Required Cover Page

1. County covered:  Schenectady County

2. Participating Local Health Department: Schenectady County Public Health Services, 107 Nott Terrace, Schenectady, New York 12308,       518-386-2810

3. Participating Hospitals: Ellis Hospital (d/b/a Ellis Medicine), 1101 Nott Street, Schenectady, New York 12308, 518-243-4000

Sunnyview Rehabilitation Hospital, 1270 Belmont Avenue, Schenectady, New York 12308, 518-382-4500

4. Coalition/entity completing assessment and plan:
Community Health Needs Assessment – Healthy Capital District Initiative (HCDI), 175 Central Avenue, Albany, New York 12206,            518- 486-8400

Prioritization and Plan – Schenectady Coalition for a Healthy Community (SCHC)

B.  Executive Summary
1. What are the Prevention Agenda priorities and the disparity you are working on with your community partners including the LHD and hospital(s) for the 2019-2021 period?  (See section E.1, pages 50-61)

The final selected top two Prevention Agenda Priorities and Focus Areas are:

1) Priority Area: Prevent Chronic Diseases, Focus Area: Tobacco Prevention, and

2) Priority Area: Promote Well-Being and Prevent Mental and Substance Use Disorders, Focus Area: 
Mental and Substance Use Disorders Prevention.

Both priorities reflect disparities; tobacco use occurs disproportionately among low-income 
individuals and in low-income neighborhoods, while mental disease and drug use diagnoses occur 
disproportionately in low-income neighborhoods.

2. What data did you review to identify and confirm existing priorities or select new ones?  (See
sections C.1.c and d., pages 14-22 and E.1, pages 50-61)

Data reviewed consisted of publicly available health and hospital data collected from twenty data 
sets (see list on page 20), gathered and interpreted for the six-county Capital Region by staff 
data experts at the Healthy Capital District Initiative (HCDI).  These data sets include detailed 
hospital-diagnosis-specific treatment and outcomes reports from the Statewide Planning and Research 
Cooperative System (SPARCS), local health survey measures from the Expanded Behavioral Risk Factor 
Surveillance System (eBRFSS), and Prevention Agenda Tracking Dashboard reports.  In almost all 
cases, data are valid at the county level, with several data sets at the sub-county level.  
Sub-county data at the ZIP code level is
attributed by “neighborhood,” based on generally agreed neighborhood designations.  The HCDI 
analysis provided comparisons to two benchmarks: the Capital Region six-county average, and the New 
York State excluding New York City (NYS excl. NYC) average. HCDI also developed a quantitative ranking 
system which evaluated data on five dimensions of:  1) absolute number, 2) relative number (to NYSexcl. NYC benchmark), 3) impact on health, 4) trend over time, and 5) disparity.  The publicly available, and locally interpreted, data were supplemented by local consumer data and opinions gathered through a telephone survey of households in the six-county region.  The survey samples 
gathered valid data for the region as a whole, for each county in the region, and for a subset of 
low-income consumers across the region.  Finally, the public engagement process included open 
discussion during three meetings over two months, with formally scheduled time for advocates to 
“pitch” their proposed priority, including the introduction of new and additional data.

3. Which partners are you working with and what are their roles in the assessment and implementation processes? How are you engaging the broad community in these efforts? (See sections C.2.c, pages 31-32, E.1, pages 50-61, and E.3.e, pages 71-72)
In addition to working through HCDI and all of the hospitals and public health departments in the six-county Capital Region for data collection and interpretation, Schenectady County and its hospitals again took a highly inclusive and collaborative approach to engaging community partners in the assessment and implementation policy. Since even before the pioneering “UMatter Schenectady” community survey and joint Local Health Department/hospital CHNA/CHIP/CSP in 2013, Schenectady’s health planning efforts have revolved around the multi-agency Schenectady Coalition for a Healthy Community (SCHC). Founded in 2008 to promote community involvement in the State-mandated consolidation of Schenectady’s hospitals, membership in SCHC has expanded to cover most of the not-for-profit provider and community service agencies in the county, as well as applicable local government agencies. Representatives from 28 agencies and organizations (see page 55) actively participated in the assessment and prioritization process. These included the local public health department and the local community services (mental health/substance use) agencies, the hospitals, the only federally qualified
health center (FQHC) in the county, faith-based organizations, a Spanish-speaking community organization, not-for-profit health plans, and such non-traditional partners as a community garden, the chamber of commerce, and the public library. As further described in the detailed Work Plan (pages 63-73 and Appendix B) all of the lead health care agencies and many of the community agencies have accepted active roles in implementation of the selected interventions. In particular, Capital District Tobacco Free Communities will be engaged in the Tobacco Prevention priority area, while certified substance use providers such as New Choices Recovery Center and Hometown Health Centers will actively inform work on the Substance Use Disorders priority. Individual participant organizations will be engaging their consumers and community members.

4. What specific evidence-based interventions/strategies/activities are being implemented to address the specific priorities and the health disparity and how were they selected? (See sections E.2, pages 61-63, E.3, pages 63-65 and 69-72, and Appendix B)
Evidence-based interventions were selected directly from those offered in the Prevention Agenda. For the Tobacco Prevention priority they are: 1) Use media and health communications to highlight the dangers of tobacco, promote effective tobacco control policies and reshape social norms (3.1.2) and 2) Promote Medicaid and other health plan coverage benefits for tobacco dependence counseling and medications (3.2.4). For the Prevent Mental and Substance Use Disorder priority they are: 1) Increase availability of/access and linkages to medication-assisted treatment (MAT) including Buprenorphine (2.2.1), 2) Increase availability of/access to overdose reversal (Naloxone) trainings to prescribers, pharmacists and consumers (2.2.2), 3) Establish additional permanent safe disposal sites for prescription drugs and organized take-back days (2.2.5), and 4) Integrate trauma informed approaches in training staff and implementing program and policy (2.2.6). As with the priorities, the interventions were selected from among those offered in the Prevention Agenda through a stakeholder-involved, iterative
process. Meetings in June and July (see Appendix A) engaged invited stakeholders and then the full SCHC membership in reviewing alternatives and selecting those to be implemented.