The Onondaga County Community Health Assessment and Improvement Plan 2014 2017

The Onondaga County Community Health Assessment and Improvement Plan 2014 2017 Cynthia B. Morrow, MD, MPH, Commissioner of Health Rebecca Shultz, MPH, Director, Bureau of Surveillance and Statistics

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Table of Contents 1) Executive Summary... 7 2) Community Health Assessment... 11 a) Overview of Onondaga County... 11 b) Part A: Population Characteristics... 13 c) Part B: Socioeconomic Characteristics... 18 d) Part C: Health Status and Distribution of Health Issues... 24 i) Improving Health Status and Reducing Health Disparities... 24 ii) Prevention Agenda Area: Preventing Chronic Disease... 29 iii) Prevention Agenda Area: Promoting a Healthy and Safe Environment... 35 iv) Prevention Agenda Area: Promoting Healthy Women, Infants and Children... 40 v) Prevention Agenda Area: Promoting Mental Health and Preventing Substance Abuse... 45 vi) Prevention Agenda Area: Preventing HIV/STDs, Vaccine Preventable Diseases and Health Care Associated Infections... 49 e) Part D: Determinants of Health and Main Health Challenges... 51 f) Part E: The Onondaga County Health Department and Other Assets and Resources... 55 g) Part F: Community Engagement Process and the Methodology of the Community Health Assessment... 59 3) Community Health Improvement Plan... 62 a) Background... 62 b) Drug Related Discharges in Newborns in Onondaga County... 65 c) Impacting Chronic Disease in Onondaga County... 71 i) The Near Westside Neighborhood... 71 ii) Healthy Syracuse... 75 d) Process Improvement: Lessons Learned... 77 e) Sustainability of Community Engagement... 78 1

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Appendices To access the appendices referenced in this document, please visit our website at www.ongov.net/health 1. Data Tables a) Preventing Chronic Disease b) Promoting a Healthy and Safe Environment c) Promoting Healthy Women, Infants and Children d) Birth Outcomes by Zip Code e) Promoting Mental Health and Preventing Substance Abuse f) Preventing HIV/STDs, Vaccine Preventable Disease and Health Care Associated Infections g) Data Table Technical Notes 2. Expanded BRFSS Preliminary Report, 2013 2014 3. Onondaga County Health Department Organizational Chart 4. Onondaga County Assets and Resources 5. Report on Findings of Community Forums 6. Schedule of CHA meetings 7. State of the County s Health 8. The Community Health Assessment Process a) Community Health Needs Assessment and Community Engagement b) Lerner Center and MPH Program Community Engagement Forums 9. Drug related Discharges in Newborns in Onondaga County 10. Onondaga County Health Department s Journey to the Summit 11. Prevention Quality Indicators 12. The Tree of Health Acknowledgement The Onondaga County Health Department gratefully acknowledges the contributions of Thomas H. Dennison, PhD and his Masters students from Syracuse University and Upstate Medical University for all of their hard work in the research and preparation of this document. 2

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 List of Figures Figure 1: Location of Onondaga County within New York State... 11 Figure 2: Map of Onondaga County... 11 Figure 3: Urban population by census tract, Onondaga County, 2010... 12 Figure 4: Population distribution by age group, Syracuse, Onondaga County and New York State, 2009 2011... 13 Figure 5: Projected age distribution for Onondaga County, 2030... 14 Figure 6: Population by race, Onondaga County, 2009 2011... 15 Figure 7: Population by race, Syracuse, 2009 2011... 15 Figure 8: Population by Hispanic ethnicity, Onondaga County, 2009 2011... 16 Figure 9: Population by Hispanic ethnicity, Syracuse, 2009 2011... 16 Figure 10: Unemployment by race, Syracuse, Onondaga County and New York State, 2009 2011... 19 Figure 11: Percent of residents by income, Onondaga County and Syracuse, 2009 2011... 20 Figure 12: Percent of families living below the federal poverty level, Onondaga County and Syracuse, 2009 2011... 21 Figure 13: Demographic disparities between Onondaga County and the City of Syracuse... 23 Figure 14: Racial and ethnic disparities in premature deaths, 2008 2010... 25 Figure 15: Percent of deaths by age category, race and sex, Onondaga County, 2008 2010... 26 Figure 16: Survivorship by sex and age for selected races, Onondaga County, 2008 2010... 26 Figure 17: Racial and ethnic disparities in preventable hospitalizations, 2008 2010... 27 Figure 18: Age adjusted mortality rate for diseases of the heart, 2009 2011... 29 Figure 19: Age adjusted mortality rate for coronary heart disease, 2009 2011... 30 Figure 20: Age adjusted incidence and mortality rates for all types of cancer, Onondaga County, 1994 2008... 31 Figure 21: Incidence of breast, lung and prostate cancers in Onondaga County, New York State and the U.S., 2007 2009... 31 3

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Figure 22: Mortality from breast, lung and prostate cancers in Onondaga County, New York State and the U.S., 2007 2009... 32 Figure 23: Obesity rates in Onondaga County, New York State and the U.S.... 33 Figure 24: Diabetes mortality in Onondaga County, New York State and the U.S., 2009 2011... 33 Figure 25: Asthma hospitalizations in Onondaga County and New York State, 2009 2011... 36 Figure 26: High school graduation rates and the percent of students receiving free or reduced lunch by district, 2008 2009... 37 Figure 27: Access to grocery stores by census tract, 2010... 38 Figure 28: Age adjusted homicide rate, Onondaga County and comparison geographies, 2008 2010... 39 Figure 29: Infant mortality by race, three year averages, Syracuse, NY, 1985 2011... 40 Figure 30: Preterm births and low birth weight births by race and ethnicity, 2009 2011... 41 Figure 31: Racial and ethnic disparities in adolescent pregnancy, Onondaga County, 2009 2011... 42 Figure 32: Racial and ethnic disparities in unintended pregnancy, Onondaga County, 2009 2011... 42 Figure 33: Births to adolescent females, Onondaga County and New York State, 2009 2011... 43 Figure 34: Breastfeeding in Onondaga County, 2009 2011... 44 Figure 35: Age adjusted suicide rate, Onondaga County, New York State and the U.S., 2009 2011... 46 Figure 36: Births to women with self reported illegal drug use, Onondaga County and Syracuse, 2007 2009 and 2010 2012... 47 Figure 37: NICU admissions, Onondaga County, January May 2012... 48 Figure 38: Gonorrhea incidence by year, Onondaga County, 2010 2012... 49 Figure 39: Gonorrhea incidence by age and sex, Onondaga County, 2012... 50 Figure 40: Distribution of determinants of health... 51 Figure 41: Broadening the focus of determinants of health... 54 Figure 42: Image 1 from community forum, Onondaga County, Fall 2011... 59 Figure 43: Image 2 from community forum, Onondaga County, Fall 2011... 59 4

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 List of Tables Table 1: Highest level of education obtained among adults age 25 years and older, Syracuse, Onondaga County and New York State, 2009 2011... 18 Table 2: Free and reduced price lunch by school district, 2011 2012... 21 Table 3: Indicators for the New York State Prevention Agenda: Improve Health Status and Reduce Health Disparities... 24 Table 4: Environmental indicators... 35 Table 5: Schooling indicators... 36 Table 6: Infant mortality in Onondaga County and Syracuse, 2010 2012... 41 Table 7: Adolescent births per 1,000 females by select zip codes, 2009 2011... 43 Table 8: Self inflicted injury hospitalizations per 10,000 population, Onondaga County and New York State, 2009 2011... 45 5

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The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Executive Summary The following document, The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017, presents demographic and health indicator data for residents of Onondaga County and outlines the community s plan to address two priority health issues. The New York State Department of Health (NYSDOH) requires that local health departments (LHDs) complete a community health assessment (CHA) and community health improvement plan (CHIP) every 3 5 years. Together, the CHA and the CHIP are designed to ensure that LHD priorities accurately reflect the needs of the community and to ensure that there is accountability in addressing those needs. Recognizing that improving the public s health is a shared responsibility of many partners, the NYSDOH requires the CHA/CHIP to be developed through a collaborative process between LHDs, local hospitals, and other community partners. In Onondaga County, this process began in the fall of 2011 with graduate students in the Central New York Master of Public Health (CNYMPH) program convening and facilitating five community forums. The forums were the platform to engage a broad array of individuals and organizations to help identify important health issues in the community. Key findings from the community forums: Social factors, particularly education and the economic environment, were identified by participants as having a significant impact on the overall health status of the community. A dominant theme was how lack of access to health care, especially primary care and mental health care, is a major contributing factor to poor health outcomes. Physical activity and nutrition, mental health/substance abuse, and maternal and child health were the three most commonly identified areas of concern with respect to health indicators. A formal data collection and analysis phase followed the community forums. Regular meetings were held between Onondaga County Health Department (OCHD) leadership and representatives from each area hospital to review the data and identify areas for further collaboration. Data were collected and analyzed in alignment with the five priority areas addressed in the NYSDOH Prevention Agenda 2013 2017: Preventing Chronic Disease; Promoting a Healthy and Safe Environment; Promoting Healthy Women, Infants and Children; Promoting Mental Health and Preventing Substance Abuse; and Preventing HIV, Sexually Transmitted Diseases, Vaccine Preventable Diseases and Healthcare Associated Infections. Improving Health Status and Reducing Health Disparities is an overarching priority area that is present throughout the other five. The below highlights aspects of each priority area where Onondaga County fares either markedly better or markedly worse than the rest of NYS. Key findings on the health status of Onondaga County residents: Improving Health Status and Reducing Health Disparities Overall, Onondaga County fares better than New York State (NYS) for many baseline Prevention Agenda indicators. Despite this, the County faces considerable challenges with respect to achieving health equity. In Onondaga County: Fewer residents die before age 65 (22.4%) compared to NYS (24.2%). But more residents report 14 or more days of poor physical health in the past month (15.4%) compared to NYS (12.1%). 7

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Nearly 93% of residents report having health care coverage. For each white non Hispanic death, there are 2.5 black non Hispanic and 2.5 Hispanic deaths. Black males are much more likely to die before age 65 (59.1%) than white males (25.1%). Preventing Chronic Disease Onondaga County fares better than NYS on indicators of heart disease but worse on indicators of cancer morbidity and mortality despite high screening rates. Indicators for diabetes and obesity remain of particular concern, as rates continue to increase. In Onondaga County: The heart disease mortality rate is 150.9 per 100,000 compared to 198.6 per 100,000 for NYS. Incidence rates for both lung and prostate cancers are significantly higher in Onondaga County compared to NYS and the U.S. Among adults age 50 75, 86.0% have been screened for colorectal cancer compared to 65.7% in NYS. Obesity is increasing with 20.0% of adults and 16.1% of children considered obese. A greater percentage of residents have been told by their health care provider that they have diabetes (13.9%) compared to NYS (9.4%). Promoting a Healthy and Safe Environment For many indicators in this priority area, Onondaga County is not significantly different from NYS. There are areas that warrant further investigation, such as increased mortality due to unintentional injury. Of particular concern is the racial disparity seen in homicide rates. Numerous community partners have already committed to collaborating on this issue. In Onondaga County: Among adults, 8.7% report having physician diagnosed asthma compared to 10.0% for NYS. High school graduation rates range from 95% to 52% depending on the school district. Low access to a grocery store impacts 5.5% of low income residents and 6.3% of children. The unintentional injury mortality rate is 31.1 per 100,000 population compared to 22.7 per 100,000 for NYS. The homicide rate for black residents is 15 times the rate for white residents. Promoting Healthy Women, Infants and Children Onondaga County continues to witness challenges in this priority area, with unacceptable racial and ethnic disparities in infant mortality, low birth weight, pre term deliveries, and adolescent pregnancies. While concerning, most of the indicators are trending down, indicating that overall outcomes are improving. One area that represents a serious threat to the health of women in Onondaga County and their infants is drug dependence, which is explored thoroughly in the next section. 8 In Onondaga County: The infant mortality rate (IMR) is 5.5 per 1,000 live births. A substantial racial disparity exists between black and white residents, with IMRs of 4.3 per 1,000 and 12.4 per 1,000, respectively.

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 There are 26.4 births per 1,000 females age 15 19 compared to 22.7 per 1,000 for NYS. A disproportionate number of teen births are in Syracuse city zip codes where rates range from 42.3 per 1,000 to 107.7 per 1,000. Mothers participating in WIC are far less likely to breastfeed for at least 6 months (17.9%) compared to NYS (38.3%). Promoting Mental Health and Preventing Substance Abuse Onondaga County compares unfavorably to NYS in several key indicators in this priority area, including selfreported mental health status, suicide, self inflicted injury, and binge drinking. An alarming increase in heroinrelated overdoses has been documented in the last four years. Most shocking is the very high rate of drugrelated newborn hospital discharges in Onondaga County. While this is not a priority indicator in the NYS Prevention Agenda, it is a priority for Onondaga County, and will be addressed in the CHIP. In Onondaga County: Among adults, 17.4% reported 14 or more days of poor mental health in the past month, compared to 10.3% for NYS. Self inflicted injury hospitalizations among adults and among teens age 15 19 are significantly higher than NYS, and appear to be trending upward. Binge drinking in the past month was reported by 21.9% of adults, compared to 14.8% for NYS. The rate of overdose deaths associated with heroin use has increased substantially over the past 4 years. The newborn drug related discharge rate is more than 3 times higher than that for NYS (248.3 per 10,000 births compared to 72.6 per 10,000 births, respectively). Preventing HIV/STDs, Vaccine Preventable Diseases, and Health Care Associated Infections Overall, Onondaga County fares well compared to NYS in this priority area, particularly with respect to immunization rates and newly diagnosed cases of HIV. Unfortunately, Onondaga County has seen a dramatic increase in gonorrhea cases over the past year. Incidence rates for chlamydia and syphilis also appear to be trending upward. In Onondaga County: The HIV case rate is 8.4 per 100,000 compared to 20.0 per 100,000 for NYS. In the past year, 54.3% of adults received their flu shot or spray compared to 48.2% for NYS. The incidence rate for gonorrhea has more than doubled in 2012 compared to 2011 (188.4 per 100,000 and 86.5 per 100,000, respectively). The increase in gonorrhea incidence disproportionately impacts females age 15 24. In examining the qualitative and quantitative data in combination with community input, OCHD and hospital leadership chose two priority areas to address: Preventing Chronic Disease, with a focus on nutrition and physical activity, and Promoting Mental Health and Preventing Substance Abuse/Promoting Healthy Women, Infants and Children, with a focus on neonatal abstinence syndrome. Opportunities to address health 9

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. disparities exist within each of the chosen priority areas, and the specific areas of focus have found considerable support and momentum within the community. The CHIP specifies the activities that will be undertaken by community partners, the OCHD, and local hospitals to measurably improve health outcomes in these areas. Throughout the CHA/CHIP process it became increasingly apparent that a very strong, diverse network of committed community partners exists in Onondaga County. While there are gaps in the assets and resources available to fully address all of the public health issues noted in the CHA, the level of collaboration and engagement experienced during the development of the CHA/CHIP reinforced the vision of the OCHD: A community of partners working together for the physical, social, and emotional well being of all. 10

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Onondaga County* Onondaga County is located in Central New York State (Figure 1). It covers 780 square miles and is bordered by Oswego County to the north, Cayuga County to the west, Cortland County to the south, and Madison County to the east. Figure 1. Location of Onondaga County within New York State Source: http://en.wikipedia.org/wiki/file:map_of_new_york_highlighting_onondaga_county.svg The population of Onondaga County is 466,852 (2012) making it the sixth most populous county in upstate New York (i.e., New York excluding New York City). Onondaga County consists primarily of forests and agricultural lands, resulting in a population density of 600 persons/mi 2. The County seat is the City of Syracuse, located near the center of the county as seen in Figure 2. In addition to Syracuse, 19 towns, 15 villages and the Onondaga Nation territory lie within the County s borders. Of note, Onondaga County also contains the intersection of Interstates 90 and 81 which are major east west and north south thoroughfares. Figure 2. Map of Onondaga County Source: New York State. http://www.nysegov.com/map NY.cfm *All data in this section are from the U.S. Census Bureau unless otherwise noted. 11

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Syracuse is the largest city in the Central New York (CNY) region with a population of 145,135, accounting for almost one third of the total county population. Syracuse is the fourth largest upstate NY city, after Buffalo, Rochester, and Yonkers. Other heavily populated towns in Onondaga County include Clay, Salina, and Cicero in the northwest sector and Dewitt and Manlius in the southeast. Figure 3 shows the urban population of Onondaga County by census tract for 2010. Urban population is defined as the percentage of residents of a territory who live in areas that encompass at least 2,500 people, at least 1,500 of which reside outside institutional group quarters. Figure 3. Urban population by census tract, Onondaga County, 2010 Urban Population, Percent by Tract, 2010 Census 100% Urban Population 90.1 99.9% 50.1 90.0% Under 50.1% No Urban Population Source: Community Commons Map Room at http://www.communitycommons.org/maps data/ 12

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Part A: Population Characteristics The demographic characteristics of a population are associated with a variety of health outcomes including health associated behaviors, as well as with health care access and utilization. Significant differences in the demographics between residents of Syracuse and the rest of Onondaga County contribute to geographic disparities in health. Given the extent of these differences, data are presented separately for Syracuse and Onondaga County, where available. Other disparities are also addressed in this section. Age and Gender Age distribution can have a major impact on the health outcomes and the health care needs of a community. The median age in Onondaga County is 38.7 years; greater than the median age of 29.2 years in Syracuse. Although Onondaga County s population distribution is relatively comparable to that of New York State (Figure 4), Syracuse s population skews younger than either, with both a higher proportion of residents under age 5 years and a lower proportion over age 65. Figure 4. Population distribution by age group, Syracuse, Onondaga County and New York State, 2009 2011 Percent 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% Under 5 years 5 to 9 years 10 to 14 years 15 to 19 years 20 to 24 years 25 to 29 years 30 to 34 years 35 to 39 years 40 to 44 years 45 to 49 years 50 to 54 years 55 to 59 years 60 to 64 years 65 to 69 years 70 to 74 years 75 to 79 years 80 to 84 years 85 years and older Syracuse Onondaga County New York State Source: U.S. Census Bureau, American Community Survey, 2009 2011 13

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. There are over 27,000 children under age 5 in Onondaga County, representing 5.9% of the population. Outside of Syracuse, there are relatively large numbers of preschoolers living in the towns of Clay, Cicero, Salina, Manlius, and Dewitt. With respect to older populations, over 65,000 county residents are age 65 years and older (14.0%). Outside of Syracuse, substantial populations of senior citizens reside in the towns of Clay, Salina, Manlius, Dewitt, and Camillus. Projections from the Cornell Program on Applied Demographics indicate that by 2030, nearly 20% of Onondaga County s population will be age 65 years or older (Figure 5). Elderly populations typically encounter unique health issues that the County must be prepared to address over the next 15 years. Figure 5. Projected age distribution for Onondaga County, 2030 Source: Cornell Program on Applied Demographics, 2011: http://pad.human.cornell.edu/counties/projections.cfm With respect to gender distribution, women comprise 51.8% of the population of Onondaga County and 52.3% of the population of Syracuse. Women of childbearing age (generally 15 44 years) have specific health needs and health risks. There are nearly 95,000 women in this category in Onondaga County, with roughly 37,000 residing in Syracuse. 14

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Race and Ethnicity Among Onondaga County residents, 97.6% identify as being one race. Of these, 81.6% self identify as white and 10.9% as black (Figure 6). The majority of the County s black residents reside in Syracuse (Figure 7), particularly on the near south and near west sides of the city. Between the 2000 and 2010 Census, the black population in Syracuse increased by almost 16%. Asians and American Indian/Alaska Natives comprise additional racial groups represented in comparatively large numbers. Approximately three percent of Onondaga s total population self identifies as Asian and 0.7% self identifies as Native American. Figure 6. Population by race, Onondaga County, 2009 2011 10.9% 0.7% 3.2%1.1% 2.4% White Black or African American American Indian and Alaska Native Asian Some other race 81.6% Two or more races Source: U.S. Census Bureau, American Community Survey, 2009 2011 Figure 7. Population by race, Syracuse, 2009 2011 5.4% 0.9% 2.8% 4.1% White Black or African American American Indian and Alaska Native 29.3% Asian Some other race 57.5% Two or more races Source: U.S. Census Bureau, American Community Survey, 2009 2011 15

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Hispanic ethnicity is reported by over 19,000 County residents of all races (4.1%, Figure 8). This represents a 70% increase in Hispanic ethnicity from the 2000 U.S. Census. Currently, nearly two thirds of local Hispanics reside in Syracuse, particularly in neighborhoods on the near west side of the city (Figure 9). The towns of Clay, Geddes, and Salina also have notable numbers of Hispanic residents. Figure 8. Population by Hispanic ethnicity, Onondaga County, 2009 2011 Source: U.S. Census Bureau, American Community Survey, 2009 2011 Figure 9. Population by Hispanic ethnicity, Syracuse, 2009 2011 Source: U.S. Census Bureau, American Community Survey, 2009 2011 16

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 In Onondaga County, 7.3% of residents are foreign born. Among foreign born Onondaga County residents, the greatest percentage was born in Asia, followed by Europe, Latin America, and Africa. The percent of foreignborn residents increases to 11.2% in Syracuse, where the largest percentage was also born in Asia, followed by Latin America, Europe, and Africa. A number of foreign born residents, particularly in Syracuse, are recently settled refugees. Since 2007, over 6,000 refugees, including 2,000 children, have resettled in the Syracuse area. While refugees have resettled from many countries in Southeast Asia, Africa and the Middle East, the primary countries of origin include Burma/Myanmar, Bhutan, Thailand, Nepal, Somalia, and Iraq. Job opportunities and the relatively low cost of living continue to make the Syracuse area popular for resettlement. According to the 2012 Onondaga County Citizens League report, an estimated 12,000 refugees and former refugees currently reside in Syracuse; many in neighborhoods on the north side of the city (http://onondagacitizensleague.org/). Newly arrived refugees have specific healthcare needs, as well as a unique set of barriers to accessing care, including language, education, and transportation. Ensuring access to care and improved health outcomes for this vulnerable population requires a coordinated response among many local service agencies. Spoken languages and linguistic isolation English language proficiency can impact everything from an individual s educational success to his/her ability to communicate with healthcare providers and to secure employment. In Onondaga County, English is the most commonly spoken language. The next most commonly spoken language is Spanish, which is the primary spoken language at home for 2.9% of Onondaga County residents and 6.3% of Syracuse residents ages 5 and older. Primary speakers of other Indo European languages (e.g., French, Polish, Ukrainian, Russian, Bosnian, Turkish, etc.) account for 4.1% of county residents and 4.5% of Syracuse residents. Primary speakers of Asian and Pacific Islander languages (e.g., Chinese, Burmese, Nepalese, Karen dialects, etc.) account for 2.0% of county residents and 3.7% of Syracuse residents. Primary speakers of other languages (e.g., Arabic; American Indian languages including Onondaga; African languages including Swahili and other Bantu languages; Somali, etc.) account for 0.9% of county residents and 2.0% of Syracuse residents. A household is considered linguistically isolated if all adults (age 14 and older) speak a language other than English and none speaks English very well. Individuals who speak a language other than English at home and do not speak English very well are also considered linguistically isolated. Compared to NYS and to the U.S., Onondaga County residents are less likely to be linguistically isolated, with only about 6.2% of households speaking a language other than English and only 3.7% speaking English less than very well. As with other comparable indicators, Syracuse residents are more likely to be linguistically challenged than County residents, with 9.7% of households speaking a language other than English and 6.8% speaking English less than very well. With respect to English language proficiency among children, 11.9% of the over 22,000 students in the Syracuse City School District are English language learners (ELLs). These students represent 80 countries, with 74 different languages spoken. Approximately half of ELLs are refugees. Most other ELLs are secondary refugees or migrants, immigrants, or individuals who were born in the U.S., but grew up in a home where a language other than English is spoken. 17

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Part B: Socioeconomic Characteristics Education Educational attainment is an important predictor of health outcomes. As seen in Table 1, among adults age 25 years and older in Onondaga County, 89.3% have a high school education or higher, and 32.6% have a bachelor s degree or higher. In Syracuse, these fall to 80.2% and 26.1% respectively. Table 1. Highest level of education obtained among adults age 25 years and older, Syracuse, Onondaga County and New York State, 2009 2011 City of Syracuse Onondaga County New York State Less than high school education 19.9% 10.7% 15.1% High school graduate or higher 80.2% 89.3% 84.8% Bachelor's degree or higher 26.1% 32.6% 32.6% Source: U.S. Census Bureau American Community Survey, 2009 2011 There are 18 public school districts in Onondaga County with an enrollment of approximately 70,000 students, including over 22,000 students in the Syracuse City School District (SCSD). Thirty four private or parochial schools in the county educate an additional 8,165 students. Disparities in education outcomes between Syracuse and the rest of the county are evident, as SCSD students consistently score significantly below the state average on standardized tests. The district is generally considered one of the lowest performing in New York State, as evidenced by the low pass rate on tests administered between grades 3 and 8 (pass rates ranged from 19% to 31% for all tests over the 6 grades). In addition, the high school dropout rate in Syracuse was 11% for the 2011 12 school year, significantly higher than the average rate of 1% seen in suburban schools. Within the SCSD, the average graduation rate is 52% compared with the average suburban district rate of 84.4%. The percent of graduates in Syracuse who will go on to some type of college is 77.2%, compared with 86.8% among suburban students (New York State Report Cards, 2011 2012). Unique to the Syracuse area is the Say Yes to Education program. Initiated in 2008, the mission of this program is to dramatically increase high school and college graduation rates for urban youth. To achieve this mission, the program seeks to unite a diverse group of academics, educators, government agencies, corporations, research institutions, and community partners to provide support to SCSD students. This support is demonstrated through offering extended academic programming, mentoring, tutoring, family outreach, health care, social work, psychological services, and/or legal assistance. One exceptional feature of the Say Yes program is the promise of free college tuition at participating colleges for those SCSD students who meet residency, graduation, and admission requirements. Since 2009, nearly 2,000 Say Yes students have enrolled in 2 and 4 year colleges. Other positive outcomes have been observed, including a 3.5% increase in Syracuse city home values since the program s inception. The impact of Say Yes to Education in Syracuse will continue to be evaluated in the years to come. (Source: Say Yes to Education, Syracuse.) 18

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 The Central New York region is home to a large number and variety of post secondary educational institutions. Over 32,000 students currently attend colleges within Onondaga County, including but not limited to Syracuse University, LeMoyne College, SUNY Upstate Medical University, SUNY College of Environmental Science and Forestry, and Onondaga Community College. Two local hospitals also have Colleges of Nursing. A number of other professional and licensing programs are offered in the county. Furthermore, an additional 35 institutions of higher learning are located within 100 miles of Onondaga County. Employment According to the American Community Survey (ACS) 2007 2011, the educational services, health care and social assistance sectors employ 29.3% of Onondaga County civilians ages 16 and older. This is followed by the retail trade (11.7%); the professional, scientific, and management and administrative and waste management sectors (9.5%); manufacturing (9.1%); and the arts, entertainment and recreation and accommodation and food services sectors (8.2%). According to the Onondaga County Office of Economic Development, the leading employer in the Onondaga County area is Upstate University Health System with 9,525 employees. Other major employers in the area include Syracuse University, St. Joseph s Hospital Health Center, Wegmans, Crouse Hospital, and Onondaga County government. Recent data from the New York State Department of Labor show job growth in the Syracuse Metropolitan Statistical Area (MSA) in the fields of education and health, trade, transportation and utilities, and leisure and hospitality. Recent job losses have occurred in the manufacturing, financial activities and information sectors. According to the U.S. Bureau of Labor Statistics, the unemployment rate in Onondaga County was 7.1% in April 2013, and has declined slowly from a high of 8.8% in January 2010. The current unemployment rate is nearly identical to the statewide unemployment rate of 7.3% in April 2013. Consequences of unemployment can include a decrease in health care related expenditures and a decrease in access to employer sponsored health insurance programs, which may lead to higher rates of uninsured persons. As seen in Figure 10, racial Figure 10. Unemployment by race, Syracuse, Onondaga County and New York State, 2009 2011 disparities in unemployment exist both within Onondaga County and Syracuse. In general, white residents have lower unemployment rates than other races. The highest unemployment rate is seen in those who identify as some other race. Source: American Community Survey, 2009 2011 19

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Income The median household income in Onondaga County is $52,520. As illustrated in Figure 11, there is a significant disparity in income between Onondaga County and Syracuse residents. Figure 11. Percent of residents by income, Onondaga County and Syracuse, 2009 2011 30.0 25.0 24.6 23.1 25.7 Onondaga County Syracuse 20.9 20.0 18.5 18.7 16.5 Percent 15.0 14.2 12.6 10.0 8.1 7.0 9.9 5.0 0.0 Less than $10,000 $10,000 to $24,999 $25,000 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 or more Source: U.S. Census Bureau, American Community Survey, 2009 2011 Poverty Among all residents, 14.7% had income in the last 12 months that was below the federal poverty level. Especially striking is the poverty rate among children in Syracuse, where 49.0% of those under age 18 live in poverty, compared to 21.0% of children in Onondaga County. Poverty rates for families can be seen in Figure 12. Poverty rates are consistently higher in Syracuse than in Onondaga County, peaking at 56.0% among female headed households with related children under 18 years of age. 20

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Figure 12. Percent of families living below the federal poverty level, Onondaga County and Syracuse, 2009 2011 Source: U.S. Census Bureau, American Community Survey, 2009 2011 21

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Another indicator of poverty is the percent of students receiving free or reduced price lunch at school. As seen in Table 2, this varies by school district, with a far greater percentage of students in the SCSD receiving free or reduced price lunch compared to the surrounding suburban school districts. Table 2. Free and reduced price lunch by school district, 2011 2012 School District Minority students Free or Reduced Lunch Baldwinsville 8.9% 22.3% East Syracuse Minoa 10.6% 33.5% Fabius Pompey 4.5% 23.6% Fayetteville Manlius 14.2% 8.3% Jamesville Dewitt 21.0% 13.2% Jordan Elbridge 3.6% 40.2% Lafayette 33.1% 35.3% Liverpool 17.7% 28.8% Lyncourt 17.2% 51.4% Marcellus 3.0% 12.9% North Syracuse 11.8% 28.3% Onondaga 16.4% 34.4% Skaneateles 3.7% 8.6% Solvay Union Free 15.9% 46.5% Syracuse City 73.9% 79.8% Tully 3.6% 37.1% West Genesee 9.0% 18.3% Westhill 8.1% 6.6% Data Source: NYS Report Cards, 2011 2012. In addition to children and families, seniors living in poverty warrant special attention. In Onondaga County, 7.6% of residents ages 65 years and older live in poverty, as do 17.4% of seniors in Syracuse. The poverty burden in an area can also be assessed through utilization of public benefits. In Onondaga County, nearly 9,000 (5.4%) households receive an average of $8,715 in Supplemental Security Income each year. Of these, nearly 5,700 are in Syracuse, representing 10.2% of city households. In addition, almost 5,600 county households receive cash public assistance income, 4,100 of which are in Syracuse. Almost 23,000 (12.4%) households receive Supplemental Nutrition Assistance Program (SNAP) benefits in Onondaga County, of which nearly 15,000 (26.9%) are in Syracuse. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Onondaga County served an average of 10,077 participants per month in 2012 (Onondaga County Health Department Annual Report). 22

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Health Insurance Another important factor relating to health outcomes and access to care is the presence of health insurance. In Onondaga County, 9% of residents do not have any health insurance. This increases to 13% in Syracuse. Housing Onondaga County has been largely insulated from the unstable housing market that has plagued much of the rest of the nation over the last several years. Recent data from the U.S. Bureau of Labor Statistics accessed through National Public Radio indicate that the current foreclosure rate in Onondaga County is just 1 in 12,647 homes. The ages of housing units in Onondaga County are similar to NYS averages. Compared to NYS, housing units are more likely to be owner occupied (65%) in Onondaga County but less likely to be owner occupied in Syracuse (40%) (ACS 2007 2011). The median home value in Onondaga County in 2010 was $134,700, compared to $88,400 in Syracuse. Disparities Overall, Syracuse has a younger and more racially and ethnically diverse population when compared to the rest of Onondaga County. In addition, there is higher poverty and lower educational attainment in Syracuse than in the surrounding suburban and rural areas. These factors are important predictors of health outcomes and should be considered when evaluating populations at risk and allocating resources for public health activities. Some of these disparities are highlighted in Figure 13. Figure 13. Demographic disparities between Onondaga County and the City of Syracuse Source: U.S. Census Bureau, American Community Survey, 2009 2011 23

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Part C: Health Status and Distribution of Health Issues in Onondaga County All data are from sources accessed through the New York State Department of Health (NYSDOH) Community Health Assessment Clearinghouse unless otherwise indicated. Improving Health Status and Reducing Health Disparities: According to Healthy People 2020, a disparity exists if a health outcome is seen in a greater or lesser extent between populations (Disparities 2010, retrieved from healthypeople.gov). As part of an overall Community Health Assessment, health disparities must be addressed. Four primary indicators are intended to capture health outcome and access categories that are representative of overall health status and disparities in Onondaga County. Table 3. Indicators for the New York State Prevention Agenda: Improve Health Status and Reduce Health Disparities Indicator Percentage of premature deaths (before age 65 years) Ratio of black non Hispanic to white non Hispanic Ratio of Hispanic to white non Hispanic Age adjusted preventable hospitalization rate (per 10,000) (SPARCS) Ratio of black non Hispanic to white non Hispanic Ratio of Hispanic to white non Hispanic Percentage of adults with health care coverage (Age 18 64 years) (Expanded BRFSS Preliminary Report, 2013 2014) Percentage of adults who have a regular health care provider (Expanded BRFSS Preliminary Report, 2013 2014) Onondaga County (2008 2010) NYS (2010) NYS Prevention Agenda Objective 22.40 24.20 21.80 2.53 2.08 1.87 2.53 2.07 1.86 131.20 148.10 133.30 2.50 2.06 1.85 1.20 1.53 1.38 92.8 83.3 100.00 90.0 84.9 90.80 Source: New York State Department of Health Prevention Agenda 2013 2017. Office of Vital Statistics 24

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Premature Deaths The percentage of premature deaths was calculated by aggregating the number of deaths occuring before age 65 per 100 total deaths in the specified time period (2008 2010). Overall, 22.4% of Onondaga County residents die prematurely, compared to 24.2% for New York State. Black non Hispanics and Hispanics experience a much higher rate of premature deaths compared to white non Hispanics: for every one white non Hispanic premature death there are 2.53 black non Hispanic deaths and 2.53 Hispanic deaths (Figure 14). Figure 14. Racial and ethnic disparities in premature deaths, 2008 2010 White non Hispanics Black non Hispanics and Hispanics For every one white non Hispanic premature death, there are 2.53 for both black non Hispanic deaths and Hispanic deaths in Onondaga County Source: http://www.health.ny.gov/prevention/prevention_agenda/2013 2017/indicators/2013/onondaga.htm Local life table analyses provide a deeper look into the disparities surrounding mortality in Onondaga County. Figure 15 shows the percent of deaths in each age catgory by race and sex for 2008 2010. In Onondaga County, 59.1% of black males will die before age 65 years, compared to 25.1% for white males. Overall, there is a substantial disparity in mortality across all age groups between black and white residents of Onondaga County. Another way to assess disparities in premature death is by examining survivorship. Survivorship curves for race and sex are shown in Figure 16. This again illustrates the disparity in survival between white and black Onondaga County residents. 25

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Figure 15. Percent of deaths by age category, race, and sex; Onondaga County, 2008 2010 Source for Figures 15 and 16: Onondaga County Health Department, Bureau of Statistics and Surveillance Figure 16. Survivorship by sex and age for selected races, Onondaga County, 2008 2010 26

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Preventable Hospitalizations The number of preventable hospitalizations is measured by the Prevention Quality Indicators (PQIs), a set of measures developed by the Agency for Healthcare Research and Quality (AHRQ) used to assess the quality of outpatient care for "ambulatory care sensitive conditions" (ACSCs). The term preventable hospitalization refers to the combination of the 12 PQIs that pertain to adults: short term complication of diabetes, long term complication of diabetes, uncontrolled diabetes, and lower extremity amputation among patients with diabetes, hypertension, congestive heart failure, angina, chronic obstructive pulmonary disease, asthma, dehydration, bacterial pneumonia, and urinary tract infection. In 2010, the baseline rate of age adjusted preventable hospitalizations in New York State was 148.1 per 10,000 compared to Onondaga County s rate of 131.2 per 10,000. Onondaga County has already met the New York State Prevention Agenda goal of 133.3 overall age adjusted preventable hospitalizations per 10,000 for ages 18 and older. As with premature deaths, racial disparities in preventable hospitalization rates are apparent. This is most pronounced in the ratio of preventable hospitalization rates for white non Hispanics to black non Hispanics: for every one white non Hispanic preventable hospitalization, there are 2.5 preventable hospitalizations for black non Hispanics (see Figure 17) and 1.38 preventable hospitalizations for Hispanics. The Prevention Agenda goal is to reduce disparities in the ratios of preventable hospitalizations for black non Hispanics and Hispanics to white non Hispanics by 10%, to 1.85 and 1.38, respectively. Onondaga County has met the Prevention Agenda objective for reducing the disparity of Hispanic to white non Hispanic preventable hospitalizations but still has significant work to reduce the disparity between black non Hispanics and white non Hispanics. Figure 17. Racial and ethnic disparities in preventable hospitalizations, 2008 2010 White non Hispanics Black non Hispanics For every one White non Hispanic preventable hospitalization, there are 2.5 black non Hispanic preventable hospitalizations Source: http://www.health.ny.gov/prevention/prevention_agenda/2013 2017/indicators/2013/onondaga.htm 27

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Access to Care Ninety percent of Onondaga County adults report having a regular health care provider and 92.8% report having health care coverage. These rates are higher than those reported for NYS as a whole, 84.9% and 83.3%, respectively. Despite a relatively high level of access to care, Onondaga County adults are less likely to have had a checkup within the past 12 months (66.9%) compared to NYS (71.2%) and more likely to report 14 or more days of poor physical health in the past month (15.4%) compared to NYS (12.1%) (Expanded BRFSS Preliminary Report, 2013 2014). Summary of Improving Health Status and Reducing Health Disparities At the county level, Onondaga fared better than NYS with respect to the baseline Prevention Agenda indicators for improving health status and reducing health disparities. However, as illustrated by the life table analyses in Figures 15 and 16, the County still faces considerable challenges with respect to achieving health equity through reducing disparities. In addition, more Onondaga County adults report poor physical health. To gain a deeper understanding of the health status of Onondaga County residents, data are presented below from each of the five Prevention Agenda Priority Areas. 28

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Prevention Agenda Area: Preventing Chronic Disease A comprehensive table of health indicators related to chronic disease is presented in Appendix 1.a. The section below highlights areas of interest in the domain of chronic disease for Onondaga County. Cardiovascular Disease Cardiovascular disease includes all diseases of the heart, coronary artery disease, and vascular diseases. Onondaga County enjoys a high standard of care for diseases of the heart and coronary heart disease. Mortality and hospitalization rates for these conditions are statistically significantly lower than NYS and the U.S. In 2005, as heart disease mortality rates decreased more rapidly than cancer mortality rates, the leading cause of death shifted from heart disease to malignant neoplasms in Onondaga County. Currently in Onondaga County mortality due to coronary heart disease is 103.8 per 100,000, approaching the Healthy People 2020 target of 100.8 per 100,000. Overall rates are seen in Figures 18 and 19. Figure 18. Age adjusted mortality for diseases of the heart, 2009 2011 Sources: NYSDOH County Health Indicators, Cardiovascular Disease, http://www.health.ny.gov/statistics/chac/indicators/chr.htm Healthy People 2020 http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=21 National Center for Health Statistics http://www.cdc.gov/nchs/fastats/deaths.htm 29

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Figure 19. Age adjusted mortality for coronary heart disease, 2009 2011 Sources: NYSDOH County Health Indicators, Cardiovascular Disease, http://www.health.ny.gov/statistics/chac/indicators/chr.htm Healthy People 2020 http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=21 National Center for Health Statistics http://www.cdc.gov/nchs/fastats/deaths.htm Cancer In Onondaga County, the incidence of all cancers is increasing. However, as seen in Figure 20, mortality associated with cancer is decreasing. Presumably these differences are attributable to improvements in screening, and thus an increase in early detection of cancer, as well as to improvements in cancer treatment. Each week, approximately 52 Onondaga County residents are diagnosed with cancer and approximately 19 die from cancer. 30

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Figure 20. Age adjusted incidence and mortality rates for all types of cancer in Onondaga County, 1994 2008 Source: http://www.acscan.org/ovc_images/file/action/states/ny/ny_cancer_burden_report_2012.pdf Note: Rates are age adjusted to the 2000 U.S. Standard Population The incidence rates of three common cancers (breast, lung, and prostate) are illustrated in Figure 21. The incidences of both lung cancer and prostate cancer are statistically significantly higher in Onondaga County compared to NYS and the U.S. Figure 21: Incidence of breast, lung and prostate cancers in Onondaga County, New York State, and the U.S., 2007 2009 250.0 Rate per 100,000 200.0 150.0 100.0 132.4 126.9124.3 Onondaga NYS U.S. 83.6 63.8 62.6 216.8 166.9 154.8 50.0 0.0 Breast Lung Prostate Source: http://seer.cancer.gov/csr/1975_2009_pops09/browse_csr.php?section=36&page=sect_a_table.03.html NYSDOH County Health Assessment Indicators, Cancer, 2007 2009 http://www.health.ny.gov/statistics/chac/chai/docs/can_31.htm Note: Rates are per 100,000, age adjusted to the 2000 U.S. Standard Population 31

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Mortality from these common cancers is shown in Figure 22. Interestingly, while both incidence of and mortality from lung cancer is statistically significantly higher in Onondaga County compared to NYS, the mortality rate of prostate cancer is not significantly different, despite a dramatically higher incidence. One possible explanation may be the high level of attention to prostate cancer screening in our community. Figure 22: Mortality from breast, lung and prostate cancers in Onondaga County, New York State, and the U.S., 2007 2009 60.0 55.8 50.0 42.8 50.6 Onondaga NYS Rate per 100,000 40.0 30.0 20.0 23.6 21.7 23.0 U.S. 20.7 21.6 23.6 10.0 0.0 Breast Lung Prostate Source: http://seer.cancer.gov/csr/1975_2009_pops09/browse_csr.php?section=36&page=sect_a_table.03.html NYSDOH County Health Assessment Indicators, Cancer, 2007 2009 http://www.health.ny.gov/statistics/chac/chai/docs/can_31.htm Note: Rates are age adjusted to the 2000 U.S. Standard Population Among the cancer data for Onondaga County, screening rates stand out as a bright spot. Data from the Expanded BRFSS Preliminary Report, 2013 2014 show that 86.0% of Onondaga County adults age 50 75 have been screened for colorectal cancer using the most recent guidelines. This meets the Prevention Agenda 2013 2017 goal of 71.4% and is higher than the current NYS rate of 65.7%. In addition, 93.9% of Onondaga County women age 50 74 have had a mammogram within the last two years, compared to 81.6% in NYS. Obesity and Diabetes Like NYS and the rest of the country, obesity and diabetes present significant challenges in Onondaga County. In Onondaga County, while adult overweight/obesity rates (BMI >25) are comparable to NYS and U.S. rates, adult obesity rates (BMI >30) are statistically significantly lower than the national average. Data from the Expanded BRFSS Preliminary Report, 2013 2014 indicate that 20.0% of adults are obese in Onondaga County, compared to 26.2% in NYS. The Prevention Agenda 2013 2017 goal of 23.2% has been achieved in Onondaga County. Obesity rates are shown below in Figure 23. 32

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Figure 23. Obesity rates in Onondaga County, New York State, and the U.S. Source: Adults NYSDOH Expanded BRFSS Preliminary Report, 2013 2014, NHANES 2005 2008, Children / Adolescents Student weight status category reporting system, 2010 2012, NHANES 2005 2008 http://www.health.ny.gov/prevention/prevention_agenda/2013 2017/indicators/2013/onondaga.htm *Obesity is defined as weight category 95 th percentile among children and as BMI 30.0 among adults The crude and age adjusted rates of mortality due to diabetes in Onondaga County, NYS, and the U.S. are seen in Figure 24. The crude and age adjusted rates of diabetes mortality in Onondaga County are not significantly different than the New York State rates. With respect to prevalence, although screening rates (residents reporting that they have had a diabetes test within the past three years) are comparable in Onondaga County and NYS, 13.9% of Onondaga County residents report being told that they have diabetes compared to 9.4% of NYS residents (Expanded BRFSS Preliminary Report, 2013 2014). Figure 24. Diabetes mortality in Onondaga County, New York State and the U.S., 2009 2011 Source: NYSDOH Community Health Assessment Indicators: http://www.health.ny.gov/statistics/chac/mortality/d22.htm Note: Rates are age adjusted to the 2000 U.S. Standard Population 33

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Summary Prevention Agenda Area: Preventing Chronic Disease Overall, Onondaga County fares better than NYS in heart disease health indicators as shown in this section and in Appendix 1.a. With respect to all cancer morbidity and mortality, Onondaga County is faring worse than NYS despite higher screening rates. Despite doing relatively well compared to NYS on indicators for diabetes and obesity, these health indicators remain of significant concern; particularly as trend analyses show that the rates of diabetes and obesity continue to increase. Asthma (to be addressed in the next section) and chronic lower respiratory disease rates are favorable for Onondaga County. 34

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Prevention Agenda Area: Promoting a Healthy and Safe Environment A comprehensive table of health indicators related to Healthy and Safe Environment is presented in Appendix 1.b. The section below highlights areas of interest in this domain. The Prevention Agenda Priority Area Promote a Healthy and Safe Environment gauges the conditions impacting individuals living, working, and going to school in Onondaga County. This section examines the community s work and school environments, as well as rates of violence. Environment Onondaga County offers citizens clean air and water as demonstrated by the number of days with unhealthy ozone or particulate matter levels. Several environmental indicators are listed in Table 4. According to the NYS Department of Environmental Conservation, all citizens of Onondaga County live within communities that have taken the Climate Smart Communities Pledge: 1. Pledge to Combat Climate Change by Becoming a Climate Smart Community 2. Set Goals, Inventory Emissions, Move to Action 3. Decrease Energy Demand for Local Government Operations 4. Encourage Renewable Energy for Local Government Operations 5. Realize Benefits of Recycling and Other Climate Smart Solid Waste Management Practices 6. Plan for Adaptation to Unavoidable Climate Change The goal of the pledge is to keep the air and water clean while reducing energy needs and waste to protect the region s natural resources. An area that continues to be a challenge is the suboptimal utilization of mass transit/alternative transportation in Onondaga County. Utilization of mass transit/alternative transportation is 19.4%, which is substantially lower than both NYS and the U.S. The impact of recent local efforts, such as the development of the Connective Corridor, an expansion of walking, biking, and mass transit services between Syracuse University and the City, has not yet been fully evaluated. Table 4. Environmental indicators Indicator Annual number of days with unhealthy ozone (Air quality index > 100) Annual number of days with unhealthy particulate matter % of population that lives in a jurisdiction that adopted the Climate Smart Communities pledge % of commuters who use alternate modes of transportation % of homes in Healthy Neighborhood Program that have fewer asthma triggers during the home revisits Percentage of residents served by community water systems with optimally fluoridated water Source: Health Indicators Warehouse, http://healthindicators.gov/ Onondaga Prevention County NYS U.S. Agenda 3 5 0 3 5 15.3 0 100.0 26.7 32.0 19.4 44.7 22.7 49.2 n/a 12.9 20.0 99.6 71.4 73.8 78.5 35

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Asthma While asthma can be considered a chronic disease, asthma data are included in this section to reflect the impact of the environment on the disease. According to the Expanded BRFSS Preliminary Report, 2013 2014, 8.7% of Onondaga County adults currently report having physician diagnosed asthma, compared to 10.0% in NYS. In addition to the lower asthma prevalence, Onondaga County has lower hospitalization rates due to asthma (see Figure 25) and a lower mortality rate from asthma compared to NYS and the nation. This could be associated with the air quality indicators listed in Table 4. Figure 25. Asthma hospitalizations in Onondaga County and New York State, 2009 2011 60.0 56.8 Onondaga 50.0 NYS Rate per 10,000 40.0 30.0 20.0 10.0 20.9 18.1 6.6 15.1 HP 2020 8.6 12.2 32 20.3 0.0 Ages 0 4 Ages 5 64 Ages 65+ Source: NYSDOH County Health Assessment Indicators, Respiratory Disease 2009 2011 http://www.health.ny.gov/statistics/chac/chai/docs/res_31.htm Healthy People 2020 Objectives: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=21 School and Adolescent Indicators Schools are an essential element of a Healthy and Safe Environment. Table 5 illustrates that overall, Onondaga County is quite similar to NYS and the U.S. in schooling indicators. Table 5. Schooling indicators Indicator Onondaga NYS U.S. HP 2020 Objective High school on time graduation rate 68.6 67.4 74.9 82.4 Free school lunch eligibility percent 28 43.5 Illegal drugs on school property (percent) 39.5/22.6* 24.0 22.7 20.4 % of bullying among adolescents 18.2 19.9 10.0 % of adolescents who meet Federal physical activity requirement 23.1 20.4 Source: Health Indicators Warehouse, http://healthindicators.gov/ *Source: NY State Youth Development Survey Onondaga County; lifetime and past 30 days in 11th graders 36

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Higher graduation rates are generally associated with healthier communities. As seen in Figure 26, a direct correlation is seen between graduation rates and the percent of students who qualify for free/reduced lunch in Onondaga County. For additional information on education, please refer to Section 1 Demographics. Figure 26. High school graduation rates and the percent of students receiving free or reduced lunch by district, 2008 2009 Source: NYStart 2008 2009 Note: Lyncort School District is not included as it is a PreK 8 school district therefore graduation rates do not apply. Additional information is needed to further examine bullying within schools and physical activity by adolescents. Neither topic was addressed in the most recent survey of students in Onondaga County. Bullying has become a national issue and comes in many forms, including physical and emotional intimidation. Access to Grocery Stores In Onondaga County, low income residents, particularly children, are disproportionately affected by low access to grocery stores. Overall, 5.5% of low income residents have low access to a grocery store compared to 2.5% in NYS (Figure 27). Among children, 6.3% have low access to a grocery store. 37

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Figure 27. Access to grocery stores by census tract, 2010 Community Commons 2.0 Starter Map, Community Health Needs Assessment USDA Food Environment Atlas, 2010 Facility associated Outbreaks In June 2012, an outbreak of shigella was associated with a child care facility. This outbreak was propagated and continued for over six months. Throughout that period of time, additional clusters were seen in other child care facilities. As a result of the first identified cluster, numerous policies and procedures were recommended by the Onondaga County Health Department (OCHD) to child care facilities in our community in an effort to promote a healthy and safe environment for all Onondaga County residents. Unintentional Injuries The rate of age adjusted unintentional injury mortality is significantly higher in Onondaga County (31.1/100,000) compared to NYS (22.7/100,000) for 2009 2011. However, the Onondaga County unintentional injury hospitalization rate (46.1/10,000) is significantly lower than NYS (64.0/10,000). This discrepancy warrants further investigation. Homicides Overall, Onondaga County is a safe place to live and work based on non violent injury/death indicators. Although assault related hospitalizations are lower in Onondaga County than in NYS, the homicide rate is higher. When the data for personal safety are viewed at a more detailed level, a disturbing disparity is seen between black and white residents. In NYS and the nation, blacks have a homicide rate that is six times that of whites; in Onondaga County, the rate for blacks is 15 times that of whites. When looking specifically at firearmrelated deaths, the rate among blacks is roughly 2 3 times that of whites in NYS and the U.S.; in Onondaga County, the firearm related death rate among blacks is six times that of whites. 38 Figure 28 presents the homicide rate for Onondaga County compared to a similar upstate NY county (Monroe), and two New York City counties (Bronx and Queens). For all counties, the homicide rate among blacks is substantially higher than for whites, though this disparity is most pronounced in Onondaga County.

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Figure 28. Age adjusted homicide rate, Onondaga County and comparison geographies, 2008 2010 30.0 26.7 Rate per 100,000 25.0 20.0 15.0 10.0 5.0 5.6 3.5 18.4 21.6 13.6 5.6 5.8 4.5 2.5 2.5 2.5 Total White Black/AA 11.4 11.9 9.1 8.4 4.2 2.6 0.0 United States New York State Onondaga County Monroe County Bronx County Queens County Source: Health Indicators Warehouse via National Vital Statistics System Mortality, 2008 2010: http://healthindicators.gov/indicators/homicide deaths per 100000_1041/Profile/Data Summary Prevention Agenda Area: Promoting a Healthy and Safe Environment For many of the indicators in this domain, Onondaga County is not significantly different from NYS. There are areas that warrant more investigation (such as increased mortality due to unintentional injury). One area that stands out is the disparity in homicide rates. Onondaga County s Strategic Plan includes a strategy to highlight three health issues for educational campaigns each year. Based on this CHA, homicides will be the first issue highlighted in this process. Preliminary discussions with local health care providers, the Medical Examiner s Office, the County Executive s Office, and community partners have already taken place in support of this effort. 39

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Prevention Agenda Area: Promoting Healthy Women, Infants and Children Onondaga County, specifically Syracuse, has historically experienced disproportionately poor birth outcomes, particularly with respect to infant mortality rates and disparities. In the mid 1980s, Syracuse had one of the highest infant mortality rates among blacks in the United States when compared to similar sized communities. While there have been impressive gains in reducing infant mortality, Onondaga County still has significant challenges in protecting and improving the health of women, infants, and children in our community. A comprehensive table of health indicators related to Healthy Women, Infants, and Children and a table of zip code level data for select birth outcomes can be found in Appendices 1.c and 1.d. The following section will highlight OCHD s priority areas for action in this domain. Infant Mortality As seen in Figure 29, tremendous gains have been made in reducing infant mortality rates in Syracuse. However, as illustrated in Table 6, significant disparities continue to plague our community. Figure 29. Infant mortality by race, three year averages, Syracuse, NY, 1985 2011 35.0 Infant deaths per 1,000 live births 30.0 25.0 20.0 15.0 10.0 5.0 White Black 0.0 Source: Onondaga County Health Department, Bureau of Statistics and Surveillance 40

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Table 6. Infant mortality in Onondaga County and Syracuse, 2010 2012 Infant deaths Locality per 1,000 live births Onondaga County 5.5 White 4.3 Black 12.4 Hispanic 8.3 Syracuse 6.7 White 4.6 Black 11.5 Hispanic 7.8 Source: Statewide Perinatal Data System, OCHD Bureau of Surveillance and Statistics *2011 and 2012 data are provisional Other Maternal and Infant Health Outcomes and Disparities in these Outcomes With respect to preterm births and low birth weight, Onondaga County is faring better than NYS and is approaching Prevention Agenda goals in these areas. However, the OCHD remains concerned about disparities in these birth outcomes, as shown in Figure 30. Figure 30. Preterm births and low birth weight births by race and ethnicity, 2009 2011 Source: NYSDOH Community Health Indicators by Race/Ethnicity, 2009 2011 41

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. While the adolescent pregnancy rate is lower in Onondaga County compared to NYS (Figure 31) and the overall unintended pregnancy rate is higher in Onondaga County than in NYS (Figure 32), the adolescent birth rates are statistically significantly higher as seen in Figure 33. The disparity by highest risk zip code is shown in Table 7. This warrants further analysis and potential intervention. Figure 31. Racial and ethnic disparities in adolescent pregnancy, Onondaga County, 2009 2011 70.0 65.2 60.0 53.3 Rate per 1,000 females 50.0 40.0 30.0 20.0 13.2 White non Hispanic Black non Hispanic Hispanic (all races) 10.0 0.0 Pregnancies in females age 15 17 years Source: NYSDOH Community Health Indicators by Race/Ethnicity, 2009 2011, and NYSDOH Prevention Agenda Indicators http://www.health.ny.gov/prevention/prevention_agenda/2013 2017/indicators/2013/onondaga.htm Figure 32. Racial and ethnic disparities in unintended pregnancy, Onondaga County, 2009 2011 70.0 60.0 60.5 Rate per 100 live births 50.0 40.0 30.0 20.0 30.0 49.3 White non Hispanic Black non Hispanic Hispanic (all races) 10.0 0.0 Unintended pregnancies Source: NYSDOH Community Health Indicators by Race/Ethnicity, 2009 2011, and NYSDOH Prevention Agenda Indicators http://www.health.ny.gov/prevention/prevention_agenda/2013 2017/indicators/2013/onondaga.htm 42

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Figure 33. Births to adolescent females, Onondaga County and New York State, 2009 2011 Births per 1,000 females 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 Onondaga County New York State 14.0 11.2 41.2 38.7 26.4 22.7 5.0 0.0 0.5 0.3 Ages 10 14 Ages 15 17 Ages 18 19 Ages 15 19 Source: NYSDOH Community Health Assessment Indicators, Family Planning/Natality: http://www.health.ny.gov/statistics/chac/chai/docs/fp_31.htm Table 7. Adolescent births per 1,000 females by select zip codes, 2009 2011 Locality Birth rate among ages 15 19 Onondaga County 29.2 13202 88.4 13203 74.8 13204 107.7 13205 92.4 13206 42.4 13207 63.3 13208 90.9 13224 42.3 Source: NYS County/Zip Code Perinatal Data Profile, NYSDOH Bureau of Biometrics and Statistics http://www.health.ny.gov/statistics/chac/perinatal/county/onondaga.htm 43

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Breastfeeding Rates With respect to breastfeeding, the data for Onondaga County show mixed results. As seen in Figure 34, delivery hospitals do a good job supporting mothers to breastfeed exclusively while in the hospital, however the rate of infants fed any breastmilk in the delivery hospital is lower than that of NYS. Furthermore sustaining these efforts appears problematic, at least among mothers enrolled in WIC (for whom data are reported). WIC participants in Onondaga County are significantly less likely to breastfeed for at least six months compared to their peers throughout NYS. This issue has been identified as a target for quality improvement efforts within the WIC program. Figure 34. Breastfeeding in Onondaga County, 2009 2011 Source: NYSDOH Community Health Assessment Indicators, Maternal and Infant Health: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm Summary Prevention Agenda Area: Healthy Women, Infants and Children Onondaga County continues to witness challenges in this domain, with unacceptable racial and ethnic disparities in infant mortality, low birth weight, pre term deliveries, and adolescent pregnancies. While concerning, most of the indicators are trending down, indicating that overall maternal and child health outcomes are improving. Other outliers include indicators relating to breastfeeding, where Onondaga County is doing poorly compared to NYS. On a positive note, indicators assessing access to care demonstrate that Onondaga County fares better than the rest of NY with women more likely to receive early prenatal care and children more likely to be screened for lead poisoning. Childhood mortality indicators are not significantly different from the rest of NYS and hospitalization rates for gastroenteritis and pneumonia are significantly lower in Onondaga County. (For details about these indicators please refer to Appendix 1.c.) One area that does represent a serious threat to the health of women in Onondaga County and their infants is drug dependence. This will be thoroughly explored in the next section. 44

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Prevention Agenda Area: Promoting Mental Health and Preventing Substance Abuse A comprehensive table of health indicators related to mental health and substance abuse is presented in Appendix 1.e. The section below highlights areas of interest in this domain. Mental Health According to the Expanded BRFSS Preliminary Report, 2013 2014, 17.4% of Onondaga County adults reported 14 or more days of poor mental health in the past month. This is higher than the NYS rate of 10.3%, and underscores the importance of having mental health services available to all residents of Onondaga County. Suicide and Self inflicted Injury A significantly higher rate of self inflicted injury hospitalizations, particularly among those age 15 19 years, is seen in Onondaga County compared to NYS (Table 8). As seen in Figure 35, Onondaga County has a higher rate of suicide than NYS, though this difference is not statistically significant and is still lower that the national average. It is very concerning that these rates appear to be trending up. These indicators warrant further investigation. Table 8. Self inflicted injury hospitalizations per 10,000 population, Onondaga County and New York State, 2009 2011 Indicator Onondaga County NYS Self inflicted injury hospitalizations per 10,000 population 8.2 5.3 Self inflicted injury hospitalizations per 10,000 population (ages 15 19) 15.1 10.1 Source: NYSDOH County Health Assessment Indicators, Injury, 2009 2011, http://www.health.ny.gov/statistics/chac/chai/docs/inj_31.htm 45

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Figure 35: Age adjusted suicide rate, Onondaga County, New York State and the U.S., 2009 2011 Source: NYSDOH County Health Assessment Indicators, Injury, 2009 2011, http://www.health.ny.gov/statistics/chac/chai/docs/inj_31.htm Binge Drinking The percentage of adults who reported binge drinking in the last month in Onondaga County is 21.9% compared to 14.8% in NYS (Expanded BRFSS Preliminary Report, 2013 2014). The alcohol related motor vehicle injuries and death rate in Onondaga County (47.7 per 100,000) is significantly higher than NYS as a whole (36.2 per 100,000) although it is comparable to other communities outside of the downstate region. Heroin Overdose Mortality In recent years, Onondaga County has seen an increase in the rate of drug overdose deaths related to heroin use. Data from the Onondaga County Medical Examiner s Office show that in 2010, mortality from heroinrelated overdoses was 0.21 per 100,000. Preliminary data from 2013 show an increase of more than 20 fold to 4.50 per 100,000. This increase reflects a broader trend seen throughout Upstate New York in the last several years. Drug Dependent Newborns While the newborn drug related discharge rate is not a priority indicator within the Prevention Agenda, it is a priority indicator for Onondaga County as the local rate dramatically exceeds the NYS rate. For 2009 2011, the Onondaga County rate was 248.3 per 10,000 births compared to 72.6 per 10,000 births for NYS. This represents a statistically significant difference and is supported by an increase in self reported illegal drug use (Figure 36). This appears to be problem specific to the maternal and infant population, as the overall drug related hospitalization rate is significantly lower in Onondaga County compared to NYS (Appendix 1.e). 46

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Figure 36. Births to women with self reported illegal drug use, Syracuse and Onondaga County, 2007 2009 and 2010 2012 Source: Statewide Perinatal Data System, Onondaga County Bureau of Surveillance and Statistics, 2011 and 2012 data are preliminary. A local analysis of mothers and infants who had positive drug screens in delivery hospitals between January and May 2012 identified maternal risk factors associated with newborn drug related discharges. These included Medicaid paid birth, black race, lower educational achievement, younger maternal age, decreased paternal involvement, and increased self reported use of illegal drugs/tobacco/alcohol during pregnancy. Infants born to mothers identified with positive drug screens were more likely to require admission to the Neonatal Intensive Care Unit (NICU) (Figure 37). Infants with positive drug screens admitted to the NICU were far more likely to be exposed to cannaboids and opiates than to other drugs. 47

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Figure 37. NICU admissions, Onondaga County, January May 2012 Source: Siddiqui S, 2012; Statewide Perinatal Data System; Laboratory Alliance of CNY Summary Prevention Agenda Area: Mental Health and Substance Abuse There are several areas of concern within this domain, the most shocking of which is the drug related hospital discharge rate in newborns in Onondaga County. Given the extent of this problem, this will be a community wide priority for intervention in the 2014 2017 Community Health Improvement Plan (CHIP). The CHIP describes numerous initiatives that are already underway to address substance abuse in Onondaga County, including those with a focus on pregnant and parenting women. 48

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Prevention Agenda Area: Preventing HIV/STDs, Vaccine Preventable Diseases, and Health Care Associated Infections A comprehensive review of all of the indicators for this Prevention Agenda Priority Area is seen in Appendix 1.f. In general, Onondaga County fares very well, particularly with respect to immunizations and to newly diagnosed cases of HIV, when compared to NYS. Unfortunately, Onondaga County has higher than expected rates for gonorrhea and, as seen in Figure 38, recent trends are alarming. This increase has been investigated; however no plausible explanation for the increase has yet been identified. Figure 38. Gonorrhea incidence by year, Onondaga County, 2010 2012 Source: NYSDOH Communicable Diseases Electronic Surveillance System (CDESS); U.S. Census Bureau, 2010 Census An analysis of the increase demonstrates that females, ages 15 24, are disproportionately impacted as seen in Figure 39. Furthermore, blacks are overwhelmingly disproportionately represented (data available on request). 49

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Figure 39: Gonorrhea incidence by age and sex, Onondaga County, 2012 Source: NYSDOH Communicable Diseases Electronic Surveillance System (CDESS), U.S. Census Bureau, 2010 Census Summary Prevention Agenda Area: Preventing HIV/STDs, Vaccine Preventable Diseases, and Health Care Associated Infections As with the previous section, there are several areas of concern within this domain, the most alarming of which is the recent increase in the rate of gonorrhea in Onondaga County. In October 2013, the OCHD was awarded a NYSDOH grant from the Centers for Disease Control to embark on a public education campaign to address STDs in the community. Other areas of concern include the increased rates of shigella (previously described in Healthy and Safe Environments) and pertussis (Appendix 1.f), both of which are associated with recent outbreaks. Rates of these two diseases in 2013 to date indicate that the incidence has returned to baseline. On a positive note, vaccination rates in Onondaga County are generally higher than NYS average vaccination rates. 50

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Part D: The Public Health Context: Identifying the Determinants of Health in Onondaga County and the Main Health Challenges Determinants of Health A lens broader than the presence of disease must be used to assess the health of a community. The social and economic environment such as education, economic opportunity, affordable, safe and healthy housing, access to food, and accessibility to health resources significantly impacts the health of a community. To address health challenges, one must address the contributing root determinants. Research suggests that a community s Figure 40: Distribution of Determinants of Health ability to address factors like education, workforce development, and housing has an impact on individuals health outcomes. 1,2 The prevalence of poor to fair health among children is six times greater among children of parents who did not complete high school, compared to children of at least one parent who received a college degree. 3 Adults living in poverty are five times as likely as those living 400% above the poverty level to report being in poor or fair health. 3 Health status for children often is predictive of their health as an adult, 4 thereby strengthening the case for early interventions that address From: McGinnis MJ, Williams Russo, P, Knickman JR: The case for more active education, job skill development, and policy attention to health promotion. Health Affairs 2002; 21: 78 93 access to relevant health education and care. Employment and affordable, safe and healthy housing are factors related to stable health. Social factors account for a 15% influence on an individual s health status, while individual behavioral patterns make up an even larger portion of the factors influencing health (see Figure 40). 5 However, access and opportunity play a large role in individuals behavioral choices and work in concert with other influential determinants such as genetics, health care, and the environment. Environmental/Socioeconomic Determinants Specific determinants of health identified in the first section of the CHA illustrate that like many other comparable communities, Onondaga County is made up of a wide range of social and built environments. There are urban, suburban, and rural communities within Onondaga County with highly variable built environments. The most dramatic difference is that between the City of Syracuse and the rest of the county. As noted in the CHA, residents of Syracuse are younger, poorer, less educated, more likely to be unemployed, more likely to live in public housing, more racially and ethnically diverse, more likely to be foreign born 51

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. (including refugees), and more likely to be linguistically isolated. All of these determinants of health are associated with poorer health outcomes. With respect to the built environment, much of Onondaga County is rural with numerous county and state parks. Within the City of Syracuse, there are many parks/green spaces, a large central Farmer s Market, and many mobile markets. Despite this, too many Syracuse residents have low access to healthful foods and ready access to corner stores and fast food outlets. Behavioral Determinants For the county as a whole, the Expanded BRFSS Preliminary Report, 2013 2014 (Appendix 2.) shows that with respect to accessing health care, Onondaga County fares better than NYS as a whole with greater insurance coverage; more adults with a regular health care provider; and more adults with current dental visits. Breast cancer and colorectal cancer screening rates are also higher in Onondaga County than NYS. While the numbers are too small to report an association with confidence, there also appears to be higher vaccination rates (flu/pneumonia) for adults. These data are consistent with Onondaga County s ranking in the top four counties in NY for Clinical Care in the County Health Indicators Report for the past four years (www.countyhealthrankings.org). Other Notable Behavioral Determinants Other behavioral risk factors identified in the 2013 2014 report demonstrate that for binge drinking and overall tobacco use rates, Onondaga County fares worse than NYS as a whole. Of significant concern, pregnant women have higher than expected rates of self reported tobacco and drug use (local data from electronic birth records). In addition, there are lower than expected rates of breastfeeding. For obesity related behaviors, it appears that Onondaga County residents are more likely to engage in leisurely physical activity. There does not appear to be a difference in daily consumption of sugar sweetened beverages between Onondaga County and NYS. Policy Determinants Much of the recent policy work in Onondaga County has focused on tobacco control; healthful eating and physical activity; and the built environment. Onondaga County has a history of developing strong tobacco control policies. This includes enactment of local laws as well as work with local municipalities, businesses, landlords and property owners, healthcare organizations, and college campuses to adopt tobacco free policies. 52 Between 2007 and 2011, all 29 municipalities (including 15 towns, 12 villages, the City of Syracuse, and Onondaga County) that have municipally owned parks participated in the Young Lungs at Play initiative and adopted tobacco free grounds policies for their parks and/or playgrounds. During this same period, eight municipalities adopted tobacco free grounds policies for their municipal buildings. In addition, over 60 businesses and community organizations in Onondaga County have adopted tobacco free grounds policies in recent years, including many daycares, churches, and non profit organizations. All branches of the Onondaga County Public Library and several other independent libraries within the county have policies that restrict tobacco use on library grounds. Local property owners working with the OCHD have adopted smoke free policies for over 200 buildings in Onondaga County. Collectively, these policies reduce secondhand smoke in over 2,200 units of multi unit

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 housing, much of which is occupied by senior citizens and low income tenants. In fall 2013, the Commissioner of Health and key staff participated in two discussions with the Syracuse Housing Authority (SHA), a public housing authority, to encourage and support the adoption of such policies within SHA. Initial feedback from these discussions has been promising. In 2009, Onondaga County enacted two local laws related to tobacco. The County s Tobacco 19 law raised the minimum purchasing age for tobacco to 19. The purpose of this law is to make tobacco products inaccessible to high school age youth to reduce the chances that they will become addicted to cigarettes at any age. The second local law adopted by the Onondaga County Legislature in 2009 prohibited smoking within 100 feet of the perimeter of hospital grounds. This includes areas of hospital grounds open to the public such as public streets, sidewalks, parking lots, and parking facilities. In 2010, the OCHD established a working committee for Tobacco Free Healthcare Facilities. Members of the committee work with the local healthcare community by expanding tobacco free grounds policies to all healthcare facilities/offices in Onondaga County. Over 22 healthcare facilities have adopted tobacco free grounds policies. Most recently, in 2013, the Board of Family Care Medical Group (FCMG), with over 30 locations, adopted a tobacco free grounds policy for all facilities that will go into effect January 2014. The OCHD also has a history of success working with college campuses to adopt tobacco free grounds policies. In 2007, Onondaga Community College adopted a tobacco free grounds policy for the campus. In 2011, SUNY Cortland voted to enact a 100% tobacco free grounds policy. This decision was made in part due to collaboration with the OCHD through the Advocacy in Action program, which was a New York State Department of Health grant funded program. In 2013, LeMoyne College passed a tobacco free campus policy that will be fully implemented in 2015. Onondaga County has been fortunate to receive grant funding from NYSDOH for Eat Well Play Hard and Creating Healthy Places to Live, Work, and Play in Onondaga County. Both of these initiatives have addressed the establishment of healthful policies within child care centers to support sustainable changes that influence healthy eating and increase physical activity for children. As a result of this work, 19 policy changes were implemented at child care centers throughout Onondaga County within the last five years. In November 2012, the first Complete Streets policy in Onondaga County was passed by the Village of Fayetteville. The Complete Streets policy has the potential to change how the Village of Fayetteville residents travel from place to place, regardless of their mode of transportation. The Complete Streets policy will now require the Village Transportation Department to consider the needs of all roadway users when making any changes to or creating new roadways within the Village of Fayetteville. In October 2013, the City of Syracuse Common Council voted to establish a health committee to identify policies to address health concerns within the City of Syracuse. An OCHD staff member will participate as a technical advisor to the committee. 53

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Main Health Challenges Detailed descriptions of the health status are available in Part C of this community health assessment, with summaries within each of the five Prevention Agenda Priority Areas. Overall, Onondaga County is similar to the rest of NYS and the U.S. with major health challenges in the areas of chronic disease (cancer, obesity, and diabetes); violence and unintentional injury; poor birth outcomes (infant mortality and low birth weight); mental health (substance abuse as it impacts neonates) ; and STDs (gonorrhea). A successful set of community strategies must address health issues on many levels. As shown in Figure 41, interventions to improve health must be targeted toward the broader issues that contribute to good health, not just to those health care services that improve an individual s health. Figure 41: Broadening the focus of determinants of health From: Braverman, et al.: Broadening the Focus: The need to Address the Social Determinants of Health. American Journal of Preventive Medicine 2011; 40(1D1):S4 S18. 54 This community health assessment was framed in this broader context, looking not only at the health problems in the community but at those causal variables as well. The strategies that will be adopted by the partners for the Community Health Improvement Plan (CHIP) will be broad, taking into consideration this public health framework. References: 1. Anderson, L. M., Scrimshaw, S. C., Fullilove, M. T., & Fielding, J. E. (2003). The Community Guide's Model for Linking the Social Environment to Health. American Journal of Preventive Medicine, 24(3S), 12 20. 2. McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1998). An Ecological Perspective on Health Promotion Programs. Health Education & Behavior, 15(4), 351 377. 3. Braverman, P. A., Egerter, S. A., & Mockenhaupt, R. E. (2011). Broadening the Focus: The need to address the social determinants of health. American Journal of Preventive Medicine, 40(1SI), S14 S18. 4. Case, A., Fertig, A., & Paxson, C. (2005). The Lasting Impact of chidhood Health and Circumstance. Journa of Health Economicx, 24, 365 389. 5. McGinnis MJ, Williams Russo, P, Knickman JR: The Case for More Active Policy Attention to Health Promotion. Health Affairs 2002; 21: 78 93

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Part E: Assets and Resources The Onondaga County Health Department (OCHD) is a large academic local health department with a mission to protect and improve the health of all Onondaga County residents. With a 2014 budget of approximately $76 million (including over $10 million in grants) and approximately 300 employees, the OCHD is a full service health department providing a wide range of public health services to the community since 1965. For a description of all the programs and services offered by the OCHD, please see the Annual Report at www.ongov.net/health. The OCHD core values are: Respect, Excellence, Accountability, Collaboration, and Health Equity. The OCHD envisions a community of partners working together for the physical, social, and emotional well being of all. With a proud history of quality improvement, OCHD is currently pursuing accreditation through the Public Health Accreditation Board in order to best meet the community s needs. Please see Appendix 3 for an organizational chart of the OCHD. According to the latest census data, Onondaga County has over 467,000 residents. One third of people living in the county seat, Syracuse, are living below the poverty level. Many of the key health indicators disproportionately impact racial and ethnic minorities, and women and children. Because health equity is a core department value, every OCHD program is expected to address racial, ethnic, and economic disparities in program development, implementation and evaluation. The OCHD is fortunate to have a strong network of partners working together to improve the health of the community. As an example, in the 2008 2012 CHIP, Refugee Health was identified as a community priority. Since then, community collaborations to support the needs of this vulnerable population have been greatly strengthened. In 2012, the Onondaga Citizen s League did a year long study of the challenges facing, and assets and resources available for, the refugee population. (Report is available at http://onondagacitizensleague.org/) As described in this CHIP, a large number of agencies and individuals are contributing assets and resources toward the selected priority areas: Preventing Chronic Disease and Preventing Substance Abuse/Promoting Healthy Women, Infants and Children. In addition to the support detailed in the CHIP, Onondaga County has a variety of resources devoted to improving health, some of which are outlined below. For a broader profile of selected assets and resources in Onondaga County, please see Appendix 4. Environmental assets and resources A number of resources are available in Onondaga County to promote an environment conducive to physical activity and good nutrition. The Onondaga County Parks system covers nearly 6,500 acres and includes a nature center, beaches, forested areas, recreational facilities, athletic fields and other historic features. Many county parks are accessible by public transportation. According to the Onondaga County Parks Annual Report, nearly 3 million people enjoy the parks each year. Onondaga County is also home to a number of fitness facilities, athletic clubs, and sporting groups. Since 2011, the OCHD has been working to educate and encourage local municipalities to adopt Complete Streets policies. Improving access for bicyclists and pedestrians can increase physical activity in a community. As described earlier, the first such policy in Onondaga County was passed by the Village of Fayetteville in 2012. 55

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. In the last several years, the City of Syracuse has also made progress toward expanding opportunities for alternate modes of transportation. Recent completion of the Connective Corridor has linked the Syracuse University community with downtown Syracuse through a stretch of road that was modified to facilitate safe access for bicyclists, pedestrians, motorists and bus passengers. Additional projects are under consideration in other parts of the city. During the growing season there are 12 farmers markets operating in Onondaga County, including a large, central Farmers Market open year round, and many mobile markets that operate throughout the City of Syracuse. In addition, at least 14 community gardens are tended in Syracuse. Each of these efforts increases the accessibility of healthy, safe and affordable foods, and many have incorporated educational components to provide culturally appropriate information on health and nutrition. Food insecurity can be a major barrier to healthful eating. The Food Bank of Central New York serves 11 counties including Onondaga, providing food, nutrition education, and technical assistance to food programs, including emergency food shelters. Over 75 food pantries/soup kitchens operate in Onondaga County to help ensure that residents do not go hungry. Healthcare assets and resources According to the Annual New York Physician Workforce Profile, there are 1,555 physicians practicing in Onondaga County, and 321 FTE physicians per 100,000 population (2010) including 82 92 primary care FTEs per 100,000 population. While Onondaga County appears to compare favorably to NYS and CNY with respect to the number of physicians per population, the data do not address the geographic distribution of physicians within the county or whether the physicians accept Medicaid as payment. These factors contribute to overall healthcare access, and should be further explored. There are five hospitals located within Onondaga County: Upstate University Hospital Community Campus, Crouse Hospital, St. Joseph s Hospital Health Center, Upstate University Hospital (including Golisano Children s Hospital) and Syracuse VA Medical Center. Upstate University Hospital Community Campus maintains 306 acute care beds. The Hospital offers emergency services, medical and surgical care, intensive care, maternity services, acute physical rehabilitation, inpatient psychiatric care, and outpatient testing. In addition, the hospital operates an inpatient physical medicine and rehabilitation program as well as an outpatient physical & occupational therapy service. They also are part of the Upstate Midwifery Program which offers gynecological care, family planning, perimenopause and menopause management. Crouse Hospital operates 506 acute care beds and 57 neonatal intensive care bassinets. Crouse Hospital s inpatient services include comprehensive maternity, labor and delivery care, including high risk maternity/obstetrics (with Central New York s only Level 4 neonatal intensive care unit); coronary, intensive and progressive care; adult and pediatric cardiac catherization; chemical dependency treatment services ; emergency care; surgical services; oncology; pharmacy; radiology; and laser services. Together with SUNY Upstate Medical University, Crouse Hospital provides the services of the Central New York Regional Perinatal Program. 56

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Upstate University Hospital is a facility with 409 licensed inpatient beds and 10 observation beds. University Hospital has a Level 1 Trauma Center. The hospital provides services including stroke care, AIDS care, trauma care, epilepsy care, a diabetes program, a burn unit and Poison Control, as well as 77 unique specialty clinics. A recent addition to the hospital is Golisano Children s Hospital which offers general pediatrics, pediatric surgery, hematology/oncology, pediatric intensive care and a pediatric emergency department. St. Joseph s Hospital Health Center has 431 beds, and offers several specialty services, including aesthetic surgery, The Birth Place, wound care and hyperbaric medicine, dental services, diabetes self management, emergency and intensive care services, hemodialysis, maternity and outpatient pediatric services, neurosurgery, orthopedic diagnostics, surgery and rehabilitation, outpatient surgery centers, rehabilitation services, a sleep lab, and certified home health care. St. Joseph s also offers behavioral health services for adults and children, including a Comprehensive Psychiatric Emergency Program (CPEP) with a licensed Psychiatric Emergency room fully staffed 24/7. The Syracuse VA Medical Center has 106 beds and provides primary care, mental health care, tertiary care, long term care, physical medicine, rehabilitation, neurology, oncology, dentistry and geriatric services to veterans in the central New York area. In addition to the local hospitals, there are seven urgent care facilities in Onondaga County. Residents of each quadrant in the County have access to an urgent care facility, with additional facilities available in Syracuse. Upstate Golisano Children s hospital provides after hours care for children birth to age 21 years at the Community Campus. Syracuse is home to the Syracuse Community Health Center, a Federally Qualified Health Center that offers comprehensive care for children and adults, and operates six school based health centers in the Syracuse City School District. Two hospital based outpatient clinics also provide medical services to un or underinsured individuals, or those who cannot pay. Five additional community based clinics are also available to meet this need. The OCHD provides testing and treatment for STDs and tuberculosis, and testing for HIV in a clinic setting. Family planning care is available through Family Planning Service and Planned Parenthood, with several sites throughout the County. Employer and business assets and resources: Onondaga County is fortunate to have a cadre of employers and businesses that are engaged in promoting health throughout the community. This is most evident in preparedness efforts and in worksite wellness efforts. With respect to the former, in 2013 the OCHD held a public health preparedness exercise in partnership with the Texas Engineering Extension Service. Participants included Syracuse University, LeMoyne College, Onondaga Community College, and the Long Term Care Council as major local employers in the area. Several of these employers have agreed to provide support for closed point of distribution sites in the event of an emergency. With respect to the latter, one of the initiatives described in the Community Health Improvement Plan, Healthy Syracuse, has been successful in engaging numerous businesses to begin to adopt worksite wellness policies. In 2013, the conference was attended by over 300 individuals. In 2014, the conference was able to secure former Surgeon General Dr. Regina Benjamin as the keynote speaker. 57

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Media assets and resources Onondaga County is home to a major daily newspaper, the Post Standard, which frequently features stories on health related issues. There are several weekly/monthly newspapers, as well as 20 local AM and FM radio stations. One radio station and one monthly newspaper target the Spanish speaking community. Residents have access to four standard commercial television stations, one public broadcasting station, and one station with 24 hour local news broadcasting. The OCHD routinely works with media partners to promote healthrelated messages. In 2012, nine print media sources and one radio channel committed to support the OCHD media series, and nearly 80% of submissions were published or aired. High speed internet service is available to most county residents. The OCHD maintains a website, as well as a social media presence on Facebook and Twitter to provide information to the community on services and health conditions. Each of these media platforms will be utilized to publicize and distribute the Community Health Assessment and Community Health Improvement Plan. Academic assets and resources Onondaga County is home to a number of academic institutions with health related programs whose students are ready and willing to assist in addressing community health needs. Upstate Medical University graduates approximately 150 physicians each year, the majority of whom have experienced two site visits at the OCHD as part of their pediatric rotation. Additionally, every year approximately 10 15 fourth year students do a month long rotation at the OCHD. Upstate also houses a joint Central New York Master of Public Health program with Syracuse University. Since the program s inception, over 15 students have completed field placement or capstone projects with the OCHD. Syracuse University is home to the Lerner Center for Public Health Promotion, and offers a variety of health related programs including a Bachelor s degree in public health. In addition, St. Joseph s Hospital Health Center, Crouse Hospital and Upstate Medical University offer various nursing degree programs. Community based health and human service agency assets and resources Central New York, including Onondaga County, has more than seventy community based health and human service agencies. The Human Services Leadership Council is a membership organization of the chief executive officers of these agencies and was established as a collaborative to facilitate information sharing and increase cooperation among the agencies. More information about each of these community based service agencies is available at www.hslccny.org. Other governmental agency assets and resources With respect to protecting the public s health, the OCHD has close working relationships with the New York State Departments of Health, Education, Environmental Conservation, and Agriculture and Markets. In addition to these state resources, the OCHD works closely with other departments within Onondaga County, particularly the Departments of Children and Family Services, Emergency Management, Parks and Recreation, and Social Services: Economic Security. The OCHD works closely with all town and village governments both proactively (e.g., Complete Streets initiatives) and reactively as needed (e.g., mosquito control, sewer issues). 58

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Part F: Community Engagement Process and the Methodology of the Community Health Assessment The Onondaga County Health Department (OCHD) partnered with the hospitals in Onondaga County to conduct a community health assessment (CHA) process that engaged health improvement efforts already underway and drew on local resources. The process was designed to result in a clear picture of the health of the community and to identify meaningful and realistic community health improvement initiatives that are supported by key constituencies. The Onondaga County CHA process was also structured to meet the requirements of the New York State Prevention Agenda and Title IX of the Patient Protection and Affordable Care Act of 2010. The initial CHA process began in the fall of 2011 with graduate students in the Central New York Master of Public Health program (CNYMPH), a graduate program in public health sponsored by Syracuse University and SUNY Upstate Medical University. The graduate students began their work by convening and facilitating five community forums in October and November 2011. The purpose of the forums was to identify the health issues that are perceived to be of importance in the community. The Lerner Center for Public Health Promotion at the Maxwell School for Citizenship and Public Affairs at Syracuse University provided logistical support and assistance with recruiting forum participants in collaboration with the Onondaga County Advisory Board of Health, the Syracuse City Schools, and Say Yes to Education. The forums were held at the Central New York Community Foundation Philanthropy Center; the school focused forum was held at the Say Yes to Education offices. Altogether, 92 people, including local residents and individuals representing a wide range of community organizations, participated in the forums. Two photos from one of the community forums are seen in Figures 42 and 43. Figures 42, 43: Images from one of the community forums, Onondaga County, Fall 2011 59

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. After the community forums were held, the data collection and analysis phase began. Data from a number of sources were utilized, including the New York State Department of Health, the U.S. Census, internal information from the OCHD and hospitals, the 2013 Community Needs Assessment Report developed by the United Way of CNY as well as many other local sources of data as identified Parts A E of this CHA. The qualitative findings identified in the community forums provided a backdrop against which data were collected and analyzed to better understand the concerns raised by community members. The results of the forum, summarized in a report issued in January of 2012, are included in Appendix 5. In early 2013, meetings between the leadership of the Onondaga County Health Department (Commissioner of Health and Chair of the Advisory Board of Health) with the chief executive officers of the three civilian hospitals in the community (St. Joseph s Hospital Health Center, Crouse Hospital and Upstate University Hospital (including the Golisano Children s Hospital and Upstate at Community General)) were held to discuss both the CHA and the Community Health Improvement Plan(CHIP)/Community Service Plans (CSP) processes and to gain support of the leadership. The outcome of the meeting was an agreement that all processes would be collaborative and would focus on building on existing partnerships to ensure that the outcome would incorporate initiatives that already had a strong base of support. Over the course of 2012/2013, a task force composed of representatives from the LHD and the hospitals met regularly to review the data and explore areas for collaboration. Appendix 6 includes a list of some of the meeting dates for the CHA/CHIP, excluding the community forums. In the spring of 2013, another group of students from the CNYMPH program were engaged to support the CHA/CHIP/CSP effort. Teams of students were paired with the hospitals and with the OCHD to support further data collection and analysis. The teams, at the direction of the hospital and LHD, collected and organized data that was used by the leadership of the organizations to understand the health needs of the community. The students provided formal reports to each of the organizations in the spring of 2013. In addition, in the spring and fall of 2013, all first year medical students at Upstate Medical University were required to participate in a modified CHA process for a class assignment. Students overwhelmingly selected indicators in the chronic disease domain (obesity, cardiovascular disease, cancer and diabetes all ranking the highest within the domain). Their second priority was communicable disease with an emphasis on STDs. Indicators in the domains of maternal and child health, environmental health, and mental health were much less commonly selected. During the course of the community health assessment, an issue related to neonatal abstinence syndrome, drug withdrawal in a baby, surfaced. The issue was identified concurrently by the NYSDOH and by local physicians and hospital staff. It was also raised at an Onondaga County Advisory Board of Health meeting by a neonatologist on the Board. A review of the data revealed that Onondaga County has the highest rate of hospital discharges for newborns with drug related issues in NYS. A community solution is one of the priority/focus areas chosen by local hospitals and the OCHD in Onondaga County. 60 The findings of the community forum as well as further data collection and analysis revealed that the other priority issue should address chronic disease and more specifically, physical activity and nutrition as they relate to chronic disease.

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 In summary, through discussions with the task force and the leadership of the OCHD and the local hospitals, two priority areas were chosen: Preventing Chronic Disease Promoting Mental Health and Substance Abuse/ Promoting Healthy Women, Infants and Children o Neonatal Abstinence Syndrome At a meeting on May 1, 2013 of the Thursday Morning Roundtable (a community forum sponsored by Syracuse University) the Commissioner of Health and Chair of the Advisory Board of Health presented The State of Our County s Health: An Assessment of Onondaga County s Health. This was the first of several presentations on the CHA in Onondaga County. The original presentation is included as Appendix 7. 61

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Community Health Improvement Plan Background The two shared priority areas were identified by the community, and by health and public health professionals over a two year process. In 2011, community forums were held to identify the community s areas of concern with respect to health. (The process is described in Section F of the Community Health Assessment and in greater detail in Appendices 8.a and 8.b.) The summary of the input gathered from these forums concluded that the community participants identified that: Health status was also negatively impacted by a number of variables including physical activity and nutrition which drives, in large measure, chronic disease, another area of concern frequently cited. Other health concerns relate to mental health and substance abuse as well as maternal and child health, problems exacerbated by limited access to care and poor social conditions. In early spring 2012, the New York State Department of Health (NYSDOH) reached out to the OCHD to share concerns about the rate of drug related discharges in newborns in Onondaga County. Given the information provided by NYSDOH, the OCHD engaged obstetric and neonatology providers in the community and initiated a study with the local laboratory, Laboratory Alliance of Central New York, to further investigate this public health threat. (Refer to Appendix 9 for results of the investigation.) With these areas of concern in mind, the OCHD reviewed the health indicator data for chronic disease, mental health/substance abuse, and maternal and child health. The data identified that Onondaga County is disproportionately impacted by certain chronic diseases (e.g., diabetes, cancer) and that substance abuse, particularly with respect to maternal and child health, is an ongoing public health threat in Onondaga County. All supporting data are presented in Onondaga County s Community Health Assessment. In addition, community assets and resources, including existing community partnerships were identified. All of this was done keeping the complex interactions of determinants of health in mind. The Commissioner of Health (Cynthia B. Morrow, MD, MPH) and the Chair of the Health Advisory Board (Thomas H. Dennison, PhD) met with the Chief Executive Officers of St. Joseph s Hospital Health Center (Kathryn H. Ruscitto), Crouse Hospital (Paul Kronenberg, MD), and Upstate University Hospital (John McCabe, MD) in February 2013 to discuss shared Prevention Agenda Priority Areas. All parties agreed that the Prevention Agenda Priority Areas that would be addressed in Onondaga County over the next four years were: Promoting Mental Health and Preventing Substance Abuse/Promoting Healthy Women, Infants, and Children with focus of preventing substance abuse in this target population and Preventing Chronic Disease with a focus on nutrition/physical activity. Given the disproportional racial and ethnic distribution of the health indicators in these priority areas, both of these priority areas will address disparity. 62 The following sections will address each of the shared Prevention Agenda Priority Areas. The first priority area, Promoting Mental Health and Preventing Substance Abuse/Promoting Healthy Women, Infants, and Children with focus of preventing substance abuse in this target population, will concentrate on Onondaga s

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 high rate of drug related discharges in newborns and several community initiatives that are addressing this priority. The second priority area, Preventing Chronic Disease with a focus on nutrition/physical activity will concentrate on two different community collaborations, the Near Westside Initiative and Healthy Syracuse, both of which are implementing population based initiatives to decrease the impact of chronic disease in Onondaga County. Key partners for each of the initiatives reviewed the pertinent sections of the Community Health Improvement Plan (CHIP) to ensure accuracy of the content. Addendum It is important to note that while this CHIP details specific efforts of the OCHD and community partners to improve the public s health in the identified priority areas, the Onondaga County Health Department continues to use multiple approaches to improve the health of the community it serves. Numerous examples of ongoing OCHD led public health initiatives were discussed throughout the CHA. (Refer to page 38 for OHCD s response to the high rate of violence/homicide, and page 49 for OCHD s response to the increase in gonorrhea.) Furthermore, as discussed in Policy Determinants on page 52, the OCHD is involved in numerous activities to change local policies to improve the public s health. The OCHD is in the process of finalizing a strategic plan which will better align services to community health needs and will further strengthen the health department s robust quality improvement program. (A published review of the OCHD s culture of QI is available in Appendix 10.) Below please find two examples of the OCHD Strategic Plan and how it will incorporate the Prevention Agenda goals, objectives, and tracking measures when feasible. 63

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Two examples of a goal and strategies of the Onondaga County Health Department s Strategic Plan with Integration of the Prevention Agenda: Strategic Priority: Health Promotion Goal 1.2: Promote an environment that minimizes exposure to disease and potential hazards. Strategy 1.2.1: Develop and implement a comprehensive Healthy Homes model and train all home visiting and/or field staff in the department about the model. Division of Environmental Health: Improve home environments to promote health and reduce asthma triggers through staff training in the Division Prevention Agenda Focus Area: Built Environment Prevention Agenda Goal: Improve the design and maintenance of home environments to promote health and reduce related illness Prevention Agenda Objective: Reduce the asthma triggers during Healthy Neighborhood Program home revisits by 55% Bureau of Health Promotion/Disease Prevention: Improve home environments to promote health and reduce by training of all OCHD home visitors/field staff about Healthy Homes Prevention Agenda Focus Area: Built Environment Prevention Agenda Goal: Improve the design and maintenance of home environments to promote health and reduce related illness Strategic Priority: Health Improvement Goal 2.2: Promote population health with a focus on prevention through education. Strategy 2.2.1: Develop and implement an educational campaign for the top three prevention priorities identified each year. Bureau of Statistics and Surveillance: Develop and implement a system to identify the top three prevention priorities each year. Prevention Agenda Focus Area: Improve health status and reduce disparities Prevention Agenda Goal: Improve the health status of all (Onondaga County residents) Prevention Agenda Objective: Reduce the percentage of premature deaths by 10% Bureau of Health Promotion and Disease Prevention: Develop and implement an educational campaign for the top three prevention priorities identified each year. Prevention Agenda Focus Area: Improve health status and reduce disparities Prevention Agenda Goal: Improve the health status of all (Onondaga County residents) Prevention Agenda Objective: Reduce the percentage of premature deaths by 10% Division of Healthy Families: Develop and implement educational campaigns that address maternal and child health outcomes Medical Examiner s Office: Educate the public about preventable causes of death 64

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Drug Related Discharges in Newborns in Onondaga County Introduction*: According to the New York State Health Department, Onondaga County has the highest rate of newborn drugrelated discharges in the state with 248.3 discharges per 10,000 births compared to the state average of 72.6. 1 Although these numbers do not take into account the differing screening methods and protocols per county, the numbers do represent the increasing number of infants physiologically dependent on drugs of abuse. In an analysis of five months of data on drug screening laboratory results from newborns and/or their mothers in Onondaga County over a five month time period, opiates and cannaboids were the most commonly identified drugs. 2 Neonatal abstinence syndrome (NAS) is one of the most concerning drug related discharges in newborns. NAS is defined as the presence of withdrawal symptoms in the newborn caused by prenatal maternal use of illicit drugs. This syndrome is primarily caused by maternal opiate use. 3 Adverse neonatal outcomes including low birth weight and increased morbidity and mortality have been associated with illicit drug use and specifically the dependence of opioids during pregnancy. 3 7 In neonates, the withdrawal symptoms are similar to those experienced by adults and include feeding intolerance, seizures, emesis, and respiratory distress. 3,9 This syndrome reflects a growing concern over the prescription drug abuse epidemic in the United States. The national incidence of NAS increased from 1.2 to 3.39 per 1,000 births from 2000 to 2009. 3 During the same period, the number of mothers using or dependent on opiates at the time of birth, increased from 1.19 to 5.63 per 1,000 births. 3 The 3 fold increase in NAS diagnosis and 5 fold increase in maternal opiate use have significantly increased health care expenditures nationwide. In hospitals across the United States, newborns diagnosed with NAS were associated with a 35% increase in hospital expenses when compared to the 30% increase in expenses for all other hospital births. 3 Total hospital charges for NAS were estimated to have increased from 190 million dollars to 720 million dollars after adjusted for inflation. 3 The Centers for Disease Control and Prevention found that sales and deaths related to opiate pain relievers quadrupled between 1999 and 2008. 3 Acknowledgement * The Onondaga County Health Department gratefully acknowledges the contributions of Sufyan Siddiqui and Sarah Tabi, fourth year medical students in 2012 and 2013 respectively who wrote papers addressing this challenge. The Introduction is adapted from Mr. Siddiqui s work while the section on Community Collaborations is adapted in partfrom Ms. Tabi s project. 65

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Given the extent of the problem, the Onondaga County Health Department, Crouse Hospital, St. Joseph s Hospital Health Center and Upstate University Hospital have all agreed to address this challenge in their Community Health Improvement Plan/ Community Service Plans. In addition, numerous community partners have also become involved in addressing this acute public health challenge. Five current collaborative efforts to address the multiple issues related to prescription and illicit drug use, as well as alcohol use are described below. Onondaga County s County Executive and the County Legislature have supported this priority by providing funding in the 2014 Budget to support a position (through Prevention Network) to ensure that there is a comprehensive and coordinated approach for these collaborative efforts. Community Collaborations Addressing Drug Related Discharges in Newborns Syracuse Healthy Start Perinatal Substance Abuse Committee: Description: This committee is convened by SUNY Upstate Center for Maternal and Child Health (CMATCH) as a collaborative effort of the Syracuse Healthy Start program, a program of the Onondaga County Health Department, to improve outcomes of mothers and infants affected by substance abuse (e.g., tobacco, alcohol, recreational drugs, prescription medications) and to reduce disparities in infant mortality by data analysis, making recommendations, and developing educational materials. The Committee was formed out of recognition that substance use in the prenatal period presents a major risk to the health of woman and infants and contributes to poor birth outcomes. The Committee brings together clinical and human service providers to share information from practice, examine local data, share current medical literature, and identify best practices with the goal of developing policies, procedures, and educational messages to improve local efforts to prevent, identify, and treat perinatal substance abuse among pregnant and parenting women in Syracuse. CMATCH, as a part of the CNY Regional Perinatal Program, often shares the efforts and recommendations of the Committee throughout the CNY Region. Committee recommendations may be reviewed by the Upstate OB/GYN Department and Crouse Hospital s Policies and Standards Committee then, if appropriate, the Regional Perinatal Center sends the recommendations to the hospitals/health care providers in Central NY. Members: Open to clinical and human service providers interested in this issue. Current members include Crouse Hospital s NICU, St. Joseph s Hospital Health Center, SUNY Upstate Center for Maternal Child Health, Reach CNY, Neonatal Associates of CNY/Regional Perinatal Center, Onondaga County Health Department, Prevention Network, and Upstate Poison Control Center. Initiatives: This ongoing committee has the opportunity to shape policies for participating institutions. Currently the committee is considering policies to standardize patient education vis à vis prescription and recreational drug use at prenatal visit as well as policies to address universal drug screening for pregnant women. (Currently considering verbal screening via a standard tool (e.g., 4 P s) and urine drug screening.) Outcome and Performance Measures: Number of policies developed, disseminated, and implemented 66

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Neonatal Abstinence Syndrome Elimination Team: Description: A collaboration to address current drug trends in the community based on identified needs assessments. The NAS team is currently focused reducing and eliminating Onondaga County s extremely high rate of neonatal drug related discharges (248.3/10,000 births) with an emphasis on babies with neonatal abstinence syndrome. Environmental strategies have been developed to assist women of child bearing age and pregnant women in targeted City zip codes. Members: Upstate Poison Control Center, Prevention Network, CONTACT Community Services, Crouse Hospital (including Outpatient Rehabilitation Services and Chemical Dependency Service), Reach CNY, Onondaga County Departments of Health and Mental Health Initiatives: SBIRT Training (Screening/Brief Intervention/Referral to Treatment). The objective of this training is to identify patients in the early stages of addiction. Prevention Network will train health care providers from various local hospitals, practices, and clinics to identify drug using mothers. OASAS (Office of Alcoholism and Substance Abuse Services) is writing the SBI training curriculum. o Outcome and Performance Measures: Number of health care providers trained in SBIRT Public Health Campaign. Community partners are working together to eliminate NAS in Onondaga County by educating and providing help to drug using females who are pregnant or of child bearing age via billboards and brochures. Focus groups were created to test market materials for the campaign. The focus groups consisting of women who child bearing age with a history of substance abuse during pregnancy were selected by the Crouse Chemical Dependency Treatment Program to participate. Prevention Network provided funding for the billboards; Reach CNY helped develop a script to guide the process and provided $500 for gift cards for focus group participants; the Onondaga County Health Department assisted with development of educational materials based on focus group feedback. o Outcome and Performance Measures: Number of educational materials distributed Number of referrals received as a result of this campaign District Attorney s Opiate Task Force: Description: In the spring of 2012, the Prescription Drug Abuse Task Force was formed to develop recommendations to combat the synthetic marijuana and bath salts concerns in Onondaga County. As these drug related issues receded, the group refocused on opiates and prescription drugs as needs indicated. This group s collaborative effort targets policies and enforcement regarding opiates including expanding the prescription drug take back, community awareness, cross system networking, information sharing and potentially other legislative matters. This is the only group with a significant presence of both enforcement and health care providers that meets monthly to discuss possibilities and trends to combat drug use in the community. 67

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Members: Onondaga County District Attorney s Office, DeWitt Police, Onondaga County Departments of Health, Mental Health and Social Services, Crouse Chemical Dependency treatment Services, Upstate Poison Control, Prevention Network, Upstate Hospital, Kinney Drugs, Wegman s Pharmacy, Syracuse Behavioral Healthcare, NY State and Federal legislative personnel. Initiatives: The Task Force is currently discussing potential options to change existing laws to allow pharmacies to take back controlled substances in an effort to reduce the supply of unused medication. This could establish formal take back days and could increase education of the public on proper disposal methods (e.g., placing pills in coffee grounds or cat litter before throwing it away). Drug Take Back Day (October 26, 2013): An initiative of the Drug Enforcement Agency in collaboration with Prevention Network and the Alcohol and Drug Abuse Prevention Program. o Outcome and Performance Measures: Number of events to facilitate drug take back Contribution to/ number of policy changes developed, disseminated, and implemented to reduce supply of controlled substances FASD Center for Excellence (Fetal Alcohol Spectrum Disorders) Description: The Prevention Network, with support from the Perinatal Substance Abuse Committee, was recently awarded a grant from SAMSHA to focus on SBI (Screening and Brief Intervention) training. The purpose of the FASD Center for Excellence is to expand capacity in FASD prevention service delivery and produce new knowledge on effective FASD prevention and services in Onondaga County. The FASD Center for Excellence will work with five key community stakeholders to target pregnant women for universal screening and provide brief interventions to those women who report current alcohol use or past high risk alcohol use. FASD is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. Alcohol can permanently damage the developing fetal brain during pregnancy and is the leading preventable cause of developmental disabilities and birth defects. Results of the damage that alcohol can cause include lifelong physical, behavioral, mental, and/or learning disabilities. Specific effects on any individual fetus depend on a range of factors, including the amount of consumption, and the time of exposure during the pregnancy. 10 The prevalence of the full spectrum of FASD in the general population is estimated at 9.1 per 1,000 live births, but a review of in school screening and diagnosis studies suggests that the national rate could be potentially closer to 50 per 1,000. 11 These figures suggest that it is imperative to make women of childbearing age aware of the risks of alcohol consumption during pregnancy. The FASD Center for Excellence Program proposes to do just that. Members: Members of the NAS Elimination team (see above) and the DA s Task Force as well as community stakeholders and representatives from targeted community agencies/organizations serving pregnant women in Onondaga County. 68 Initiatives: The FASD Center for Excellence is working with key community agencies to provide screening and brief intervention (SBI) to pregnant women who are reporting current alcohol use or past high risk alcohol use. SBI will be infused into screening procedures for the following agencies that interact with the target

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 population: Salvation Army, Children s Consortium, REACH Inc., Catholic Charities, and Onondaga County Health Department: Healthy Families Division. Outcome and Performance Measures: o Number of staff trained in SBI o Number of women screened with SBI Safe & Healthy Neighborhoods (SaHN) Description: This newly formed committee aims to ensure safe and healthy neighborhoods in the city of Syracuse through collaborative planning, community action, civic engagement and policy advocacy. This committee will address how current corner stores negatively impact the health of a community and will strive to implement environmental changes within these stores to improve health outcomes Members: Prevention Network, Syracuse United Neighbors (SUN), New York Alcohol Policy Alliance, Creating Healthy Places to Live, Work and Play in Onondaga County (Onondaga County Health Department), Tobacco Free Onondaga County (Onondaga County Health Department), Interdenominational Ministerial Alliance of Syracuse and Vicinity, Alliance of Communities Transforming Syracuse (ACTS) and Model Neighborhood Facility, Inc. (Southwest Community Center). Technical Assistance is provided by the Central Region Prevention Resource Center, an initiative of the New York State Office of Alcoholism and Substance Abuse Services. Initiatives: Sub committees have been formed to plan activities to support the Safe and Healthy Neighborhood goals to enforce the City of Syracuse Business Certificate of Use Ordinance and to advocate for health in all policies. Enforcement of such policies will increase healthy and safe resources and reduce unhealthy and unsafe resources with special focus on young adults, youth, and children. Specific areas of interest are to: Reduce access and availability of alcohol, tobacco and other drugs. Decrease crime and violence by increasing health and safety. Increase access and availability to healthy food options. Outcome and Performance Measures: o To be determined by sub committees References: 1) www.healthy.ny.gov/statistics/chac/chai/docs/sub_31.htm Accessed October 2013. 2) Siddiqui S. Fourth Year Medical Student. Neonatal Abstinence Syndrome in Onondaga County, 2012 Onondaga County Health Department report. 3) Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: U.S., 2000 2009. JAMA. 2012;307 (18): 1934 1940) 4) Hulse GK, Milne E, English DR, Holman CDJ. The relationship between maternal use of heroin and methadone and infant birth weight. Addiction. 1997; 92 (11): 1571 1579 5) Madden JD, Chappel JN, Zuspan F, Gumpel J, Mejia A, Davis R. Observation and treatment of neonatal narcotic withdrawal. Am J Obstet Gynecol. 1977; 127(2):199 201. 69

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. 6) Dryden C, Young D, Hepburn M, Mactier H. Maternal methadone use in pregnancy: factors associated with the development of neonatal abstinence syndrome and implications for healthcare resources. BJOG. 2009; 116(5): 665 671. 7) Minozzi S, Amato L, Vecchi S, Davoli M. Maintenance agonist treatments for opiate dependent pregnant women. Cochrane Database Syst Rev. 2008;(2): CD006318 8) American Academy of Pediatrics Committee on Drugs. Neonatal drug withdrawal. Pediatrics. 1998; 101 (6):1079 1088 9) Centers for Disease Control and Prevention (CDC). Vital signs; overdoses of prescription opioid pain relievers U.S.. 1999 2008. MMWR. 2011; 60 (43):1487 1492. 10) Guerri C, Bazinet A, Riley E. Foetal Alcohol Spectrum Disorders and Alterations in Brain and Behavior. Alcohol and Alcoholism. 2009; 44 (2); 108 114. 11) May P, Gossage J, Kalberg W et al. Prevalence and epidemiologic characteristics of FASD from various research methods with an emphasis on recent in school studies. Dev Disabil Res Rev. 2009; 15(3): 176 92. 70

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Impacting Chronic Disease in Onondaga County The Near Westside Neighborhood* The Near Westside is one of the most impoverished and diverse neighborhoods in Syracuse with disproportionately poor health status as indicated by several Prevention Quality Indicators including COPD and diabetes (see Appendix 11). Led by Syracuse University since 2007, the Near Westside Initiative (NWI) comprises numerous community partners working together to improve the neighborhood by combining the power of art, technology, and innovation with neighborhood values and culture. More recently, health has been incorporated into the revitalization plan with St. Joseph s Hospital Health Center and local grocer, Paul Nojaim, playing an essential role in addressing health concerns in the neighborhood through several different initiatives. Healthy Eating/ Access to Healthful Food: Healthy Shoppers Reward Program: A Data Driven Solution Description: Nojaim Brothers Supermarket will be developing a Healthy Shoppers rewards program. Each consenting shopper will have their food purchases tracked and scored using the food indexing system, NuVal. Shoppers will earn points for purchasing healthier foods. As their average score improves, they will be eligible to win prizes that may lead to other healthy choices, such as a bike, gym membership or gift certificates for fruits and vegetables. Furthermore, consenting customers who are also patients at the neighboring St. Joseph s Westside Family Health Center will have these data linked with their electronic medical record, allowing clinic staff to evaluate what patients are purchasing and have informed discussions of simple ways to make better choices. With grant support, Nojaim is currently providing a Neighborhood Navigator in the store. This navigator directs residents to community resources including housing and healthcare. In addition, the store is undergoing a $2.5 million renovation, partly funded by a $1 million grant from NYS Regional Economic Development Council initiative. The store will double in size and will be constructed with sensitivity to how product placement influences consumer choice. Acknowledgement * The Onondaga County Health Department gratefully acknowledges the contributions of Melissa Kaye, fourth year medical student in 2013 who wrote a paper summarizing the public health aspects of the NWI. Much of this section is adapted from her work. 71

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Community Partners: A health committee of the Near Westside Initiative comprises representatives from Nojaim Brothers Supermarket, St. Joseph s Hospital Health Center (including the Westside Family Health Center), Syracuse University (including the Lerner Center for Public Health Promotion), YMCA, Cornell Cooperative Extension, and the Onondaga County Health Department. Excellus BlueCross Blue Shield of Central New York has provided funds to offset IT costs as well as funds to run the Diabetes Prevention Program (DPP) with the West Side Family Health Center patients. Performance or Outcome Measures: o Number of active Healthy Shopper cards o Number of people who have consented to have records shared with St. Joseph s o Health indicators (blood pressure, activity levels, body mass index, hemoglobin A1C, tobacco use and more) on participants v. non participants o Product movement in the supermarket Mobile Market: Bringing the Food to the People Description: A mobile market to increase access to fresh produce by selling fruits and vegetables in various locations, primarily in the City of Syracuse. The mobile market accepts Supplemental Nutrition Assistance Program (SNAP) benefits and WIC checks, making them more accessible to low income residents who are already at greater risk for obesity related diseases and for reduced access to produce. This initiative also aims to educate the public on nutrition. Community Partners: Initial partners were the Allyn Foundation, Wegmans, SUNY Morrisville and the Gifford Foundation. Current partners include the Southside Interfaith Community Development Corporation and the Onondaga County Health Department. Performance or Outcome Measures: o Utilization data on these mobile markets Saint Lucy s Church Programs: Feeding the Spirit and Body Description: Saint Lucy s Church is in the heart of the Near Westside and provides numerous services in the neighborhood. The pastor, Reverend James Mathews, is actively involved with the NWI. Two programs that impact the health of neighborhood residents include Bread of Life, a free weekly lunch program, and the Agape shop. The Agape shop is an accessible store that sells used clothing, shoes, toys and household items to families in need and collaborates with the food pantry by providing books to be given out along with the food. Community Partners: St. Lucy s, Wegmans, Pastabilities, other churches in Roma Catholic Diocese of Syracuse, the Food Bank of CNY, neighborhood schools, Price Chopper, and Green Hill Farms. 72

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Schools: Feeding the Mind and Body Description: There are several initiatives to try to ensure that school children within the City of Syracuse have access to healthful food. Through grant support from the American Association of School Administrators and the Wal Mart Foundation, Breakfast in the Classroom is a program that can provide free breakfast for every student. The breakfast includes a fruit or juice, cereal or grain and milk, all of which can be taken into the classroom. Say Yes to Education also provides a snack for children before they go home. In addition, Wegmans has donated boxes of fruits and vegetables for students. Community Partners: Syracuse City Schools, Say Yes to Education, Wegmans Performance or Outcome Measures: o Utilization data on the programs Fitness: Movement on Main Description: Community partners are joining together to create an interactive, engaging space that is aesthetically pleasing, safe and encourages exercise to revitalize Wyoming Street, a major street in the neighborhood. A contest was held for designs with the Boston based group, STOSS, winning with a design that incorporated a rubber room, green infrastructure, exercise station, street seating, seniors gathering area, a sidewalk stage, a play hill, a bouncy field, additional lighting, sitting areas, seat walls and reflective lights. A trial prototype will be built and shared with community members in late 2013. Community Partners: SUNY Upstate ( A Center for Design, Research and Real Estate), Syracuse University (School of Architecture), City of Syracuse, Onondaga Historical Society, Onondaga County(Save the Rain). Performance or Outcome Measures: o Measures of progress in creating this space o Once space is created, discussions may ensue about evaluation of utilization of the space 73

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Medical Care: St. Joseph s Family Health Clinic Expansion Description: St. Joseph s Westside Family Health Center is currently undergoing a renovation that will include expansion to 25 exam rooms. Staffing will also be increased to increase the clinic s capacity, including a full time psychiatrist and counselor. There will be an increased emphasis on patient education about nutrition and obesity in conjunction with the Healthy Shoppers Rewards program. At this time, the intent is for the new Westside Family Health Center to increase their hours of operations to improve access to primary care and decrease emergency department utilization for neighborhood residents. Community Partners: St. Joseph s, Nojaim Brothers Supermarket Performance or Outcome Measures: o Number of educational materials/sessions on nutrition and obesity to patients of the clinic o Number of people who shop at Nojaim Brothers Supermarket who have consented to have their shopping records shared with St. Joseph s Westside Family Health Center o Health indicators (blood pressure, activity levels, body mass index, hemoglobin A1C, tobacco use and more) on participants v. non participants 74

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Impacting Chronic Disease in Onondaga County Healthy Syracuse Description: The Healthy Syracuse coalition was initially founded in 2010 by the YMCA of Greater Syracuse and the Onondaga County Health Department. The YMCA was awarded a Centers for Disease Control and Prevention's (CDC) ACHIEVE (Action Communities for Health, Innovation, and Environmental change) grant in 2010 which provided both staffing resources and funding for specific grant initiatives. The initial focus was to engage communities and collaborate with national networks to focus on chronic disease prevention. In 2013, YMCA of Greater Syracuse received additional funding through the CDC's Racial and Ethnic Approaches to Community Health (REACH) Initiative. Funding from REACH gives participating communities the opportunity to develop and implement initiatives to eliminate racial and ethnic disparities in health. The goal of REACH is to improve health and eliminate disparities related to chronic diseases in African Americans/Blacks and Hispanics/Latinos. To achieve the REACH goals, both community wide and targeted interventions addressing the specific needs of African Americans/ Blacks and Hispanics/Latinos will be developed, implemented, and evaluated. Specifically, strategies will address: healthy weight, access to nutritious foods, ability to be physically active, reduced exposure to smoke and other tobacco products, and living spaces that encourage emotional well being Progress to date: Through assessment and data collection, the Healthy Syracuse coalition developed its vision and mission. The program operates with yearly objectives. The mission of Healthy Syracuse is to facilitate community efforts to improve overall health by addressing chronic disease prevention through policy, systems, and environmental change. The vision of Healthy Syracuse is to create a sustainable healthy community for living, working, and playing by creating an environment that promotes healthy behaviors and reduces the prevalence of chronic disease. Community Partners (key partners are listed but partnership is not limited to this list): American Cancer Society, American Heart Association, Arthritis Foundation, City of Syracuse (Mayor s Office / Parks Department), Crouse Hospital, Excellus Blue Cross/Blue Shield, HealtheConnections, Internist Associates, MVP Healthcare, OCM BOCES, Onondaga County Health Department, SUNY Oswego, Say Yes to Education, St. Joseph s Hospital Health Center, Syracuse City School District, Syracuse Community Health Center, Syracuse University, Tobacco Free Onondaga County, Upstate Medical University, YMCA of Greater Syracuse and local residents. 2012 Healthy Syracuse Worksite Wellness Initiative The goal of the Healthy Syracuse Worksite Wellness Initiative is to encourage and support local employers in adopting wellness policies and programs that promote the health of employees while reducing health care costs and increasing productivity. The Initiative is the outgrowth of a grant from the CDC and the Y USA. Several community partners are working together to achieve the initiative s goals: American Cancer Society, 75

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. American Heart Association, CenterState CEO, City of Syracuse, HealtheConnections, Manufacturers Association of CNY, Onondaga County Health Department, Say Yes To Education, Stickley Audi, Syracuse City School District, Syracuse University & Maxwell s Lerner Center, Upstate Medical University, and YMCA of Greater Syracuse. In March 2012, Healthy Syracuse coordinated and hosted a conference dedicated to worksite wellness. Over 300 individuals participated, including representatives from profit and non profit worksites as well as city and county government. The area s largest employers were all represented showing a potential impact of over 20,000 individuals within those employers. Participants were able to attend sessions on understanding wellness, understanding the impact of the Affordable Health Care Act, understanding return on investment, use of social media, employee engagement, and connecting the New York State Prevention Agenda to worksite wellness. The event also highlighted over 30 local vendors that offer low cost or no cost support for employers to assist in worksite wellness efforts. A 2014 Worksite Wellness is currently being planned and will have a focus on health equity. 2013 Healthy Syracuse Initiatives Physical Activity: Promote national standard for physical activity of 60 minutes per day in schools in the district Performance or Outcome Measures: o Number of elementary schools in the Syracuse City School District that have opportunities to meet the national standard for physical activity of 60 minutes per day Healthy Weight: Promote participation in YMCA s Diabetes Prevention Program Performance or Outcome Measures: o Conduct 8 diabetes prevention programs in minority communities for people diagnosed with prediabetes. o Collaborate with child care centers and after school programs to promote screen time reduction policies, environmental changes, and practice changes. o Increase the number of worksites that implement policy and environmental changes that increase no cost opportunities for employees to participate in physical activity and increased access to healthy foods. Promote Nutritious Food: Introduce and implement interventions to promote nutrition Performance or Outcome Measures: o Review of Syracuse City School District Wellness policies o Number of new policies/revised policies and/or educational programs to promote nutritious food o Rate of youth obesity Decrease Tobacco Use: Performance or Outcome Measures: o Plan, develop, and implement a tobacco ban in the Cathedral Square Neighborhood. o Identify and implement strategies to decrease tobacco initiation among Hispanic/Latino youth ages 12 25 living in the City of Syracuse. 76

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017 Process Improvement: Applying Lessons Learned The 2013 2017 Community Health Improvement Plan is the culmination of over two years of planning and community input. Compared to the last CHA cycle there are three overarching differences in approach. The first is the utilization of more avenues to analyze, share, and receive feedback on the data. The second is the inclusion of much more specific outcome and process measures which should help with better tracking of progress towards goals. The third difference is that the Onondaga County Health Department is planning to submit its letter of intent to apply for accreditation to the Public Health Accreditation Board (PHAB) by January 1, 2014. With respect to the first difference, for this cycle, there was greater utilization of students both from the Masters in Public Health program and from Upstate Medical University, which provided additional opportunities for in depth, comprehensive analyses of the information as well as another perspective from the community. Furthermore, there was greater opportunity for community participation as a PowerPoint presentation of an initial Community Health Assessment was developed and used in Ground Round presentations as well as in community presentations. This also allowed for greater transparency of the process and more opportunity for feedback. This presentation is considered to be a living document that has already been significantly revised. It will continue to be revised as new data on health indicators become available. Finally, while the process is not yet complete, the OCHD has engaged medical students to develop a Prezi presentation, The Tree of Health (Appendix 12) which will provide another opportunity to engage community partners. Once complete, this presentation will be available on the OCHD website to increase accessibility to the information. With respect to the second difference, the integration of the guidance from the NYSDOH and a review of some of the examples on the Chronic Disease fact sheets led to the development of more specific and measurable outcomes for the next four years. One of the greatest lessons learned from the last CHA/Prevention Agenda cycle was that while there was a great deal of community input, particularly from the local hospitals, in retrospect there was not enough time spent developing more concrete and measurable strategies to implement the ideas gathered from the community. As stated earlier, the OCHD is planning to submit a letter of intent to PHAB by January 1, 2014. Because PHAB accreditation requires a Community Health Assessment, a Community Health Improvement Plan, and a Strategic Plan, the OCHD leadership felt that it would be efficient and effective to coordinate the PHAB requirements and the NYSDOH CHA/CHIP requirements. The Strategic Plan provides another tool to increase the likelihood of success in systematizing OCHD program implementation and evaluation. By integrating Prevention Agenda focus areas, goals, and objectives into the Strategic Plan, the OCHD hopes to achieve success in many Prevention Agenda tracking indicators. A sample of the OCHD draft plan with such integration was provided on page 57. 77

The Onondaga County Community Health Assessment and Improvement Plan, 2014 2017. Sustainability of Community Engagement The OCHD is fortunate to work in a community in which collaboration is an integral part of the culture. As per the above, all of the initiatives have an existing committee structure with routine ongoing meetings. All elements of the CHIP, including the outcome/performance measures, have been reviewed and approved by leaders on the committees. Because the Onondaga County Health Department has a presence with all of the coalitions, OCHD staff members will be accountable to ensuring progress continues to be made. Although the OCHD is not the lead on many of the committees, if any of the committees stalls, it will be responsible for earning buy in to convene a special meeting to re evaluate and make mid course corrections as necessary. In addition to the committee structure, the OCHD is dedicated to ensuring transparency. The CHA and the CHIP will be disseminated through social media (OCHD s website, Facebook, and other venues). This type of public transparency will encourage progress which in turn will encourage engagement of our community partners. Finally, because the CHA and the CHIP will be linked with the PHAB accreditation process, additional requirements for documentation about processes and performance management will ensure accountability for and sustainability of the current plan. 78

Appendix 1.a Priority Area: Preventing Chronic Diseases Indicator * Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective Cardiovascular disease Hospitalization rate (per 10,000) 128.9 159.9 150.9 Mortality rate (per 100,000) 205.5 242.3 237.9 Pretransport mortality (per 100,000) 137.2 144.2 157.1 Premature death per 100,000 (ages 35-64) Diseases of the heart 89.6 100.0 94.7 Hospitalization rate (per 10,000) 83.4 107.9 103.3 Mortality rate (per 100,000) 150.9 198.6 190.4 193.6 Pretransport mortality (per 100,000) 102.5 124.7 130.2 Premature death rate per 100,000 (ages 35-64) Coronary heart disease 69.6 81.2 77.3 Hospitalization rate (per 10,000) 28.2 43.0 39.7 Mortality rate (per 100,000) 103.8 160.4 139.8 116.1 100.8 Pretransport mortality (per 100,000) 75.2 104.0 98.7 Premature death rate per 100,000 (ages 35-64) Congestive heart failure 51.2 66.5 58.9 Hospitalization rate (per 10,000) 23.6 27.6 25.7 Mortality rate (per 100,000) 11.2 11.2 15.3 No change Pretransport mortality (per 100,000) 6.9 7.2 11.0 No change Premature death rate per 100,000 (ages 35-64) Cerebrovascular disease 0.9 1.5 2.0 No change Hospitalization rate (per 10,000) 23.9 24.9 25.0 Mortality rate (per 100,000) 35.2 26.9 31.4 41.9 33.8 Pretransport mortality (per 100,000) 22.1 11.3 16.8 Premature death rate per 100,000 (ages 35-64) 12.1 10.7 10.5 Hypertension Hospitalization rate (per 10,000) 2.6 6.6 4.5 % of adults ever told they have high blood pressure 27.7 28.3 27.1 29.9 26.9

Indicator Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective Heart attack / Cholesterol % of adults with physician diagnosed angina, heart attack or stroke Age-adjusted heart attack hospitalization rate per 10,000 (2010) 7.0 7.6 7.2 % adults with high cholesterol 45.5 40.5 13.5 15.5 14.0 % of adults with cholesterol checked in the last 5 years 82.6 77.3 79.3 74.6 82.1 Cirrhosis Hospitalization rate (per 10,000) 2.2 2.6 2.2 No change Mortality rate (per 100,000) 6.6 6.4 6.7 No change Diabetes Hospitalization rate per 10,000 (primary dx) 13.5 18.8 14.4 Hospitalization rate per 10,000 (any dx) 188.0 226.0 197.8 Hospitalization rate per 10,000 for short-term complications Ages 6-17 years Hospitalization rate per 10,000 for short-term complications Ages 18+ years 3.5 3.2 No change 3.06 5.6 5.6 4.86 Mortality rate (per 100,000) 15.9 17.0 15.1 % of adults with a diabetes test within the past 3 years % of adults with physician diagnosed diabetes Adult obesity % of adults who are overweight or obese (BMI 25) 58.9 59.6 13.9 9.4 8.5 55.5 59.3 60.6 % of adults who are obese (BMI 30) 20.0 26.2 24.3 33.9 30.5 23.2 % of pregnant women in WIC who were pre-pregnancy obese 27.5 23.4 26.7

Indicator Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective Nutrition and physical activity % of adults eating 5 fruits or vegetables per day % of adults who consume sugarsweetened drinks one time per day % of adults who participated in leisure time physical activity in the last 30 days 33.7 27.1 27.7 21.7 23.2 83.6 75.3 78.9 % of adults with some form of arthritis 39.4 24.2 % of adults with disability 30.1 20.9 Child obesity % of students who are obese 16.1 17.6 % obese elementary students 15.6 17.2 16.7 (NYS excl. NYC) % obese middle/high school students 16.7 18.2 % obese children in WIC (2-4 yrs) 13.7 14.4 15.3 No change % children in WIC viewing 2 hours or less of TV per day % students in 7 th, 9 th and 11 th grades who report exercising vigorously at least most days 87.3 79.1 80.7 62.6 Indicator Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective All cancer Incidence rate (per 100,000) 544.2 499.9 522.6 443.1 Mortality rate (per 100,000) 181.4 162.5 170.3 178.4 160.6 Lip, oral cavity and pharynx cancer Incidence rate (per 100,000) 12.2 10.5 10.9 10.3 Mortality rate (per 100,000) 2.2 2.1 2.0 2.4 2.3 Colon and rectum cancer Incidence rate (per 100,000) 40.5 44.7 44.3 40.5 Mortality rate (per 100,000) 14.0 15.4 14.9 16.7 14.5

Lung and bronchus cancer Incidence rate (per 100,000) 82.5 63.6 71.0 52.4 Mortality rate (per 100,000) 54.4 42.3 47.6 50.6 45.5 Indicator Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective Female breast cancer Incidence rate (per 100,000) 125.6 127.8 134.3 122.4 Late-stage incidence rate (per 100,000) 4.7 6.9 6.6 43.2 41.0 No change Mortality rate (per 100,000) 21.3 21.6 21.7 22.3 20.6 Cervix uteri cancer Incidence rate (per 100,000) 7.3 8.3 7.4 7.1 Mortality rate (per 100,000) 1.5 2.3 1.9 2.3 2.2 No change Ovarian cancer Incidence rate (per 100,000) 14.1 12.9 13.2 12.3 No change Mortality rate (per 100,000) 9.3 7.8 8.3 8.2 No change Prostate cancer Incidence rate (per 100,000) 204.7 159.7 161.1 140.1 Late-stage incidence rate (per 100,000) 6.9 7.0 6.5 No change Mortality rate (per 100,000) 19.9 21.1 19.6 22.0 21.2 No change Melanoma cancer Mortality rate (per 100,000) 2.3 2.2 2.7 2.8 2.4 Cancer screening % women 18 years with pap smear in past 3 years 89.4 82.7 82.6 % women 40 years with mammography in past 2 years 87.5 79.7 81.9 67.1 % women aged 50-74 who had a mammogram within the past 2 years 93.9 81.6 % of adults age 50-75 years who receive a colorectal cancer screening based on the most recent guidelines 86.0 65.7 71.4

Indicator Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective Chronic lower respiratory disease Hospitalization rate (per 10,000) 25.6 37.0 31.5 No change Mortality rate (per 100,000) 39.3 31.0 37.6 No change Asthma Hospitalization rate per 10,000 (all ages) 8.3 19.9 12.3 No change Ages 0-4 years 20.9 56.8 35.0 41.4 18.1 No change Ages 5-14 years 6.3 20.8 11.3 No change Ages 0-17 years 9.6 28.3 15.9 No change Ages 5-64 years 6.6 15.1 9.4 11.1 8.6 No change Ages 15-24 years 3.1 7.4 4.1 Ages 25-44 years 6.6 10.1 7.9 No change Ages 45-64 years 8.8 21.6 12.6 Ages 65 years or older 12.2 32.0 19.0 25.3 20.3 Emergency department visits per 10,000 43.3 83.7 75.1 Emergency department visits per 10,000 (Ages 0-4 years) 134.3 221.4 132.8 95.6 196.5 Mortality rate (per 100,000) 0.8 1.2 0.7 1.1 % of adults with current asthma 8.7 10.0 10.1 *See the Technical Notes table for more information on data sources and years. The Onondaga County rate is statistically significantly different than the NYS rate. The Onondaga County rate is statistically significantly different than the NYS Exc. NYC rate.

Appendix 1.b Priority Area: Promoting a Healthy and Safe Environment Indicator * Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective Injury Hospitalizations due to falls per 10,000, ages 65+ Emergency department visits due to falls per 10,000, ages 1-4 Unintentional injury mortality (per 100,000) Unintentional injury hospitalizations (per 10,000) 173.7 204.6 Maintain 408.0 476.8 429.1 31.1 22.7 26.9 38.2 36.0 46.1 64.0 64.1 50.6 Poisoning hospitalizations (per 10,000) 12.1 10.4 10.6 8.9 Motor vehicle mortality (per 100,000) 8.0 6.0 8.0 12.0 12.4 No change Traumatic brain injury hospitalizations (per 10,000) 8.0 9.4 9.3 8.6 7.7 Occupational health Work-related hospitalizations (per 100,000) 214.3 171.9 215.6 Fatal work-related injuries (per 100,000) 3.5 2.3 2.6 4.0 3.6 Elevated blood lead levels ( 10 mcg/dl) in employed persons aged 16+ (per 100,000) Crime Assault-related hospitalizations (per 10,000) Ratio of Black non-hispanics to White non- Hispanics Ratio of Hispanics to White non-hispanics Ratio of low income zip codes to non-low income zip codes 11.8 23.6 24.2 3.5 9.36 4.02 7.47 4.5 7.43 3.06 Homicides (per 100,000) 5.0 4.3 3.0 Firearm related crimes (per 100,000) 7.3 NA 3.25 2.7 3.3 4.3 Property crimes (per 100,000) 253.2 190.0 Violent crimes (per 100,000) 37.5 40.5

Environment % of population that lives in a jurisdiction that adopted the Climate Smart Communities pledge % of commuters who use alternate modes of transportation % of population with low-income and low access to a supermarket or large grocery store % of homes in Healthy Neighborhood Program that have fewer asthma triggers during home revisits % of residents served by community water systems with optimally fluoridated water 100.0 26.7 32.0 19.4 44.6 5.5 2.5 2.24 0.0 12.9 20.0 99.6 71.4 78.5 *See the Technical Notes table for more information on data sources and years. The Onondaga County rate is statistically significantly different than the NYS rate. The Onondaga County rate is statistically significantly different than the NYS Exc. NYC rate.

Appendix 1.c Priority Area: Promoting Healthy Women, Infants and Children Indicator * Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective Family planning / Natality % of births within 24 months of previous pregnancy 24.4 18.9 21.1 No change 17.0 % of births to teens Aged 15-17 years Aged 15-19 years 2.5 County 4.9 - Syracuse 8.8 1.8 6.2 1.8 6.5 No change % of births to women aged 35 and older 14.0 19.8 18.9 Fertility rate per 1,000 females Total Age 10-14 years Age 15-17 years Age 15-19 years Age 18-19 years Pregnancy rate per 1,000 females Total Age 10-14 years Age 15-17 years Ratio of Black non-hispanics to White non- Hispanics Ratio of Hispanics to White non-hispanics Age 15-19 years Age 18-19 years % of unintended pregnancy among live births Ratio of Black non-hispanics to White non- Hispanics Ratio of Hispanics to White non-hispanics Ratio of Medicaid births to non-medicaid births Abortions per 100 live births Total Age 15-19 years Pregnancy % of births with early (1 st trimester) prenatal care % of pregnant women in WIC with early (1 st trimester) prenatal care % of births with late (3 rd trimester) or no prenatal care 57.8 0.5 14.0 26.4 41.2 77.9 1.1 26.2 4.98 4.82 44.8 66.8 36.7 2.02 1.65 2.28 60.3 0.3 11.2 22.7 38.7 92.0 1.3 28.5 5.74 5.16 50.2 80.3 31.1 2.09 1.58 1.69 30.9 67.3 45.1 114.1 76.8 County 67.7 - Syracuse 57.8 0.3 9.2 19.8 34.1 75.5 0.7 18.3 34.6 56.8 26.1 71.4 No change No change 40.2 36.2 25.6 4.90 4.10 117.7 105.9 49.0 44.0 24.2 No change 72.4 74.3 70.8 77.9 No change 86.7 85.6 86.1 No change 3.5 5.6 4.1 1.88 1.36 1.56

Indicator * Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective % of births with early and adequate prenatal care 77.2 65.9 67.6 70.5 77.6 % of pregnant women in WIC with gestational diabetes 4.0 5.4 5.7 % of pregnant women in WIC with hypertension during pregnancy 8.9 7.2 9.0 % women who smoke during pregnancy 17.4 County 24.3 Syracuse 10.4 1.4 % women who report alcohol use during pregnancy 0.9 County 1.3 Syracuse % women who report illegal drug use during pregnancy 5.0 County 8.8 Syracuse Birth outcomes % of pre-term births 10.7 11.6 11.1 12.7 11.4 10.2 Ratio of Black non-hispanics to White non- Hispanics Ratio of Hispanics to White non-hispanics Ratio of Medicaid births to non-medicaid births 1.46 1.15 1.12 1.61 1.25 1.10 1.42 1.12 1.00 Less than 32 weeks gestation 32 less than 37 weeks gestation Birthweight % very low birthweight births % very low birthweight singleton births % low birthweight births % low birthweight singleton births Infant mortality (per 1,000 live births) Neonatal Post-neonatal Perinatal Fetal death % of births with a 5 minute APGAR less than 6 % of births delivered by cesarean section Newborn drug-related discharges (per 10,000 newborn discharges) Maternal mortality (per 100,000 live births) 2.0 8.8 1.6 1.3 8.2 6.2 6.4 4.4 2.0 6.8 7.0 1.9 9.6 1.5 1.1 8.2 6.2 5.1 3.5 1.6 5.5 6.9 1.9 9.2 1.5 1.0 7.8 5.7 5.6 4.0 1.6 5.5 4.6 2.0 1.5 8.2 6.7 4.5 2.2 6.6 6.2 1.8 1.4 7.8 6.0 4.1 2.0 5.9 5.6 No change No change No change No change No change No change No change 0.9 0.6 0.7 No change 32.0 34.4 36.0 248.3 72.6 89.6 12.3 22.4 19.3 12.7 11.4 No change 21.0

Indicator * Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective Socioeconomic risk factors % of births paid by Medicaid 43.1 County 68.5 Syracuse 48.6 38.2 No change % of births to women aged 25 years and older without a high school education 10.5 14.6 10.4 % of births to out-of-wedlock mothers 46.5 41.5 38.2 % of births to women enrolled in WIC 48.6 County 73.2 Syracuse No change % of women with healthcare coverage ages 18-64 Breastfeeding % of infants fed any breast milk in delivery hospital % infants fed exclusively breast milk in delivery hospital Ratio of Black non-hispanics to White non- Hispanics Ratio of Hispanics to White non-hispanics Ratio of Medicaid births to non-medicaid births % WIC mothers breastfeeding at least 6 months 88.7 86.1 100.0 68.4 77.8 72.6 54.9 0.45 0.63 0.54 40.5 0.50 0.55 0.57 49.2 No change 48.1 17.9 38.3 27.9 0.57 0.64 0.66 Child health % of children who have had the recommended number of well child visits in government sponsored insurance programs 66.9 69.9 76.9 Ages 0 15 months Ages 3 6 years Ages 12 21 years % of children with any kind of health insurance Ages 0 19 years % of third-grade children with evidence of untreated tooth decay 83.0 78.3 58.0 82.8 82.8 61.0 95.4 94.9 100.0 24.9 24.0 91.3 91.3 67.1 21.6 Ratio of low income to non-low income children 4.68 2.46 2.21

Indicator * Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective Childhood mortality (per 100,000) Age 1 4 years 18.4 19.5 21.2 28.6 25.7 Age 5 9 years 9.4 10.2 10.0 13.7 12.3 No change Age 10 14 years 11.0 12.1 12.4 16.9 15.2 No change Age 5 14 years 10.2 11.2 11.2 Age 15 19 years 36.4 37.9 38.5 61.9 55.7 Gastroenteritis hospitalizations per 10,000 (age 0 4 years) 5.3 13.8 10.1 Otitis media hospitalizations per 10,000 (ages 0 4 years) Pneumonia hospitalizations per 10,000 (ages 0 4 years) % of children born in 2008 with a lead screening by 9 months % of children born in 2008 with a lead screening between 9 months to < 18 months % of children born in 2008 with a least two lead screenings by 36 months Incidence of confirmed high blood lead level (10mcg/dL or higher) per 1,000 children tested (age <72 months) 2.3 3.2 2.7 28.2 45.1 36.9 1.1 6.3 2.9 75.2 70.5 65.8 65.8 54.7 46.8 9.6 4.9 7.5 *See the Technical Notes table for more information on data sources and years. The Onondaga County rate is statistically significantly different than the NYS rate. The Onondaga County rate is statistically significantly different than the NYS Exc. NYC rate.

Appendix 1.d Birth Outcomes by Zip Code, Onondaga County, 2010-2012* Zip LBW (%) (<2500g) VLBW (%) (<1500g) Births age Births age Births age Born <37 10-14 15-17 18-19 weeks (%) Early PNC (%) No PNC (%) Medicaid paid (%) No HS diploma (%) Smoke - 1 st trimester (%) 13027 4.5 0.9 0.1 0.8 2.1 9.1 90.2 0.2 23.1 4.1 9.6 0.4 1.4 13029 4.0 1.5 0.0 0.7 5.4 10.9 90.2 0.0 29.7 6.2 16.3 0.4 2.9 13030 3.7 0.0 0.0 0.0 5.6 3.7 83.3 0.0 44.4 14.8 25.9 0.0 5.6 13031 4.8 2.4 0.0 0.5 3.1 9.4 85.1 0.0 18.1 2.4 8.9 1.0 2.2 13039 5.1 1.4 0.0 1.0 2.2 8.7 91.9 0.0 15.6 3.9 8.3 0.4 1.6 13041 6.3 1.5 0.0 0.2 1.7 9.4 92.1 0.0 14.2 2.7 6.8 0.0 0.5 13057 4.5 1.5 0.0 2.8 4.0 8.6 86.9 0.3 29.2 9.3 20.7 0.3 3.8 13060 5.1 1.3 0.0 0.0 1.3 6.3 89.9 0.0 41.8 13.9 20.3 0.0 3.8 13063 3.8 0.0 0.0 1.9 3.8 11.3 84.9 0.0 18.9 5.7 7.6 0.0 1.9 13066 5.7 1.2 0.0 0.4 0.8 8.8 90.5 0.0 11.5 4.6 5.3 1.2 1.2 13078 5.7 1.4 0.0 0.5 2.9 8.1 91.9 0.5 12.9 3.8 10.0 1.0 2.4 13080 0.0 0.0 0.0 1.6 4.8 1.6 90.5 0.0 22.2 9.5 12.7 1.6 4.8 13082 4.2 0.0 0.0 2.1 8.3 6.3 83.3 0.0 35.4 16.7 27.1 0.0 6.3 13084 3.6 1.4 0.0 0.7 2.8 9.2 87.2 0.0 27.0 6.4 12.8 0.0 0.7 13088 4.6 1.6 0.3 0.6 2.8 10.3 86.4 0.9 29.1 8.5 11.7 0.4 2.9 13090 5.0 1.3 0.0 0.5 4.0 7.6 90.6 0.1 25.0 4.9 11.1 0.4 1.4 13104 5.0 0.3 0.0 0.3 3.0 7.4 91.5 0.6 13.2 2.5 5.2 1.4 1.1 13108 5.5 0.7 0.0 0.7 1.4 9.6 92.5 0.0 17.1 3.4 10.3 1.4 2.7 13110 7.0 0.0 0.0 2.3 7.0 11.6 95.4 0.0 44.2 18.6 11.6 0.0 2.3 13112 5.4 0.0 0.0 0.0 7.1 8.9 82.1 1.8 33.9 5.4 16.1 1.8 1.8 13116 10.3 0.0 0.0 2.4 1.6 9.5 88.1 0.0 20.6 5.6 14.3 0.0 3.2 13120 4.4 0.0 0.0 2.7 8.0 4.4 73.5 0.9 56.6 13.3 26.5 0.9 7.1 13152 5.5 0.7 0.0 0.7 0.7 9.0 89.0 0.0 12.4 2.8 7.6 1.4 2.1 13159 6.3 1.1 0.0 0.0 5.3 14.7 87.4 1.0 25.3 5.3 13.7 0.0 2.1 13164 2.9 0.0 0.0 1.9 0.0 2.9 91.4 0.0 15.4 4.8 4.8 0.0 0.0 13202 8.2 0.7 0.3 4.5 11.0 8.9 67.8 0.7 84.9 51.4 21.6 0.7 7.9 13203 8.6 2.2 0.3 3.1 8.8 11.4 68.5 0.5 68.0 40.5 21.6 0.9 8.8 13204 8.5 2.0 0.3 6.5 12.2 9.3 67.8 1.9 77.5 41.0 30.9 1.2 11.7 13205 10.0 2.0 0.2 6.8 12.7 11.1 66.6 1.6 73.0 37.1 24.3 1.6 10.5 13206 8.7 1.7 0.0 2.5 5.4 10.0 80.0 0.3 46.3 17.0 20.2 1.6 6.0 13207 8.0 2.2 0.6 6.3 8.0 10.1 73.8 1.2 61.0 25.5 22.2 1.5 8.3 Alcohol use (%) Illegal drug use (%)

Zip LBW (%) (<2500g) VLBW (%) (<1500g) Births age Births age Births age Born <37 10-14 15-17 18-19 weeks (%) Early PNC (%) No PNC (%) Medicaid paid (%) No HS diploma (%) Smoke - 1 st trimester (%) 13208 6.7 1.6 0.2 3.7 9.5 9.0 66.6 1.2 71.4 45.0 28.0 0.5 10.8 13209 3.5 1.2 0.0 1.4 5.4 7.2 82.8 1.2 40.8 11.9 23.1 0.5 4.9 13210 7.0 2.0 0.0 0.8 5.5 8.6 75.3 1.1 52.3 22.7 10.5 1.0 5.5 13211 3.4 1.1 0.0 2.7 8.4 8.4 81.4 0.0 46.0 20.2 28.5 0.0 3.8 13212 5.2 1.4 0.0 1.4 4.4 9.1 87.3 1.1 29.3 10.0 15.2 0.6 2.2 13214 5.6 0.9 0.0 0.9 1.9 7.0 84.1 1.4 21.5 4.7 4.2 0.0 1.4 13215 4.5 1.0 0.0 1.3 1.3 7.0 88.5 0.3 14.7 3.8 8.6 1.0 1.9 13219 4.0 1.5 0.0 0.4 2.6 9.3 90.5 0.0 17.0 3.8 10.4 0.6 1.7 13224 9.0 1.9 0.0 2.8 10.2 10.8 76.9 0.9 52.8 19.4 13.3 0.6 6.5 County 6.3 1.5 0.1 2.4 5.9 9.2 80.8 0.7 42.3 18.5 16.9 0.8 5.2 Alcohol use (%) Illegal drug use (%) *Data are from the OCHD Bureau of Surveillance and Statistics. Data for 2011 and 2012 are preliminary. Births per 1,000 females in that age group

Appendix 1.e Priority Area: Promoting Mental Health and Preventing Substance Abuse Indicator * Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective Mental Health % of adults with poor mental health for 14 or more days in the last month 17.4 10.3 10.9 10.1 Suicides (per 100,000) 8.5 7.2 8.6 11.3 10.2 5.9 Self-inflicted injury hospitalizations (per 10,000) Self-inflicted injury hospitalizations per 10,000 (age 15-19) Substance Abuse % adult binge drinking during the past month Alcohol-related motor vehicle injury and death rate (per 100,000) % women who report alcohol use during pregnancy 8.2 5.3 6.5 15.1 10.1 11.6 21.9 14.8 19.8 27.1 24.4 18.4 46.1 34.8 47.8 0.9 County 1.3 Syracuse % adults who currently smoke cigarettes 19.3 16.0 18.9 20.6 12.0 % adults who currently live in homes where smoking is prohibited % women who smoke during pregnancy % students in 7 th, 9 th and 11 th grades who report ever smoking cigarettes Drug-related hospitalizations (per 10,000) Newborn drug-related hospitalizations (per 10,000 newborn discharges) 78.6 80.9 79.3 79.1 87.0 17.4 County 24.3 Syracuse 13.0 19.5 26.1 21.8 248.3 72.6 89.6 % women who report illegal drug use during pregnancy 5.0 County 8.8 Syracuse *See the Technical Notes table for more information on data sources and years. The Onondaga County rate is statistically significantly different than the NYS rate. The Onondaga County rate is statistically significantly different than the NYS Exc. NYC rate.

Appendix 1.f Priority Area: Preventing HIV/STDs, Vaccine Preventable Diseases and Healthcare-Associated Infections Indicator * Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective HIV / STDs HIV case rate (per 100,000) Difference in rates (Black and White) of new HIV diagnoses Difference in rates (Hispanic and White) of new HIV diagnoses 8.4 24.2-20.0 59.4 31.1 7.3 15.7 AIDS case rate (per 100,000) 5.4 15.2 5.2 13.8 12.4 AIDS mortality rate (per 100,000) 1.4 4.7 1.4 3.7 3.3 14.7 45.7 22.3 Gonorrhea case rate (per 100,000) Age 15-19 Women age 15-44 Men age 15-44 Chlamydia case rate Males (per 100,000) Chlamydia case rate Females (per 100,000) Age 15-19 Age 20-24 Age 15-19 Age 20-24 Age 15-44 188.4 631.7 505.2 349.3 332.7 1,128.8 1,730.5 698.3 3,805.9 3,492.0 1,687.5 95.8 362.0 203.4 221.7 323.0 1,077.1 1,484.3 674.0 3,773.9 3,344.7 1,619.8 54.4 200.7 190.0 614.2 1,009.1 445.8 2,417.2 2,542.6 103.0 256.9 803.0 1,343.3 648.9 3,416.5 3,722.5 183.1 199.5 1,458.0 Early syphilis case rate (per 100,000) 2.0 12.4 2.6 4.3 Primary and secondary syphilis case rate Males (per 100,000) Primary and secondary syphilis case rate Females (per 100,000) Pelvic inflammatory disease hospitalization rate per 10,000 females age 15-44 Vaccine-preventable diseases 2.7 11.2 10.1 0.0 0.5 0.4 2.1 3.5 2.4 Pertussis incidence rate (per 100,000) 12.4 4.2 5.7 6.1 Mumps incidence rate (per 100,000) 0.1 5.5 3.9 0.1 No change Meningococcal incidence rate (per 100,000) 0.1 0.2 0.2 0.3 Indicator * Onondaga County NYS NYS Exc. NYC US HP 2020 Onondaga Trend NYS 2017 Objective

H. influenza incidence rate (per 100,000) 2.3 1.5 1.6 1.2 Hepatitis A incidence rate (per 100,000) 0.2 0.7 0.5 0.5 No change Acute hepatitis B incidence rate (per 100,000) Hepatitis C screening rate per 100, age 47-68 0.6 0.7 0.5 0.9 No change 46.4 37.1 Shigella incidence rate (per 100,000) 53.3 7.2 7.4 4.3 Pneumonia / influenza hospitalization rate per 10,000 age 65 years and older % of adults aged 65 years and older with a flu shot in the last year % of adults who received their flu shot or spray in the past year % of adults aged 65 years and older who ever received a pneumonia shot % of adults who report ever having received a pneumonia shot % of children with 4:3:1:3:3:1:4 immunization series, age 19-35 months % of adolescent females with 3-dose HPV immunization, ages 13-17 years 161.3 122.3 132.7 82.4 75.0 66.6 90.0 66.2 54.3 48.2 83.0 64.7 71.2 60.1 90.0 40.0 31.0 59.8 47.6 80.0 35.8 26.0 50.0 *See the Technical Notes table for more information on data sources and years. The Onondaga County rate is statistically significantly different than the NYS rate. The Onondaga County rate is statistically significantly different than the NYS Exc. NYC rate.

Appendix 1.g CHA Data Table Technical Notes Preventing Chronic Disease Cardiovascular disease Hospitalization rate Hospitalizations due to cardiovascular disease per 10,000 population, 2009-2011. Mortality rate Pretransport mortality Premature death (ages 35-64) Deaths due to cardiovascular disease per 100,000 population, 2009-2011. Deaths due to cardiovascular disease that occurred any place other than a hospital, clinic or medical center per 100,000 population, 2009-2011. Deaths due to cardiovascular disease among persons age 35-64 years per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/chr_31.htm. Diseases of the heart Hospitalization rate Hospitalizations due to diseases of the heart per 10,000 population, 2009-2011. Mortality rate Pretransport mortality Premature death (ages 35-64) Coronary heart disease Deaths due to diseases of the heart per 100,000 population, 2009-2011. Deaths due to diseases of the heart that occurred any place other than a hospital, clinic or medical center per 100,000 population, 2009-2011. Deaths due to diseases of the heart among persons age 35-64 years per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/chr_31.htm. Data for the U.S. are from the NCHS National Vital Statistics Reports, Vol. 61, No. 4 (2010). Hospitalization rate Hospitalizations due to coronary heart disease per 10,000 population, 2009-2011. Mortality rate Pretransport mortality Premature death (ages 35-64) Deaths due to coronary heart disease per 100,000 population, 2009-2011. Deaths due to coronary heart disease that occurred any place other than a hospital, clinic or medical center per 100,000 population, 2009-2011. Deaths due to coronary heart disease among persons age 35-64 years per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/chr_31.htm. Data for the U.S. are from the National Vital Statistics System Mortality (NVSS-M), CDC/NCHS, 2007.

Congestive heart failure Hospitalization rate Hospitalizations due to congestive heart failure per 10,000 population, 2009-2011. Mortality rate Pretransport mortality Premature death (ages 35-64) Cerebrovascular disease Deaths due to congestive heart failure per 100,000 population, 2008-2009-2011. Deaths due to congestive heart failure that occurred any place other than a hospital, clinic or medical center per 100,000 population, 2009-2011. Deaths due to congestive heart failure among persons age 35-64 years per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/chr_31.htm. Premature death (ages 35-64) Hospitalizations due to cerebrovascular disease per 10,000 population, 2009-2011. Mortality rate Pretransport mortality Premature death (ages 35-64) Hypertension Deaths due to cerebrovascular disease per 100,000 population, 2009-2011. Deaths due to cerebrovascular disease that occurred any place other than a hospital, clinic or medical center per 100,000 population, 2009-2011. Deaths due to cerebrovascular disease among persons age 35-64 years per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/chr_31.htm. Data for the U.S. are from the NCHS National Vital Statistics Reports, Vol. 61, No. 4 (2010). Hospitalization rate Hospitalizations due to hypertension per 10,000 population, 2009-2011. % of adults ever told they have high blood pressure Heart attack / Cholesterol % of adults with physician diagnosed angina, heart attack or stroke Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/chr_31.htm. The percent of adults who report being told by a doctor, nurse, or other health professional of having high blood pressure. Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. Data for New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/chr_31.htm. The age-adjusted percent of adults with physician diagnosed angina, heart attack or stroke, 2008-2009. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community

Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/chr_31.htm. The original data source is the Expanded BRFSS, 2008-2009. Heart attack hospitalization rate Age-adjusted number of hospitalizations due to heart attack, 2010. Data for Onondaga County and New York State are available from NYS Prevention Agenda indicators at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/p27.htm. The original data source is SPARCS, 2010. % adults with high cholesterol The percent of adults who reporting being told by a doctor, nurse, or other health professional of having high cholesterol. % of adults with cholesterol checked in the last 5 years Cirrhosis Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. The age-adjusted percent of adults who have had their cholesterol checked in the last 5 years, 2008-2009. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/chr_31.htm. The original data source is the Expanded BRFSS, 2008-2009. Data for the U.S. are from the National Health Interview Survey (NHIS), CDC/NCHS, 2008. Hospitalization rate Age-adjusted hospitalizations due to cirrhosis per 10,000 population, 2009-2011. Mortality rate Diabetes Age-adjusted deaths due to cirrhosis per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/dia_31.htm. Hospitalization rate (primary dx) Age-adjusted hospitalizations with diabetes as the primary diagnosis per 10,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/dia_31.htm. Hospitalization rate (any dx) Age-adjusted hospitalizations with diabetes as any diagnosis per 10,000 population, 2009-2011. Hospitalization rate for short-term complications Ages 6-17 years Hospitalization rate for short-term complications Ages 18+ years Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/dia_31.htm. Age-adjusted hospitalizations for diabetes short-term complications per 10,000 population aged 6-17 years, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/dia_31.htm. Age-adjusted hospitalizations for diabetes short-term complications per 10,000 population aged 18 years and older, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/dia_31.htm.

Mortality rate Age-adjusted deaths due to diabetes per 100,000 population, 2009-2011. % of adults with a diabetes test within the past 3 years % of adults with physician diagnosed diabetes Adult obesity Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/dia_31.htm. Percent of adults having had a test for diabetes in the past 3 years. Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. The percent of adults who report being told of having diabetes (other than diabetes during pregnancy). Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. Data for New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/dia_31.htm. % of adults who are overweight or obese (BMI 25) % of adults who are obese (BMI 30) % of pregnant women in WIC who were pre-pregnancy obese Nutrition and physical activity % of adults eating 5 fruits or vegetables per day % of adults who consume sugarsweetened drinks one time per day % of adults who participated in leisure time physical activity in the last 30 days The percentage of adults with body mass index (BMI) of 25 or greater, 2008-2009. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/obs_31.htm. The original data source is the Expanded BRFSS, 2008-2009. The percentage of adults with body mass index (BMI) of 30 or greater. Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. Data for New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/obs_31.htm. Data for the U.S. are from the National Health and Nutrition Examination Survey (NHANES), CDC/NCHS, 2005-2008. The percentage of pregnant women in the WIC program with a pre-pregnancy BMI of 30 or greater, 2010-2012. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/obs_31.htm. The age-adjusted percent of adults eating 5 or more fruits or vegetables per day, 2008-2009. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/obs_31.htm. The original data source is the Expanded BRFSS, 2008-2009. The percentage of adults who consume regular soda or other sugar-sweetened drinks (fruit drinks, sweet tea, and sports or energy drinks) at least one or more times per day. Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. The percentage of adults who participated in leisure time physical activities for exercise in the past month. Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. Data for New York State

Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/obs_31.htm. % of adults with some form of The percentage of adults who report being told of having some form of arthritis. arthritis Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. % of adults with disability The percentage of adults who report activity limitations due to physical, mental, or emotional problems or having health problems that require the use of special equipment. Child obesity Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. % of students who are obese The percentage of all students (Pre-K, K, 2 nd, 4 th, 7 th, and 10 th grades) attending public schools with a BMI at or above the 95 th percentile. Data for Onondaga County and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/obs_31.htm. The original data source is the Student Weight Status Category Reporting System (SWSCR), 2010-2012. % obese elementary students The percentage of all elementary students (Pre-K, K, 2 nd and 4 th grades) attending public schools with a BMI at or above the 95 th percentile. % obese middle/high school students Data for Onondaga County and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/obs_31.htm. The original data source is the Student Weight Status Category Reporting System (SWSCR), 2010-2012. The percentage of all middle/high school students (7 th and 10 th grades) attending public schools with a BMI at or above the 95 th percentile. Data for Onondaga County and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/obs_31.htm. The original data source is the Student Weight Status Category Reporting System (SWSCR), 2010-2012. % obese children in WIC (2-4 yrs) Children ages 2-4 years participating in the WIC program whose weight was at or above the 95 th percentile based on BMI-for-age. % children in WIC viewing 2 hours or less of TV per day Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/obs_31.htm. The original data source is the NYS Pediatric Nutrition Surveillance System (PedNSS) WIC program, 2010-2012 The percent of children ages 2-4 years enrolled in WIC who watched TV for 2 hours or less per day. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/obs_31.htm. The original data source is the NYS Pediatric Nutrition Surveillance System (PedNSS) WIC program, 2009-2011

% students in 7 th, 9 th and 11 th grades who report exercising vigorously at least most days The percent of students in 7 th, 9 th and 11 th grade who report exercising vigorously most days, nearly every day or every day, Onondaga County, 2012-2013 Data are available from the New York State Youth Development Survey, 2012-2013 Onondaga County Schools: http://www.preventionnetworkcny.org/index.php/youth. Cancer indicators Incidence rate Age-adjusted new cancer cases per 100,000 population, 2008-2010. Late-stage incidence rate Mortality rate Cancer screening % women 18 years with Pap smear in past 3 years % women 40 years with mammography in past 2 years % women aged 50-74 who had a mammogram within the past 2 years % of adults who receive a colorectal cancer screening based on the most recent guidelines Age-adjusted new cancer cases per 100,000 population, where the cancer has already spread to distant lymph nodes or other organs at the time of diagnosis, 2008-2010. Age-adjusted cancer deaths per 100,000 population, 2008-2010. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/can_31.htm. The original data source is the NYS Cancer Registry. U.S. incidence data are from the National Cancer Institute Surveillance, Epidemiology and End Results (SEER) Program, 2010. U.S. mortality and late-stage incidence data are from the National Vital Statistics System Mortality (NVSS-M), CDC/NCHS, 2007. Age-adjusted percent of women 18 years and older with a Pap smear in the past 3 years, 2008-2009. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/can_31.htm. The original data source is the Expanded BRFSS, 2008-2009. Age-adjusted percent of women age 40 and older with mammography in the past 2 years, 2008-2009. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/can_31.htm. The original data source is the Expanded BRFSS, 2008-2009. The percentage of women aged 50-74 years who received a breast cancer screening based on the most recent clinical guidelines (mammography within the past 2 years). Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. The percentage of adults aged 50-75 years who received a colorectal cancer screening based on the most recent clinical guidelines (blood stool test in the past year; or sigmoidoscopy in the past 5 years and a blood stool test in the past 3 years; or a colonoscopy in the past 10 years). Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014.

Chronic lower respiratory disease Hospitalization rate Age-adjusted hospitalizations due to chronic lower respiratory disease per 10,000 population, 2009-2011. Mortality rate Asthma Age-adjusted deaths due to chronic lower respiratory disease per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/res_31.htm. Hospitalization rate Asthma hospitalizations by age group per 10,000 population in that age group, 2009-2011. Age 0-4 years Age 5-14 years Age 0-17 years Age 5-64 years Age 15-24 years Age 25-44 years Age 45-64 years Age 65 years or older Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/res_31.htm. U.S. data are from the National Hospital Discharge Survey (NHDS), CDC/NCHS, 2007. Emergency department visits Emergency department visits per 10,000 population, 2009-2011. Emergency department visits (ages 0-4 years) Data are available from the Onondaga County Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm, and were originally collected through the Statewide Planning and Research Cooperative System (SPARCS). Mortality rate Asthma mortality rate per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/res_31.htm. U.S. data are from the National Center for Health Statistics, Final Death Data, 2010, available at: http://www.cdc.gov/nchs/deaths.htm. % of adults with current asthma The percentage of adults who report currently having diagnosed asthma. Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. Data for New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/res_31.htm

Promoting a Healthy and Safe Environment Injury Hospitalization rate due to falls, ages 65+ Emergency department visits due to falls, ages 1-4 years The number of hospitalizations (inpatient, ages 65 years and older) with primary diagnosis external cause of injury codes E880-E888 (excluding E887), per 10,000 population age 65 and older, 2008-2010. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. The number of emergency department visits (ages 1-4 years) with primary diagnosis external cause of injury codes E880-E888 (excluding E887), per 10,000 population ages 1-4 years, 2008-2010. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. Unintentional injury mortality The number of deaths due to unintentional injury per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/inj_31.htm. Data for the U.S. are from the National Vital Statistics System-Mortality (NVSS-M), CDC/NCHS, 2007. Unintentional injury hospitalizations The number of hospitalizations due to unintentional injury per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/inj_31.htm. Data for the U.S. are from the National Hospital Discharge Survey (NHDS), CDC/NCHS, 2007. Poisoning hospitalization rate The number of hospitalizations due to poisoning-related injury per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/inj_31.htm. Data for the U.S. are from the National Hospital Discharge Survey (NHDS), CDC/NCHS, 2007. Motor vehicle mortality The number of deaths due to motor vehicle injury per 100,000 population, 2009-2011. Traumatic brain injury hospitalization rate Occupational health Work-related hospitalizations Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/inj_31.htm. Data for the U.S. are from the National Hospital Discharge Survey (NHDS), CDC/NCHS, 2007. The number of hospitalizations due to traumatic brain injury per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/inj_31.htm. Data for the U.S. are from the National Hospital Discharge Survey (NHDS), CDC/NCHS, 2007. The number of hospital discharges with primary payor coded as workers compensation for persons age 16 years or older, per 100,000 employed persons age 16 years or older, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/occ_31.htm.

Fatal work-related injuries Elevated blood lead levels ( 10 mcg/dl) in employed persons aged 16 years and older Crime Assault-related hospitalizations The number of fatal work-related injuries reported to CFOI, per 100,000 employed persons age 16 years or older. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/occ_31.htm. Data for the U.S. are from the Census of Fatal Occupational Injuries (CFOI), DOL/BLS; Current Population Survey, Census, 2007. The number of residents, age 16 years or older with a blood lead level 10 mcg/dl, per 100,000 employed persons age 16 years and older, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/occ_31.htm. The age-adjusted number of hospitalizations with primary diagnosis external cause of injury codes E960-E968 per 10,000 population, 2009-2011. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. Data for New York State Excluding New York City can be found at: http://www.health.ny.gov/statistics/chac/chai/docs/inj_31.htm. Data for the U.S. are from the National Hospital Discharge Survey (NHDS), CDC/NCHS, 2007. Homicides The age-adjusted number of deaths due to homicide per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City can be found at: http://www.health.ny.gov/statistics/chac/chai/docs/inj_31.htm. Firearm related crimes The number of firearms-related crimes known to the police per 10,000 population, 2012 Data for Onondaga County are available from the NYS Division of Criminal Justice Services; Uniform Crime Report (UCR), 2012 Property crimes The number of property-related crimes known to the police per 10,000 population, 2012 Data for Onondaga County are available from the NYS Division of Criminal Justice Services; Uniform Crime Report (UCR), 2012 Violent crimes The number of violent crimes known to the police per 10,000 population, 2012 % of population that lives in a jurisdiction that adopted the Climate Smart Communities pledge % of commuters who use alternate modes of transportation % of population with low-income and low access to a supermarket or large grocery store Data for Onondaga County are available from the NYS Division of Criminal Justice Services; Uniform Crime Report (UCR), 2012 The percentage of people who live in a jurisdiction that adopted the Climate Smart Communities pledge, 2012. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. The percentage of commuters who use public transportation, carpool, bike, walk or telecommute to get to work, 2007-2011. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. The percentage of population with low-income and low-access to a supermarket or large grocery store, 2010. Low access is defined as greater than one mile from a supermarket or grocery store in urban areas, and greater than 10 miles from a supermarket or grocery store in rural areas.

% of homes in Healthy Neighborhood Program that have fewer asthma triggers during home revisits % of residents served by community water systems with optimally fluoridated water Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. Data are originally from the USDA Food Environment Atlas. The percentage of homes in Healthy Neighborhood Program that have fewer asthma triggers during home revisits, 2008-2011. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. The rate for Onondaga County is unstable, as there are fewer than 10 events in the numerator. The percentage of residents served by community water systems with optimally fluoridated water, 2012. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. Data are originally from the National Water Fluoridation Statistics. Promoting Healthy Women, Infants and Children Family Planning / Natality % of births within 24 months of previous pregnancy % of births to teens The percentage of total births to women who had had a previous pregnancy within 24 months of the current birth, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/fp_31.htm. The percentage of total births to females in the specified age groups, 2009-2011. % of births to women aged 35 and older Data for Onondaga County and Syracuse are reported from the OCHD Bureau of Surveillance and Statistics. Data were accessed from the Statewide Perinatal Data System. Data from 2011 are provisional. Data for New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/fp_31.htm. Fertility rate per 1,000 females The number of live births per year per 1,000 female population in the specified age groups, 2009-2011. Pregnancy rate per 1,000 females % of unintended pregnancy among live births Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/fp_31.htm. The number of pregnancies in a specified age group per 1,000 females in that group. Pregnancy is defined as the sum of all live births, induced terminations and fetal deaths. U.S. data are from the Guttmacher Institute Abortion Provider Survey (APS), Guttmacher Institute; Surveillance Data for Abortion, CDC/NCCDPHP; National Survey of Family Growth (NSFG), CDC/NCHS; National Vital Statistics System Natality (NVSS-N), CDC/NCHS, 2005. The number of unintended pregnancies among live pregnancies with known pregnancy intendedness, 2011. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. U.S. data are from the Guttmacher Institute Abortion Provider Survey (APS), Guttmacher Institute; Surveillance Data for Abortion, CDC/NCCDPHP; National

Survey of Family Growth (NSFG), CDC/NCHS; National Vital Statistics System Natality (NVSS-N), CDC/NCHS, 2005. Abortions per 100 live births The number of induced abortions per 100 live births in a specified age group, 2009-2011. Pregnancy % of births with early (1 st trimester) prenatal care % of pregnant women in WIC with early (1 st trimester) prenatal care % of births with late (3 rd trimester) or no prenatal care % of births with adequate prenatal care (Kotelchuck) Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/fp_31.htm. The percentage of births (excluding births without a known prenatal care start date) that began prenatal care within the first three months of pregnancy, 2009-2011. Data for Onondaga County and Syracuse are reported from the OCHD Bureau of Surveillance and Statistics. Data were accessed from the Statewide Perinatal Data System. Data from 2011 are provisional. Data for New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. Data for the U.S. are from the National Vital Statistics System Natality (NVSS-N), CDC/NCHS, 2007. The percentage of WIC program enrolled women giving birth who had their first prenatal care visit within the first three months of pregnancy, 2008-2010. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. The original data source is the NYS Pediatric Nutrition Surveillance System (PedNSS) WIC program. The percentage of births (excluding births without a known prenatal care start date) that began prenatal care during the last three months of pregnancy or not at all, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. The percentage of births to women who began care in the first trimester and have completed at least 80% of the expected prenatal visits, based on the Kotelchuck Index, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. % of pregnant women in WIC with gestational diabetes % of pregnant women in WIC with hypertension during pregnancy Data for the U.S. are from the National Vital Statistics System Natality (NVSS-N), CDC/NCHS, 2007. The percentage of WIC enrolled women who were diagnosed with gestational diabetes, 2008-2010. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. The original data source is the NYS Pediatric Nutrition Surveillance System (PedNSS) WIC program. The percentage of WIC enrolled women who were diagnosed with hypertension during pregnancy, 2008-2010. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. The original data source is the NYS Pediatric Nutrition Surveillance System (PedNSS) WIC program.

% women who smoke during pregnancy % women who report alcohol use during pregnancy % women who report illegal drug use during pregnancy The percentage of women who self-report cigarette use during pregnancy, Onondaga County and Syracuse, 2009-2011 Data for Onondaga County and Syracuse are reported from the OCHD Bureau of Surveillance and Statistics. Data were accessed from the Statewide Perinatal Data System. Data from 2011 are provisional. Data for the U.S. are from the National Vital Statistics System Natality (NVSS-N), CDC/NCHS, 2007. The percentage of women who self-report alcohol use during pregnancy, Onondaga County and Syracuse, 2009-2011 Data for Onondaga County and Syracuse are reported from the OCHD Bureau of Surveillance and Statistics. Data were accessed from the Statewide Perinatal Data System. Data from 2011 are provisional. The percentage of women who self-report illegal drug use during pregnancy, Onondaga County and Syracuse, 2009-2011. Data for Onondaga County and Syracuse are reported from the OCHD Bureau of Surveillance and Statistics. Data were accessed from the Statewide Perinatal Data System. Data from 2011 are provisional. Birth outcomes % of pre-term births The percentage of infants with known gestation born before 37 weeks; before 32 weeks; and between 32-36 weeks, 2009-2011. Birthweight Infant mortality Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. Data for the U.S. are from the National Vital Statistics System Natality (NVSS-N), CDC/NCHS, 2007. The percentage of infants born weighing less than 2500 grams (lbw) or less than 1500 grams (vlbw), 2009-2011. Singleton births include births with only one baby. Otherwise, multiple births are included. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. Data for the U.S. are from the National Vital Statistics System Natality (NVSS-N), CDC/NCHS, 2007. The number of deaths among infants less than 1 year of age per 1,000 live births, 2009-2011. Neonatal Post-neonatal Perinatal Fetal death % of births with a 5 minute APGAR less than 6 The number of deaths among infants less than 28 days old per 1,000 live births. The number of deaths among infants between 28 days and less than one year of age per 1,000 live births. The number of deaths in the first 7 days of life and spontaneous fetal deaths of gestation 28 weeks or more plus live births. The number of spontaneous fetal deaths (gestation 20 weeks or more) per 1,000 spontaneous fetal deaths (gestation 20 weeks or more) plus live births. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. Data for the U.S. are from the National Vital Statistics System Natality (NVSS-N); National Vital Statistics System Fetal Death (NVSS-FD), CDC/NCHS; and the Linked Birth/Infant Death Data Set, 2005. The percentage of births with an APGAR score of less than 6 after the first 5 minutes of life. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm.

% of births delivered by cesarean The percentage of births delivered by cesarean section, 2009-2011. section Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. Newborn drug-related discharges Newborn drug-related hospitalizations per 10,000 newborn discharges, 2009-2011. Maternal mortality Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sub_31.htm. The number of deaths to women from any causes related to or aggravated by pregnancy or its management that occurred while pregnant or within 42 days of termination of pregnancy, per 100,000 live births, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. The Onondaga County rate is unstable due to fewer than 10 events in the numerator. Data for the U.S. are from the National Vital Statistics System Mortality (NVSS-M) and the National Vital Statistics System Natality (NVSS-N), CDC/NHCS, 2007. Socioeconomic risk factors % of births paid by Medicaid The percentage of births with Medicaid as the primary payor, 2009-2011. % of births to women aged 25 years and older without a high school education % of births to out-of-wedlock mothers % of births to women enrolled in WIC % of women with healthcare coverage ages 18-64 Breastfeeding % of infants fed any breast milk in delivery hospital Data for Onondaga County and Syracuse are reported from the OCHD Bureau of Surveillance and Statistics. Data were accessed from the Statewide Perinatal Data System. Data from 2011 are provisional. Data for New York State and New York State Excluding New York City are available from NYSDOH Vital Statistics at: http://www.health.ny.gov/statistics/vital_statistics/2011/table13.htm, 2011. The percentage of births that were born to women aged 25 and older without a high school education, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. The percentage of total births to women who were not married, 2009-2011. The number is derived from the number of births for which a mother reports that a paternity acknowledgement has been filed or births for which no father information is listed. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm The percentage of births to women enrolled in WIC, 2009-2011. Data for Onondaga County and Syracuse are reported from the OCHD Bureau of Surveillance and Statistics. Data were accessed from the Statewide Perinatal Data System. Data from 2011 are provisional. The percentage of survey respondents (females, 18-64 years of age) who reported that they had health insurance coverage, 2010. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. The percentage of births that were fed any breast milk in the delivery hospital (excludes infants admitted to the NICU or transferred in or out of the hospital, and infants with unknown method of feeding), 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm

% infants fed exclusively breast milk in delivery hospital % WIC mothers breastfeeding at least 6 months Child health % of children who have had the recommended number of well child visits in government sponsored insurance programs % of children with any kind of health insurance Ages 0 19 years % of third-grade children with evidence of untreated tooth decay Childhood mortality Age 1 4 years Age 5 9 years Age 10 14 years Age 5 14 years Age 15 19 years Gastroenteritis hospitalizations (age 0 4 years) Otitis media hospitalizations (ages 0 4 years) Pneumonia hospitalizations (ages 0 4 years) The percentage of infants exclusively fed breast milk in the hospital among infants with known breastfeeding status, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm The percentage of infants enrolled in WIC who were breastfed at 6 months. Only infants who turned 6 months of age during the reporting period were included, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm. The original data source is the NYS Pediatric Nutrition Surveillance System (PedNSS) WIC program. The percentage of children in the Medicaid and Child Health Plus programs who have had the recommended number of well-child visits, 2011. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. The percentage of survey respondents (ages 0-19 years) with any kind of health insurance covereage in the past 12 months, 2010. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. The percent of third-grade children with evidence of untreated tooth decay, as determined by a dental health professional, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/ora_31.htm. The number of deaths in a particular age group per 100,000 children in that age group, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/cah_31.htm. Data for the U.S. are from the National Vital Statistics System Mortality (NVSS-M), CDC/NHCS, 2007. The number of hospitalizations for gastroenteritis among children aged 0-4 years per 10,000 children ages 0-4 years, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/cah_31.htm. The number of hospitalizations for otitis media among children aged 0-4 years per 10,000 children ages 0-4 years, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/cah_31.htm. The number of hospitalizations for pneumonia among children aged 0-4 years per 10,000 children ages 0-4 years, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/cah_31.htm.

% of children born in 2008 with a lead screening by 9 months The percentages of children in a birth cohort screened for a high blood lead level at least once before 9 months, at least once before 18 months and at least twice before 36 months. % of children born in 2008 with a lead screening between 9 months to < 18 months % of children born in 2008 with a least two lead screenings by 36 months Incidence of confirmed high blood lead level (10mcg/dL or higher) per 1,000 children tested (age <72 months) Data for Onondaga County, New York State, and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/cah_31.htm The proportion of children newly identified with a confirmed elevated blood lead level of 10 mcg/dl or greater per 1,000 children among children < 72 months tested in a given time frame. Data for Onondaga County, New York State, and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/cah_31.htm Promoting Mental Health and Preventing Substance Abuse Mental health % of adults with poor mental health for 14 or more days in the last month The percentage of adults with poor mental health for 14 or more days in the last month. Data for Onondaga County and New York State are reported from the Expanded BRFSS Preliminary Report, 2013-2014. Data for New York State Excluding New York City are age-adjusted, and are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/ses_31.htm. These were originally collected through the New York State BRFSS, 2008-2009. Suicides Age adjusted suicide deaths per 100,000 population, 2009-2011. Self-inflicted injury hospitalizations Self-inflicted injury hospitalizations, age 15-19 Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/inj_31.htm. Data for the U.S. are from the National Vital Statistics System Mortality (NVSS-M), CDC/NCHS (2007). Age adjusted self-inflicted injury hospitalizations in specified age group per 10,000 population in that age group, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/inj_31.htm.

Substance abuse % adults binge drinking during the past month Alcohol-related motor vehicle injury and death rate % women who report alcohol use during pregnancy % adults who currently smoke cigarettes The percent of adults binge drinking in the past month. Binge drinking is defined as 5 drinks (men) or 4 drinks (women) on at least one occasion during the past month. Data for Onondaga County and New York State are reported from the Expanded BRFSS Preliminary Report, 2013-2014. Data for New York State Excluding New York City are age-adjusted, and are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sub_31.htm. These were originally collected through the New York State BRFSS, 2008-2009. Data for the U.S. are from the National Survey on Drug Use and Health NSDUH), SAMHSA (2008) Alcohol-related motor vehicle injuries and deaths per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sub_31.htm. The percent of women who self-report alcohol use during pregnancy, Onondaga County and Syracuse, 2009-2011 Data for Onondaga County and Syracuse are reported from the OCHD Bureau of Surveillance and Statistics. Data were accessed from the Statewide Perinatal Data System. Data from 2011 are provisional. The percent of adults who currently smoke cigarettes. Current smoking is defined as having smoked 100 cigarettes during the lifetime and reported smoking every day or some days. % adults who currently live in homes where smoking is prohibited % women who report smoking cigarettes during pregnancy % students in 7 th, 9 th and 11 th grades who report ever smoking cigarettes Data for Onondaga County and New York State are reported from the Expanded BRFSS Preliminary Report, 2013-2014. Data for New York State Excluding New York City are age-adjusted, and are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sub_31.htm. These were originally collected through the New York State BRFSS, 2008-2009. Data for the U.S. are from the National Health Interview Survey INHIS), CDC/NCHS (2008) The percent of adults who currently live in homes where smoking is prohibited, 2008-2009 Data for Onondaga County, New York State and New York State Excluding New York City are age-adjusted, and are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sub_31.htm. These were originally collected through the New York State BRFSS, 2008-2009. Data for the U.S. are from the Current Population Survey (CPS), Census and Dept. of Labor/ Bureau of Labor Statistics (2006-2007) The percent of women who self-report cigarette use during pregnancy, Onondaga County and Syracuse, 2009-2011 Data for Onondaga County and Syracuse are reported from the OCHD Bureau of Surveillance and Statistics. Data were accessed from the Statewide Perinatal Data System. Data from 2011 are provisional. The percent of students in 7 th, 9 th and 11 th grade who report ever having smoked cigarettes, Onondaga County, 2012-2013 Data are available from the New York State Youth Development Survey, 2012-2013 Onondaga County Schools: http://www.preventionnetworkcny.org/index.php/youth. Drug-related hospitalizations Drug-related hospitalizations per 10,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sub_31.htm.

Newborn drug-related hospitalizations % women who report illegal drug use during pregnancy Newborn drug-related hospitalizations per 10,000 newborn discharges, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sub_31.htm. The percent of women who self-report illegal drug use during pregnancy, Onondaga County and Syracuse, 2009-2011. Data for Onondaga County and Syracuse are reported from the OCHD Bureau of Surveillance and Statistics. Data were accessed from the Statewide Perinatal Data System. Data from 2011 are provisional. Preventing HIV/STDs, Vaccine Preventable Diseases and Healthcare-Associated Infections HIV/STDs HIV cases The number of newly diagnosed HIV cases per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sti_31.htm. Data for the U.S. are available from the National HIV Surveillance System (NHSS), CDC/NCHHSTP, 2007. AIDS case rate The number of newly diagnosed AIDS cases per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sti_31.htm. Data for the U.S. are available from the National HIV Surveillance System (NHSS), CDC/NCHHSTP, 2007. AIDS mortality rate The number of deaths due to AIDS per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sti_31.htm. Data for the U.S. are from the National Vital Statistics System-Mortality (NVSS-M), CDC/NCHS, 2007. Gonorrhea case rate The number of cases of gonorrhea in a particular age and gender per 100,000 population in that age and gender, 2009-2011. Data for Onondaga County are available from the Communicable Disease Electronic Surveillance System (CDESS), 2012. Data for New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sti_31.htm.. Data for New York State age group 15-44 are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. Data for the U.S. are available from the MMWR Summary of Notifiable Diseases, 2011 at: http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf Chlamydia case rate The number of cases of chlamydia in a particular age and gender per 100,000 population in that age and gender, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sti_31.htm. Data for Onondaga County and New York State for females in age group 15-44 are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. Data for the U.S. are available from the MMWR Summary of Notifiable Diseases, 2011 at: http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf

Early syphilis case rate The number of cases of early syphilis per 100,000 population, 2009-2011. Primary and secondary syphilis case rate Pelvic inflammatory disease hospitalization rate (females age 15-44) Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sti_31.htm. Data for the U.S. are available from the MMWR Summary of Notifiable Diseases, 2011 at: http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf The number of cases of primary or secondary syphilis in each gender per 100,000 population in that gender, 2010. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. The number of hospitalizations among women age 15-44 with a primary diagnosis of PID per 10,000 women age 15-44 years, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/sti_31.htm Vaccine-preventable diseases Pertussis incidence rate The number of reported cases of pertussis per 100,000 population, 2012. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Communicable Disease Annual Report at: http://www.health.ny.gov/statistics/diseases/communicable/2012/. Data for the U.S. are available from the MMWR Summary of Notifiable Diseases, 2011 at: http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf Mumps incidence rate The number of reported cases of mumps per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/com_31.htm. The Onondaga County rate is unstable due to fewer than 10 events in the numerator. Data for the U.S. are available from the MMWR Summary of Notifiable Diseases, 2011 at: http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf Meningococcal incidence rate The number of reported cases of meningococcal disease per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/com_31.htm. The Onondaga County rate is unstable due to fewer than 10 events in the numerator. Data for the U.S. are available from the MMWR Summary of Notifiable Diseases, 2011 at: http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf H. influenza incidence rate The number of reported cases of H. influenza disease per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/com_31.htm.data for the U.S. are available from the MMWR Summary of Notifiable Diseases, 2011 at: http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf Hepatitis A incidence rate The number of reported cases of hepatitis A per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/com_31.htm. The Onondaga County rate is unstable due to fewer than 10 events in the numerator. Data for the U.S. are available from the MMWR Summary of Notifiable Diseases, 2011 at: http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf

Acute hepatitis B incidence rate The number of reported cases of acute hepatitis B per 100,000 population, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/com_31.htm. The Onondaga County rate is unstable due to fewer than 10 events in the numerator. Data for the U.S. are available from the MMWR Summary of Notifiable Diseases, 2011 at: http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf Hepatitis C screening rate The percentage of adults born between 1945 and 1965 who report ever having been tested for Hepatitis C, 2013-2014. Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. Shigella incidence rate The number of reported cases of shigella per 100,000 population, 2012. Pneumonia / influenza hospitalization rate (age 65 years and older) % of adults aged 65 years and older with a flu shot in the last year % of adults who received their flu shot or spray in the past year % of adults aged 65 years and older who ever received a pneumonia shot % of adults who ever received a pneumonia shot % of children with 4:3:1:3:3:1:4 immunization series, age 19-35 months % of adolescent females with 3- dose HPV immunization, ages 13-17 years Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Communicable Disease Annual Report at: http://www.health.ny.gov/statistics/diseases/communicable/2012/. Data for the U.S. are available from the MMWR Summary of Notifiable Diseases, 2011 at: http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf The number of hospitalizations for pneumonia and influenza among persons age 65 and older per 10,000 population in this age group, 2009-2011. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/com_31.htm. The percentage of respondents age 65 and older who indicated they had a flu shot in the past year, 2008-2009. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/com_31.htm. Data for the U.S. are available from the Behavioral Risk Factor Surveillance System, 2012. The percentage of adults who received their influenza vaccination in the past year, 2013-2014. Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. The percentage of adults age 65 and older who report ever having received a pneumonia shot, 2008-2009. Data for Onondaga County, New York State and New York State Excluding New York City are available from NYSDOH Community Health Assessment Indicators at: http://www.health.ny.gov/statistics/chac/chai/docs/com_31.htm. Data for the U.S. are available from the Behavioral Risk Factor Surveillance System, 2012. The percentage of adults who report ever having received a pneumonia shot, 2013-2014. Onondaga County and New York State data are from the Expanded BRFSS Preliminary Report, 2013-2014. The number of children (age 19-35 months) per 100 population who received their 4:3:1:3:3:1:4 immunization series (4 DTap, 3 polio, 1 MMR, 3 hep.b, 3 Hib, 1 varicella, 4 PCV13), 2011 Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm. The number of females (age 13-17years) per 100 population who received their 3-dose Human Papillomavirus (HPV) vaccine, 2011. Data for Onondaga County and New York State are available from the Indicators for Tracking Public Health Priority Areas, 2013-2017 at: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/onondaga.htm.

Appendix 2. Expanded BRFSS Preliminary Report, 2013-2014 E XPANDED B EHAVIORAL R ISK F ACTOR S URVEILLANCE S YSTEM 2013-2014 P RELIMINARY (4- M ONTH) D ATA R EPORT O NONDAGA COUNTY Background The New York State Expanded Behavioral Risk Factor Surveillance System (Expanded BRFSS) is a random-digit dial telephone survey of adults designed to provide local health departments and hospitals county-level information on key population health indicators. The content of the Expanded BRFSS was planned to provide measures relevant to the five Priority Areas of the Prevention Agenda and will serve as the data source for several indicators that will be used to track progress toward Prevention Agenda goals. The survey covers mental health, health care coverage, binge drinking, tobacco use, physical inactivity, diet, obesity, flu vaccination and cancer screening, among other health topics. Methods The Expanded BRFSS uses similar survey methodology to those employed for the annual BRFSS New York administers in partnership with CDC. http://www.cdc.gov/brfss/ Data collection began April 15, 2013 and will continue until March 30, 2014. Survey interviews are occurring by landline and cellphone using an established protocol. The sampling plan and weighting procedures were designed to produce representative estimates for each of the 57 counties outside of New York City, and for New York City (5 boroughs) as a single area. CONTENTS Background 1 Methods 1 Health Indicator Data 1 Summary Table 2 Technical Notes About Summary Table 2 Health Indicator Definitions 3 Future Reporting 4 Links to Prevention Agenda Indicators 4 NYSDOH Program Contact 4 Health Indicator Data This report presents preliminary estimates for health indicators calculated from data collected over four months (April to August, 2013). Weighted estimates and confidence intervals are presented for your county and New York State as a whole. The estimates reflect the percentage of the adult population in the county or state with the given attribute. Definitions for each of the health indicators are provided on page 3. The confidence intervals are ranges around the estimate that indicate the precision and stability of the measure. Estimates with particularly wide confidence intervals are noted. Estimates were suppressed when either less than 50 participants were included in the denominator or less than 10 participants were in the numerator. To compare your county information to the state as a whole, a quick rule of thumb is that when two confidence intervals do not overlap, it is likely the measures are significantly different. http://www.health.ny.gov/diseases/chronic/confint.htm

Page 2 Expanded Behavioral Risk Factor Surveillance System Preliminary Report for Onondaga County Health Indicator By Prevention Agenda Priority Area Improve Health Status and Reduce Health Disparities County %, 95% CI State %, 95% CI Adults who have a regular health care provider 90.0 (86.2-93.7) 84.9 (81.9-87.8) Health care coverage - adults 18-64 years 92.8 (89.1-96.4) 83.3 (79.1-87.5) Promote Healthy Women, Infants, and Children Checkup within the past 12 months - adults 18-64 years 66.9 (56.4-77.5) 71.2 (66.7-75.7) Dental visit within last year 76.0 (67.3-84.8) 68.1 (63.2-73.1) Promote Mental Health and Preventing Substance Abuse Binge drinking in the past month 21.9 (14.6-29.3) 14.8 (11.7-17.9) 14 or more days of poor mental health in past month 17.4 ( 8.6-26.2) 10.3 ( 7.8-12.8) Prevent HIV, STDs, Vaccine Preventable Diseases and Healthcare Associated Infections Flu shot or spray during the past 12 months 54.3 (44.0-64.6) 48.2 (43.9-52.5) Pneumonia shot (ever) 40.0 (29.5-50.5) 31.0 (26.5-35.5) HCV screening test (ever)- adults 47-68 46.4 (27.9-64.9) 37.1 (31.1-43.0) Prevent Chronic Disease Obesity 20.0 (13.6-26.5) 26.2 (22.5-29.8) Current smoking 19.3 (11.2-27.5) 16.0 (13.1-19.0) Leisure time physical activity during the past 30 days 83.6 (76.2-91.0) 75.3 (71.9-78.8) Daily sugar drink consumption 21.7 (13.6-29.8) 23.2 (19.3-27.0) Diabetes test within the past 3 years 58.9 (49.6-68.3) 59.6 (55.0-64.3) Women aged 50-74 who had a mammogram within past 2 years 93.9 (88.2-99.5) 81.6 (76.3-86.8) Adults aged 50-75 with a colorectal cancer screening within guidelines 86.0 (78.0-94.0) 65.7 (60.1-71.3) Other Relevant Indicators 14 or more days of poor physical health in past month 15.4 ( 7.1-23.7) 12.1 ( 9.7-14.6) High blood pressure 27.7 (19.1-36.2) 28.3 (25.0-31.6) High cholesterol 45.5 (33.9-57.1) 40.5 (36.2-44.7) Diabetes 13.9 ( 4.5-23.4) 9.4 ( 7.4-11.4) Current asthma 8.7 ( 4.3-13.2) 10.0 ( 8.0-12.0) Arthritis 39.4 (28.9-50.0) 24.2 (21.0-27.4) Disability 30.1 (20.7-39.4) 20.9 (17.9-23.9) Technical Notes About Summary Table % = Estimated percentage of adults in the county or state with the listed attribute; 95% CI = 95% Confidence Interval for estimate; Estimates in bold font have a confidence interval greater than +/- 10%. These estimates are considered unstable and should be interpreted with caution. Estimates based on fewer than 50 observations are suppressed. To ensure an adequate sample size for calculating county estimates for having a regular check-up in the past year and having an annual dental visit in the past year, the population of adults 18-64 years of age was used instead of the specific population stated for the Prevention Agenda, women 18-44 years. Technical specifications for the Prevention Agenda Tracking Indicators are available on the NYSDOH Website: http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/about.htm

Page 3 Health Indicator Definitions Health Indicator Adults who have a regular health care provider Health care coverage - adults 18-64 years Checkup within the past 12 months - adults 18-64 years Dental visit within last year Binge drinking in the past month 14 or more days of poor mental health in past month Flu shot or spray during the past 12 months Pneumonia shot (ever) HCV screening test (ever)- adults 47-68 Obesity Current smoking Leisure time physical activity during the past 30 days Daily sugar drink consumption Diabetes test within the past 3 years Women aged 50-74 who had a mammogram within past 2 years Adults aged 50-75 with a colorectal cancer screening within guidelines 14 or more days of poor physical health in past month High blood pressure High cholesterol Diabetes Current asthma Arthritis Disability Definition The percentage of adults who report having a personal doctor or health care provider. The percentage of adults aged 18-64 years who report that they have health insurance coverage. The percentage of adults aged 18-64 years who visited a doctor for a routine checkup within the past year. The percentage of adults who visited a dentist or dental clinic with the past year. The percentage of adults who report having >=5 drinks (men) or >=4 drinks (women) on at least 1 occasion during the past month. The percentage of adults who report experiencing poor mental health for 14 or more days in the past month. The percentage of adults who received their influenza immunization (flu shot or spray) in the past year. The percentage of adults who report ever having received a pneumococcal vaccination. The percentage of adults born between 1945 and 1965 having ever been tested for Hepatitis C (HCV). The percentage of adults who report being obese. Obesity is defined as having a body mass index (BMI) of 30.0 or greater. The percentage of adults who report having smoked at least100 cigarettes in their lifetime and are current smokers on every day or some days. The percentage of adults who participated in leisure time physical activies for exercise in the past month. The percentage of adults who consume regular soda or other sugar-sweetened drinks (fruit drinks, sweet tea, and sports or energy drinks) at least one or more times per day. The percentage of adults having had a test for diabetes within the past 3 years. The percentage of women aged 50-74 years who received a breast cancer screening based on the most recent clinical guidelines (mammography within the past 2 years). The percentage of adults aged 50-75 years who received a colorectal cancer screening exam based on the most recent clinical guidelines (blood stool test in the past year; or sigmoidoscopy in the past 5 years and a blood stool test in the past 3 years; or a colonoscopy in the past 10 years). The percentage of adults who report experiencing poor physical health for 14 or more days in the past month. The percentage of adults who report being told by a doctor, nurse, or other health professional of having high blood pressure. The percentage of adults who report being told by a doctor, nurse, or other health professional of having high cholesterol. The percentage of adults who report being told of having diabetes (other than diabetes during pregnancy). The percentage of adults who report currently having diagnosed asthma. The percentage of adults who report being told of having some form of arthritis. The percentage of adults who report activity limitations due to physical, mental, or emotional problems or having health problems that require the use of special equipment.

Page 4 Future Reports When data collection for the Expanded BRFSS is complete, a final report will be prepared. The final reports will provide more detailed information about subgroups within the population and cover additional health indicators. Measures of health indicators are expected to be more precise and stable when a larger number of respondents are included. Links to Prevention Agenda Indicators Indicators for Tracking Public Health Priority Areas - New York State - 2013-2017 http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/nys.htm New York State Prevention Agenda 2013-2017: Priorities, Focus Areas, Goals and Objectives http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/tracking_indicators.htm State and County Tracking Indicators for the Priority Areas http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/indicator_map.htm NYSDOH Contact Information: Questions about the Expanded BRFSS 2013-14 or the data included in this report should be directed to the BRFSS Coordinator: BRFSS@health.state.ny.us

Appendix 3. OCHD Organizational Chart Onondaga County Health Department 2013 Organizational Chart County Executive County Legislature Advisory Board of Health Medical Directors Commissioner Deputy Commissioner Fiscal Office Administration Surveillance and Statistics Maternal and Child Health Healthy Families Environmental Health Disease Control Health Promotion and Disease Prevention The Wallie Howard, Jr. Center for Forensic Sciences Family Planning Medical Examiner s Office Forensic Laboratories 7/9/12

Appendix 4. Onondaga County Assets and Resources The following tables were created by students in the CNYMPH program, as part of their classwork for MPH 607: Public Health Administration in the spring of 2013. The information provided here should serve as an example of the types of services available to Onondaga County residents, and is not intended to be all-encompassing. Housing and homelessness Name of Service Address/Contact Info. Service Population Services Provided & Potential Barriers Relevance to Indicators CNY Services Centralized Intake Department (CID) 375 West Onondaga Street Suite 23 Syracuse, NY 13202 Tel: (315) 478-0610 Fax: (315) 295-2031 Supported Housing Program 375 West Onondaga Street Suite 25 Syracuse, NY 13202 Tel: (315) 475-9131 Tel: (315) 475-0611 Fax: (315) 295-2031 Welch Terrace Apartments 1047 East Fayette Street Syracuse, NY 13210 Tel: (315) 422-5611 Fax: (315) 478-6972 Individuals and families in the county with diagnosed mental illness or history of substance abuse Residential, clinical (including mental health and substance abuse counseling), forensic and financial management services for individuals and families in Onondaga, Oneida, and Madison counties. Services only for people with diagnosed mental illness or documented history of substance abuse. Housing and Homeless Coalition of Syracuse and Onondaga Co. housingandhomelesscoalition@g mail.com Homeless individuals, families Community coalition that works to coordinate and improve services for the Onondaga County and Syracuse homeless populations. Peter Young Housing, Industries, and Treatment Vocational: (315) 457-3000 Parole: (315) 422-1140 Intensive Residential: (315) 457-1240 Intensive residential treatment and vocational services including for parolees The Salvation Army Emergency Shelter 749 South Warren Street Syracuse, NY 13202 Phone: 315.479.1332 Fax: 315.479.1158 Women's Shelter 1704 South Salina Street Syracuse, NY 13205 Phone: 315.472.0947 Fax: 315.422.0931

Community Support Connection (CSC) 315.479.1120 Supported Housing Initiative 315.479.3626 Corrections, Justice, and Victim Services Name of Service Address/Contact Info. Service Population Services Provided & Potential Barriers Relevance to Indicators Mary Ann Shaw Center for Public and Community Service Mary Ann Shaw Center 237 Schine Center Syracuse University Syracuse, NY 13244 315 443 3051 Syracuse City Families / Children Intellectual, ethical, professional and personal development via outreach of Syracuse Univ. students and faculty Educational assistance Mothers Against Gun Violence All citizens of Syracuse; Families of victims of gun violence Grief counseling; support for laws and actions to prevent the spread of violence Advocates of peace; reduce gun crimes/violence Onondaga County Family Court Office Onondaga County Family Court 401 Montgomery Street Syracuse, NY At risk youth Legal assistance to youths and their families. Barrier is relationship with Syracuse City Police and DA Operation SNUG New Justice Services 1153 W Fayette Syracuse, NY Syracuse citizens; at risk youth; former gang members Community mobilization; youth and public outreach; public education; law enforcement participation; Organizations mission is to control the spread of violence; proliferation of gangs Rescue Mission Alliance of Syracuse, NY 155 Gifford Street Syracuse NY Women Shelters for women Violence and creating a safe environment for women at risk of being the victim of violence (sexual and/or domestic) Say Yes to Syracuse Say Yes to Syracuse 109 Otisco St 2ndFloor Syracuse, NY 13244 315-443-4260 Syracuse City School Students and their Families Opportunity for college education; collaboration of City Schools, Teachers, Universities, and area nonprofits Increase graduation rate and those attending college Syracuse Police Gang Violence Task Force 511 S State Street Syracuse, NY 13202 315 442 5200 Syracuse citizens Crackdown on Gangs - violence and drug distribution. Create safer neighborhoods. Reduce violence, gun violence and drug trafficking. Syracuse Truce Syracuse Truce Federal Courthouse Syracuse, NY Syracuse Gang Members Drug counseling, educational support, emotional support, job services Reduce gang participation Vera House 6181 Thompson Road Suite 100 Syracuse, NY 13206 Women women of all ages; counseling to women of all ages around sexual and domestic violence Violence and creating a safe environment for women at risk of being the victim of violence (sexual and/or domestic) Reproductive Health

Name of Service Address/Contact Info. Service Population Services Provided & Potential Barriers Relevance to Indicators Onondaga County Health Department (OCHD) Bureau of Disease Control Room 80 Civic Center 421 Montgomery Street Syracuse, NY 13202 All HIV testing & counseling TB testing & control STD- Information, diagnosis, treatment & counseling No appointment necessary STDs, communicable diseases AIDS Community Resources (ACR) 627 West Genesee Street Syracuse, NY 13204 Phone: (315) 475.2430 Fax: (315) 472.6515 Care coordination Community Health Advocates Program Housing Services and Nutrition Services for those living with HIV/AIDS Transportation to the doctor Prevention services Youth services HIV/AIDS OCHD - General Immunization Clinic Dr. William A. Harris Health Clinic 301 Slocum Ave Syracuse, NY 13204 Children (2 months and older) without private health insurance Adults MMWR to adults 18+ Flu vaccination seasonally available at clinic: Thursdays, 8:30 to 11:30 a.m. The fee is $15.00 per visit Vaccine-preventable diseases F.A.C.E.S. - Syracuse Model Neighborhood Fighting HIV/AIDS through Case Management, Education and Support The Southwest Community Center 401 South Avenue Syracuse, New York 13204-4125 Tel: (315) 474-6823 Fax: (315) 479-8023 Adults Teens Children Transportation Housing Financial assistance Nutritional information Referrals Client Activities Safe Sex workshops Street outreach Condoms and barriers Agency outreach Support groups (male, female, co-ed, children) Teen/peer education Hospitality services Bilingual services Syracuse Regional Anonymous HIV Counseling and Testing Program Walk in or scheduled appointment basis, some evening clinics available. Call 1-800-562-9423 New York State Residents Anonymous HIV testing Test Results Bilingual services Educational programs available HIV/AIDS Planned Parenthood Syracuse Center 1120 E Genesee Street Syracuse, NY 13210 p: 866.600.6886 to schedule appointment Helpline also available 830am- 5pm Monday-Friday 7:30am - 5:30pm Adults Teens English, Spanish, ASL interpretation available Medicaid accepted Uninsured may qualify for state-funded program or lower fee scale Fees based upon household income HIV Testing HIV Test Education HIV referrals

STD testing, diagnosis and treatment Condoms and female condoms available Safe sex education Same Day STD Testing 1000 E Genesee St, Ste 600 Hill Medical Syracuse NY 13210 2700 Court Street Ste 6 Syracuse NY 13208 1-800-805-7837 Adults HIV testing STD testing: Chlamydia, Gonorrhea, Hepatitis, Herpes, syphilis, urinalysis STD info, videos Case management HIV/AIDS, STDs New York State Department of Health Syracuse regional office 217 S. Salina Street Syracuse 800-562-9423 Free Monday - Friday 8:30-4:30 HIV testing HIV/AIDS OCHD William A. Harris Health Center Family Planning Clinic 428 W. Onondaga Street Syracuse NY 435-3295 113 West Taft Road North Syracuse NY 435-3685 Free HIV testing Physical examinations and laboratory tests Contraceptive counseling and contraceptives Pregnancy tests and counseling STD testing and treatment HIV counseling and testing Patient education Medical Referral Social service supports Community education Emergency Contraception http://www.ongov.net/health/family Planning.html Syracuse Community Health Center Incorporated 819 S. Salina Street Syracuse 476-7921 830-800 Monday, Wednesday and Thursday 830-515pm Tuesday and Friday 9-1pm Saturday http://www.schcny.com/patients/sal ina.php HIV testing SUNY Pediatric Adolescent and Young Adult AIDS center 750 East Adams Street Syracuse 464-6331 Adolescent/Young Adult Specialized HIV Care Center Free Monday - Friday 8:30-4:30 These children and adolescents include patients who: Are newly diagnosed as HIV positive Have been exposed through at-risk behaviors Are transferring their HIV care to the University Hospital Pediatric Designated AIDS Center Have been perinatally (before birth) exposed to HIV Have been exposed through sexual assault http://www.upstate.edu/gch/service s/aids/

County Health Dept. Services, Environmental and Mental Health Resources Name of Service Address/Contact Info. Service Population Services Provided & Potential Barriers Relevance to Indicators Adventure-Based Therapy Program Program Supervisor Liberty Resources Phone: 598-4642 x118 or (800) 805-3879 x118 Fax: 592-7978 -Children and youth with serious emotional and behavioral challenges and their parents and caregivers -8-21 years old -Hands-on experience using Ropes Course with both high and low elements -One 8-hour experience -The events will be held on Saturdays, 6 times throughout the year. -The location for these events will be either (1) The Adventure Center in Liverpool, NY (indoor course) or Adams Eden Camp in Lafayette, NY (outdoor - course). The service is only available in English unless interpretation services are arranged in advance. -Lunch will be provided. Anger Busters Group for Children Arise Child and Family Service Phone: 671-2953 Fax: 671-2943 -Children and youth with serious emotional and behavioral challenges -Ages 5-13 -Group therapy for children -Two hours per week for 12 weeks. -Catholic Charities House of Providence, 1647 West Onondaga Street, Syracuse, New York -A family dinner will be provided before each session. -Interpretation services available on request Blood pressure screening service 501 East Fayette Street, Syracuse, NY 13202 Phone (315) 435-5262 Onondaga county residents Free blood pressure screenings Chronic disease Bridging the Gap Elmcrest Phone: 445-2667 Fax: 445-2667 -Children and youth with serious emotional and behavioral challenges placed in residential care at Elmcrest. - From middle childhood through young adult (approximately 8-20 years old) -Services include development of an Individualized Plan of Care, individual therapy, occupational therapy, and consultation, instruction and support for residential staff, family members, and school personnel. -Services are provided on the Elmcrest campus, in school, and in the family home or community while a child is in residential care at Elmcrest Building Strong Families/Incredible Years Catholic Charities of Onondaga County Phone: 362-7547 Parents who have children ages 5-12 years of age with serious emotional and behavioral challenges Children and parents/caregivers must live in the same household Parents who attend the evening class may also enroll their child in the ARISE Anger Busters program The Incredible Years School-Age course is a 12- week, 2 hour program that teaches parenting skills specific to the child s challenges and behaviors that affect their child s emotional and social development. For parents who would like their children to participate in an anger management group, the ARISE Anger Busters will be available to children between the ages of 5 and 12 during the evening class. There are 3 afternoon and 3 evening courses. Classes will be held at Catholic Charities sites throughout the community.

Building Strong LGBTQ Youth & Families Q Center Program Coordinator or Director of Youth Services Q Center @ ACR Phone: 315-475-2430 Fax: 315-472-6515 Children and youth ages 8-22 who identify as Lesbian, Gay, Bi-sexual, Transgender or Questioning (LGBTQ); parents of transgender youth; and children ages 8-12 with LGBTQ parents. The Q Center is a safe place for lesbian, gay, bisexual, transgender, and questioning youth and their families to gather, share, hang out, have fun, and build healthy relationships with supportive adults and peers. The Q Center offers youth and parent support groups, individual therapy sessions, referrals for clinical counseling and quarterly family events. Youth/Parent Groups The Q Center s parent agency, AIDS Community Resources, maintains a contract with MAMI Interpreters which provides interpretation services for over 47 languages. Bus passes or cab rides can be provided for youth and parents in need of transportation assistance. Cancer screening service Civic Center, 9th Floor 421 Montgomery Street, Syracuse, NY 13202 Phone 315-435-3653 Those without insurance or Medicaid/Medicare participants, age 40+ Free breast, cervical, and colorectal cancer screenings and diagnostic services. Hours, transportation, staff shortage CHOICES Central New York Services, Inc. / Centralized Intake Department Phone: 315-478-0610 Fax: 315-295-2031 or 315-478- 2510 www.cnyservices.org ( a referral form can also be found at this web address) Children and youth with serious emotional and behavioral challenges Ages 13 to 24 This program is based on The Seven Challenges, an evidenced based model of treatment for youth It will include a mix of the following: bio-psychosocial assessments, individual sessions, group sessions, family sessions and multi-family group sessions. Time commitment and length of service depend on need. Evening hours are available. CNY WIC Vendor Management Agency 375 West Onondaga Street, Syracuse, NY 13202 Phone (315) 435-5238 This program works with stores that accept WIC checks Ensures stores stock the healthy foods that WIC participants are allowed to purchase with WIC checks. - Community Environmental Health Civic Center, 12th Floor 421 Montgomery Street, Syracuse, NY 13202 Phone (315) 435-6617 Food protection Phone (315) 435-6607 Residential Environmental Health Phone (315) 435-6617 Temporary Residence and Recreational Facilities Phone (315) 435-6617 The Bureau of Community Environmental Health provides public health services in the areas of Food Protection, Residential Sanitation and Temporary Facilities. Performs inspections of food service facilities Provides plan review and approval for new food service facilities. Investigates foodborne illness outbreaks. Investigates food service facility complaints. Provides training for the food service industry. Provides public information and education concerning food safety issues. New York State Clean Indoor Air Act enforcement at food service facilities. County public health housing regulation enforcement Nuisance and general sanitation complaint investigation. Mobile home park and farm worker camp inspection. Hotel, motel and rooming house facility inspection.

School and institution food service. Children s camp and child day care facility inspection. Public water supply surveillance (permitted facilities). Inspection of public swimming pools, bathing beaches, campgrounds. Creating Healthy Places to Live, Work and Play in Onondaga County 421 Montgomery Street, Syracuse, NY 13202 Phone (315) 435-3280 Onondaga county residents Develops programs that will prevent obesity, type 2 diabetes and other chronic diseases. - Early Intervention Program 501 East Fayette Street, Suite B, Syracuse, New York 13202 Phone 315-435-3230 Infants and young children ages birth to 3, who are developmentally delayed (or who have a high probability of being developmentally delayed). The program emphasizes the earliest possible identification of infants and toddlers with disabilities. Family participation is encouraged and services are provided in the natural environment for the child whenever possible. These services may be direct or consultative and may include speech, physical and other therapies, child development groups, family counseling, and transportation Educational Counseling Referrals for Educational Consulting will be screened by the ACCESS Team. Phone: 463-1100 Fax: 435-3360 For more information about the service, contact 432-0665 Children and youth with serious emotional and behavioral challenges School aged children experiencing learning difficulties or issues in school related to academic performance (Kindergarten through 12 th grade) Services are primarily provided to the parent, but the child/youth will be included when appropriate Individual consultation with parents/caregivers; may include a review of school records, information on learning differences and success strategies, information on educational processes; coaching/support during school meetings Short-term tutoring is available to help children and youth learn new strategies for academic success based on their individual learning styles Service is available weekdays and evenings (flexible based on need of the family) Services will be provided at the family home or a convenient community location Free workshops for parents and community service providers on a variety of education-related topics Equestrian Therapy Program Clinic Director at ARISE Phone: 671-2949 Fax: 671-2943 Children and youth with serious emotional and behavioral challenges Ages 8-12 Diagnosed with Post Traumatic Stress Disorder Children must be able to safely participate in peer group activities Parent involvement is encouraged (there will be volunteer opportunities Program uses an individualized blend of hands on activities including working with horses, experience farm life, skill building and positive activities with peers Spring/Fall sessions are approximately 4 hours (3-7 p.m.), one day per week. Summer program is one week (Monday through Friday) from 9-1. Takes place at the ARISE Farm located on New Boston Road in Chittenango, New York. Beautiful farm setting complete with horses and other friendly farm animals that are very comfortable with children and adults! Transportation to the farm and back will be provided.

for parents) Many special supports are available including food, interpretation and accommodation of special needs. Family Fun Day for parents and siblings at the end of each session. Family-Driven Care/Family Tapestry Director of Family Driven Care for OnCare at Family Tapestry Phone: 472-7363 ext 276 FAX: 701-2666 Parents/caregivers of children and youth with serious emotional and behavioral challenges ages 5-25 Support Groups Parent Support Group -Childcare and a light snack are provided for the support groups. Common Sense Parenting -This class is offered in English and Spanish. Leadership training: Training for parents and caregivers on how to be an effective advocate for your child and an effective advocate for changes in the service system. Sessions occur several times a year at various community locations. Family Life Team (FLT) for SCSD Students Healthy Families Division of the Onondaga County Health Department all identified pregnant and parenting students in the Syracuse City School District schools. This program offers home visiting services. Family planning See above Immunization Clinic - OCHD See above Healthy Families 435-2000 Services provided for: infants, children, new moms, and parents This program can help participants with: Baby growth and development Breastfeeding support Children under 5 who have a developmental delay or disability Domestic violence issues Family planning Finding daycare Finding a dentist Finding a doctor for you and your baby Food stamps Getting health screenings Getting transportation Health insurance Immunizations (shots for children) Lead testing Mental health and depression Nutrition Parenting Public Assistance Substance abuse and alcohol issues WIC (Women, Infants, and Children) HELPLINE 315-435-8300 Onondaga County residents Free resource that provides human services -

http://www.ongov.net/helpline/ind ex.html information and referrals to the citizens of our community 24 hours a day, 7 days a week. HIV / STD testing - OCHD See above Home Visits OCHD See Healthy Families, above Intensive Skill Building Services Referrals are made through the ACCESS Team Phone: 463-1100 Fax: 435-3360 If you have questions about the program please contact 703-8717 Children and youth with serious emotional and behavioral challenges Ages 4-18 Services will be customized to meet the individual needs of the children/youth Emphasis is on supporting successful transitions from out-of-home care and on stabilizing crises to avoid out-of home care Services are intensive and will be provided for 8-20 hours/week for an average of 6-8 weeks Services may be delivered in the home, school or in the community Skill building may be provided weekdays, evenings or weekends Skill building may be provided on a one-to-one basis or in small group settings Crisis services and supports are available to participating youth and families Lead control program - OCHD Civic Center, 9th Floor 421 Montgomery Street, Syracuse, NY 13202 Phone (315) 435-3271 Parents, tenants, homeowners/landlords, & contractors Inspects rental properties and homes built before 1978 Provides blood lead screening tests Follows up with families whose children need testing, and Provides case management for children with lead poisoning. Mental Health Department Department of Mental Health 421 Montgomery Street, 10th Floor Syracuse, New York 13202 Phone (315) 435-3355 Onondaga county residents The Department advances the mental health of County residents by monitoring and continuously improving the system of behavioral healthcare services in Onondaga County. Nurse-family Partnership Healthy Families division of the Onondaga County Health Department Any woman can enroll who is pregnant with her first child, meets income requirements, and lives in Onondaga County. Nurse-Family Partnership (NFP) is a program for women who are having their first baby. If you enroll, a Public Health Nurse will visit you in your home throughout pregnancy and continue to visit until your baby is two years old. Your nurse will help you have a healthy pregnancy and a healthy baby. Qualifying terms, transportation, literacy level, knowledge gap New York Care Coordination Program Mental Health Department http://www.ocdmh.net/reports.asp x Mental health care coordinators in Onondaga county The New York Care Coordination Program is a notfor-profit organization governed by individuals from multi-county and multi-stakeholder groups aimed at improving outcomes for individuals with serious behavioral health conditions. - Onondaga County Health 421 Montgomery Street Onondaga county residents Protect and improve the health of all residents of

Department Syracuse, NY 13202 Onondaga County. OnCare John H. Mulroy Civic Center 12th Floor 421 Montgomery Street Syracuse, NY 13202 315-435-2985 Onondaga County children and youth (ages 5-21) with significant behavioral and emotional challenges and their families Community initiative that improves outcomes developing a more effective system of services and supports Planned Respite ACCESS: 463-1100 Youth with serious emotional and behavior problems Ages 10-17 Youth must be willing to stay overnight away from home on a trip Youth who are interested in meeting new people/having new experiences Allows parents to drop their children off to an overnight stay which makes it possible for parents to have needed alone time Promise Zone: Family School Community http://www.ocdmh.net/promisezone.aspx Syracuse City School District students with emotional and behavioral challenges Match student's emotional/behavioral needs with effective targeted interventions. Rabies - OCHD 6230 East Molloy Road, East Syracuse, NY 13057 Phone (315) 435-3165 Reported cases in Onondaga County -Rabies vaccination clinics for dogs, ferrets, and cats. -Animal bite follow-up to ensure people with animal contact have proper follow-up through confinement and examination of animals or testing of specimens for rabies -Enforcement of rabies vaccination law -Education of the public and agencies on rabies prevention and animal disease prevention Hours, transportation, staff shortage, qualifying terms Ready for Home Contact Elmcrest Ready for Home Supervisor with any questions reguarding the program. Phone: 432-9053 Children and youth in residential placement at Elmcrest Children s Center. Child or youth with identified discharge resource. This could include birth parents, step parents, extended. family, siblings, foster parents, adoptive parents, clergy, mentors, or other people the child identifies. Ready for Home will provide counseling and skillfocused services to families and youth placed in Elmcrest s residential care settings. The goal is to prepare youth and family for the youth s return home, so youth can return to their homes more quickly. The program will consist of two skill builders, two clinicians, and a program supervisor. Program clinicians and Skill builders will begin working with the families/youth as soon as youth comes into care, and will continue to work with the families/youth 3 months after the youth is discharged home. Services provided to families and youth at their homes and at agreed upon places in community. Refugee Youth Project Catholic Charities Refugee Resettlement Refugee children and youth with serious emotional and behavioral Mental Health Screenings, Family Case Management, Youth Support Groups

Phone: (315) 474-7428 ext 12 Fax: (315) 471-7215 challenges and their families. Ages 5-18 Youth who have experienced trauma, loss of a family member, or war-related violence. Refugee youth within their first year in the US. Services for up to 1 year Weekday and evening hours Drop-in services at Northside CYO (527 North Salina St.) and scheduled home visits Services provided by multi-lingual staff and ethnic outreach workers Transportation and interpretation available as needed. Skills4Success All referrals go through the ACCESS Team Phone: 463-1100 Fax: 435-3360 Program Director, or Manager. Phone: 472-6343 Children and youth with serious emotional and behavioral challenges and their families Ages 5-18 1:1 Skill-building for the youth; respite for families while child is receiving skill-building services. Typically 4-6 hours per week. Available weekdays, evenings and weekends; flexible to meet the child s and family s needs Skill-building can take place in the family home, schools, neighborhood centers, and community at large. Special Children Services Healthy Families division of the Onondaga County Health Department Children born prematurely, developmental delayed, or with a disability. Special Children Services provides evaluations, education, and therapy for children up to age five who have a developmental delay or disability. Special Children Services can help you get the health care and supplies you may need to care for your child with special health care needs. Hours, transportation, staff shortage, qualifying terms STDs - OCHD See above Syracuse Healthy Start Program 501 East Fayette Street, Syracuse, New York 13202 Phone (315)435-2000 Syracuse residents who are pregnant or with a child under the age of 2 Healthy Start can help connect you with the health care you need to have a healthy baby. Healthy Start can also help you and your children stay healthy with free classes, help quitting smoking, and help applying for WIC and public assistance. Hours, transportation, staff shortage, qualifying terms The Parent Project Onondaga Case Management Services Phone: 472-7363 x236 Fax: 701-2666 Parents of youth with defiant and/or aggressive adolescents Teen component for youth 13 18 years of age Program is designed for parents and has an accompanying teen component as well Designed to address adolescents who struggle with aggressive, outof-control behavior, suicidal ideation, substance abuse, runaway behaviors, and/or have diagnoses of ADD/ADHD or ODD. Parents/teens must attend all Parents/teens attend and learn in a classroom model utilizing large and small group activities and self-help support groups. Parents meet one night a week, two to three hours per night, for 12 16 weeks. Sessions will be held on Monday evenings from approximately 5:30 8:00. Classes will be held at Onondaga Case Management Services, 220 Herald Place, Syracuse Currently available in English only Childcare and a light meal will be provided

sessions in order to receive certification of completion Tuberculosis Room 80 Civic Center 421 Montgomery Street, Syracuse, NY 13202 Phone (315) 435-3256 Onondaga county residents This clinic is concerned with all aspects of the control of tuberculosis including case-finding, diagnosis, treatment and preventive treatment. Services include: tuberculosis skin testing (TST), chest x-ray referral (as determined by clinic staff), physician consultation and follow-up. Hours, transportation, staff shortage, language Women, Infant, Children Syracuse Office: 375 W. Onondaga Street, Room 12 Syracuse, NY 13202 Phone (315) 435-3304 Bayberry Plaza Office: 7608 Oswego Road Liverpool, NY 13090 Phone (315) 652-3117 Pregnant or breastfeeding, existing in an income bracket that is accepted by the agency, children under 5, or a mother of an infant WIC provides checks every month to buy healthy WIC foods and provides ideas on preparing healthy meals for families. WIC can also connect participants with other health care services Hours, transportation, access to healthy foods Physical Activity, Transportation, and Higher Ed Resources Name of Service Address/Contact Info. Service Population Services Provided & Potential Barriers Relevance to Indicators Gold s Gym 5791 Widewaters Pkwy, DeWitt, NY ( 5 ) - goldsgymsyracuse.com Fitness facilities and classes Cost associated Military members receive a discount Physical Activity Personal Fitness Inc 5 S Salina St, Syracuse, N ( 5 ) - personalfitnessprogram.com Fitness facilities and classes Cost associated Physical Activity YMCA Downtown Syracuse 340 Montgomery St, Syracuse, NY ( 5 ) - 5 ymcaofgreatersyracuse.org Challenge You Diabetes: Prevention Program Folksmarch Teen Challenge You Fitness Facilities and Classes Diabetes Physical Activity Adolescent Health YWCA 120 E Washington St, Syracuse, NY ( 5 ) - ywca-syracuse.org Mostly women and children Mother-Daughter Workshop Camp Discovery Fitness Facilities and Classes Mental Health Physical Activity YWCA 401 Douglas St, Syracuse, NY ( 5 ) - Mother-Daughter Workshop Camp Discovery Fitness Facilities and Classes Mental Health Physical Activity Adolescent Health Pulse Fitness Studio W Fayette St, Syracuse, N Fitness facilities and classes Physical Activity

( 5 ) - pulsecny.com Cost associated Planet Fitness 2318 W Genesee St, Camillus, NY ( 5 ) - planetfitness.com Fitness facilities and classes Cost associated Physical Activity Hercules Gym 2004 Teall Ave, Syracuse, N ( 5 ) - Fitness facilities and classes Cost associated Physical Activity Bally Total Fitness 9661 Carousel Center, Syracuse, NY Destiny USA ( 5 ) - ballyfitness.com Fitness facilities and classes Cost associated Physical Activity Personal Fitness Programs Irving Ave, Syracuse, N ( 5 ) -5 5 personalfitnessprogram.com Fitness facilities and classes Cost associated Physical Activity North Area Athletic Club 507 Pond St, Syracuse, NY (315) 471- Fitness facilities and classes Cost associated Physical Activity Curves Grant Blvd, Syracuse, N ( 5 ) - curves.com Fitness facilities and classes Cost associated Physical Activity Flex House of Fitness 919 Sunnycrest Rd, Syracuse, NY ( 5 ) - 5 Fitness facilities and classes Cost associated Physical Activity Planet Fitness 5859 Bridge St, DeWitt, NY ( 5 ) -5 planetfitness.com Fitness facilities and classes Cost associated Physical Activity Strength in Motion E st St, East Syracuse, N ( 5 ) -5 strengthinmotion.com Fitness facilities and classes Cost associated Physical Activity Trillium Wellness Center Manlius Center Rd, East Syracuse, N ( 5 ) - 55 trilliumfit.com Fitness facilities and classes Cost associated Physical Activity Neighborhood Recreation Center Bova Community Center at Schiller Park (315) 473-4780 Ages 7-15 Hot Meals / Summer Lunch program, Table Tennis Instruction, homework help, gymnasium activities, outdoor games, field trips, teen program Only for children age 7-15 Physical Activity School Year Hours: Mon-Fri: 2pm - 9pm Summer Schedule: Mon-Fri: 10am - 6pm

Cannon Street Community Center 529 Cannon St. 471-2106 Program Components: Homework help, arts and crafts, sports and games School Year Hours: Mon-Fri: 2pm - 6pm Summer Schedule: Mon-Fri: 10am - 6pm After School Program at Edward Smith School Phone: 435-4994 Program Components: Snacks, Summer Lunch program, Homework help, gymnasium activities, arts and crafts, tennis, field trips ***enrollment limited to Edward Smith students*** School Year Hours: Mon-Fri: 2pm - 6:30pm Summer Schedule: Mon-Fri: 9am - 5pm Magnarelli community center Northeast Community Center Seals Community Center at Kirk Park McChesney Park (2300 Grant Blvd) Phone: 473-2673 (716 Hawley Ave) Director: Dave Bardenett Phone: 472-6343 300 Borden Ave Phone: 473-2799 Program Components: Gymnasium activities, outdoor games, Jr. NBA League, Summer ACTION League, homework help, teen program School Year Hours: Mon-Fri: 2pm - 9pm Saturday basketball: 9am - 2pm Summer Schedule: Mon-Fri: 12noon - 4pm Program Components: gymnasium activities, basketball School Year Hours: Mon- Fri: 3pm - 8pm (drop in hours) Summer Schedule: Mon-Fri: 10am - 6pm Program Components: Kids Cafe Hot Meals program, homework help, arts and crafts, field trips, Young Sisters Unite, Fit Kids School Year Hours: Mon-Fri: 2pm - 7pm Summer Schedule: Mon-Fri: 10am - 6pm Parks and Recreation at Southwest Community Center Westmoreland Community Center (401 South Ave) Phone: 474-6823 (139 Westmoreland Ave) Phone: 473-6754 Program Components: Summer Lunch program, homework help, chess club, gymnasium activities, outdoor games, field trips, teen program, Jr. NBA basketball School Year Hours: Mon-Fri: 2pm - 8pm Saturday basketball: 9am - 3pm (December - March) Summer Schedule: Mon-Fri: 9am - 5pm Program Components: Summer Lunch program, homework help, outdoor games, field trips, crafts, board games, Kids Cafe meal program School Year Hours: Mon-Fri: 2pm - 7pm Summer Schedule: Mon-Fri: 10am - 6pm Wilson Park Community 1117 S. McBride St. Program Components: Hot Meals / Summer Lunch

Center Phone: 473-6828 program, homework help, SU Mentor program, girl scouts, outdoor games, field trips School Year Hours: Mon-Fri: 2pm - 7pm Summer Schedule: Mon-Fri: 10am - 6pm Syracuse University 900 S Crouse Ave, Syracuse, NY 0.8 mi SE ( 5 ) - syr.edu Students Faculty Staff Archbold/Flanagan Gymnasium Brockway Fitness Center Ernie Davis Fitness Center Marion Fitness Center Marshall Square Mall Fitness Center Intramurals Late night at the gym Sport clubs Fitness classes Aquatics Ice Skating Outdoor Education Healthy Monday Sex Health Alcohol Awareness Synthetic Drug Use Not open to the public Sexually Transmitted Diseases Substance Abuse Physical Activity Family Planning ESF 1 Forestry Dr, Syracuse, NY 1.1 mi SE ( 5 ) - 5 esf.edu Students Faculty Staff Fitness Center Not open to the public PhysicalActivity Bryant and Stratton College 953 James St, Syracuse, NY 0.9 mi NE ( 5 ) - bryantstratton.edu Students Faculty Staff Not open to the public Crouse Hospital College of Nursing 765 Irving Ave, Syracuse, NY Crouse Hospital Students Faculty Staff HelpPeople (Psych Help) Prompt Care Women s Health Service Employee/Student Health Office Not open to the public Mental Health Physical Activity Onondaga Community College 4585 W Seneca Turnpike, Syracuse, NY 4.0 mi SW ( 5 ) - sunyocc.edu Students Faculty Staff Fitness Center Intramurals Not open to the public Physical Activity Le Moyne College 1419 Salt Springs Rd, Syracuse, NY 3.1 mi E ( 5 ) 5 - lemoyne.edu Students Faculty Staff Diversity Events Intramurals Recreation Centers Not open to the public Physical Activity

Upstate Medical University 750 E Adams St, Syracuse, NY 0.6 mi SE ( 5 ) -55 upstate.edu Students Faculty Staff Pathway to Wellness Healthy Monday Monday Mile Healthy Monday Blog Fitness and Wellness Folksmarch Not open to the public Physical Activity Nutrition Centro 200 Cortland Ave, Syracuse, NY 0.9 mi S ( 5 ) - centro.org Syracuse Residents Transportation Access to health services Bike Paths Syracuse Residents Transportation Only available to those who own bikes and cannot be used in the winter months Physical Activity Access to Health Services Disability Resources Name of Service Address / Contact Info Service Population Services Provided & Potential Barriers Relevance to Indicators Syracuse University: Office of Disability Services 804 University Ave., Room 309, (315) 443-4498 Students Equal access to education Access to programs and activities Coordinates auxiliary aids and services Provides access to adaptive technology Advocates on behalf of students with members of the campus community Only available to students Disability and Health Learning Disabilities Association of Central New York 722 West Manlius Street, East Syracuse, NY 13057 Phone: (315) 432-0665 * Fax: (315) 431-0606 Email: LDACNY@LDACNY.org Elementary Junior/Senior High School College Adulthood Summer Adventures in Learning is for students ages 6 13 Learning Without Borders is for students ages 14 16 Educational Consulting Disability and Health Tutoring Summer Adventures in Learning (SAIL) Learning Without Borders Coaching Services Pathways Employment Services Adult Recreation Groups LIFE: Community Habilitation Workshops Transportation Syracuse University: Entrepreneurship Bootcamp for Veterans with Disabilities 700 University Avenue Suite 303 Syracuse, NY 13244-2530 (315) 443-0141 Veterans Offers experiential training in entrepreneurship and small business management to post-9/11 veterans with disabilities resulting from their service to our Disability and Health

country ARISE 1065 James Street, Syracuse, NY 13202 Phone: 472-3171 Adults Architectural, accessibility ADA and benefits consultation Peer counseling Case management Interpreter referral services Housing Advocacy Supported employment Adaptive equipment program (inc. financial aid in purchasing equipment/per eligibility) Computers Integrated recreational programs Adults only Disability and Health Aurora of CNY 518 James Street, Syracuse, NY 13203-2219 Phone: 422-7263, TDD: 422-9746 Disabled people who are blind, visually impaired, deaf or hard of hearing in Onondaga and surrounding counties and their families Iinstruction in daily living skills Safe and independent travel training instruction in adaptive technology for people with vision loss, Information and referral, counseling, outreach, volunteer services (assessment and training), the Marjorie Clare interpreter referral services alcohol and substance abuse/prevention services geared to the cultural and linguistics Needs of the deaf community. Not for learning disabilities Disability and Health Central New York Developmental Disabilities Services Office (CNYDDSO) 800 Wilbur Avenue, Syracuse, NY 13204 Phone: 473-5050 Persons of all ages who are mentally retarded or developmentally disabled and their families Community outreach and assistance Screening for placement in family care homes or CNY-DSO Not for blind/deaf Disability and Health Enable 1603 Court Street, Syracuse, NY 13208 Phone: 455-7591 Onondaga County Residents, eligible for Medicaid, with a disability that qualifies for personal services who are able to assume responsibility for the supervision of home care. Offers home care through its Self-Directed Personal Services (SDPS) program Very restrictive eligibility requirements Disability and Health Exceptional Family Resources 1065 James Street, Suite 220, Syracuse, NY 13203 Phone: 478-1462 Persons with developmental disabilities (including mental disabilities) in Onondaga County Take A Break respite services Advocacy Family support Outreach recreation Case management Residential habilitation Directory of services Senior Caregivers Project Disability and Health

Huntington Family Centers, Inc. Project Choice 401 South Avenue, Syracuse, NY 13209 Phone: 474-6823 Senior citizens with developmental disabilities 60 years and older Community based retirement and leisure time activities. Hot noon meal Only for seniors Disability and Health Invested Family Services, Inc. 103 Dewberry Lane, Syracuse, NY 13219 Phone: 488-3688 Disabled Individuals Recruitment of Day Habilitation and Residential Habilitation support people on a one-to-one basis taking into consideration specific needs of each individual Disability and Health OCPL Special Services for the Disabled Phone: 435-1876; TDD: 435-1872 Disabled Individuals Talking books program, large print collections, described videos, reference and referrals Transportation Disability and Health Onondaga Association for Retarded Citizens (ARC) 600 Wilbur Avenue, Syracuse, NY 13204 Phone: 476-7441 Disabled Adults Residential sites, vocational assessment, job training and employment, skill enhancement including transportation and social skills and a program specifically designed for seniors. Disability and Health Person to Person: Citizen Advocacy 650 James Street, Syracuse, NY 13203 Phone: 472-9190 Disabled Individuals Recruits and provides volunteer Citizen Advocates for individuals with a disability. Disability and Health Syracuse Developmental Center 800 South Wilbur Avenue, Syracuse, NY 13204 Phone: 473-5034 Disabled Individuals Senior Companions serve clientele (Office of Mental Retardation and Developmental Disabilities) 20 hours a week in work sites or group homes. Companions provide one-on-one attention at the worksite or on shopping and recreational trips. Disability and Health VESID (Office of Vocational and Educational Services for Individuals with Disabilities) 333 East Washington Street, Syracuse, NY 13202 Phone: 428-4179 Disabled Individuals Evaluation, rehabilitation counseling and planning, adaptive equipment, work training, placement, special transportation and maintenance. Some services are based on State financial need standards. Homemaker services are also available. Disability and Health Elder Care Name of Service Address/Contact Info. Service Population Services Provided & Potential Barriers Relevance to Indicators Central Park Rehabilitation and Nursing Center 116 East Castle Street Syracuse, NY 13205 (315) 475-1641 Medicare & Medicaid Certified 160 Residential health care beds Elderwood Health Care at Birchwood 4800 Bear Road Liverpool, NY 13088 (315) 457-9946 Medicare & Medicaid Certified 160 Residential health care beds

Iroquois Nursing Home Inc 4600 Southwood Heights Drive Jamesville, NY 13078 (315) 469-1300 Medicare & Medicaid Certified 160 Residential health care beds Adult day healthcare Not for profit James Square Health and Rehabilitation Centre 918 James Street Syracuse, NY 13203 (315) 474-1561 Medicare & Medicaid Certified 450 Residential healthcare beads, plus 5 ventilator dependent beds Jewish Home of Central New York 4101 E Genesee St Syracuse, NY 13214 (315) 446-9111 Medicare & Medicaid Certified 132 Residential healthcare beds Not for profit Loretto Health and Rehabilitation Center 700 East Brighton Avenue Syracuse, NY 13205 (315) 469-5570 Medicare & Medicaid Certified 583 Residential healthcare beds Not for profit Nottingham Rchf 1305 Nottingham Road Jamesville, NY 13078 (315) 446-0123 Medicare & Medicaid Certified 40 residential healthcare beds Not for profit Rosewood Heights Health Center 614 South Crouse Avenue Syracuse, NY 13210 (315) 474-4431 Medicare & Medicaid Certified 242 residential healthcare beds Not for profit St Camillus Residential Health Care Facility 813 Fay Road Syracuse, NY 13219 (315) 488-2951 Medicare & Medicaid Certified 264 residential healthcare beds 20 traumatic brain injury beds Not for profit Sunnyside Care Center 7000 Collamer Rd East Syracuse, NY 13057 (315) 656-7218 Medicare & Medicaid Certified 80 residential healthcare beds Syracuse Home Association 7740 Meigs Road Baldwinsville, NY 13027 (315) 638-2521 Medicare & Medicaid Certified 120 residential healthcare beds Not for Profit The Crossings Nursing and Rehabilitation Centre 217 East Avenue Minoa, NY 13116 Medicare & Medicaid Certified 82 residential healthcare beds

(315) 656-7277 Van Duyn Home and Hospital 5075 West Seneca Turnpike Syracuse, NY 13215 (315) 435-5511 Medicare & Medicaid Certified 513 residential healthcare beds Adult Care Facilities Name of Service Address/Contact Info. Service Population Services Provided & Potential Barriers Relevance to Indicators Alterra Clare Bridge of Manlius 5125 Highbridge Street Fayetteville, NY 13066 Phone: (315) 637-2000 52 beds Buckley Landing Enriched Housing Site #6 7430 Buckley Road North Syracuse, NY 13212 Phone: (315) 452-1207 85 beds; 65 assisted living program beds Camillus Ridge Terrace 2453 W. Genesee Turnpike Camillus, NY 13031 Phone: (315) 672-379 56 beds Crossroads 120 Gifford Street Syracuse, NY 13202 Phone: (315) 701-3894 59 beds E.R.I.E. EHP #1 Toomey Abbott Tower 1207 Almond Street Syracuse, NY 13202 Phone: (315) 482-8562 95 beds Emeritus at Bellevue Manor 4330 Onondaga Boulevard Syracuse, NY 13219 Phone: (315) 468-5108 91 beds Emeritus at East Side Manor 7164 East Genesee Street Fayetteville, NY 13066 Phone: (315) 637-5127 88 beds Emeritus at West Side Manor 4055 Long Branch Road Liverpool, NY 13090 Phone: (315) 451-3221 80 beds Highland Home 212 Highland Street Syracuse, NY 13203 Phone: (315) 474-2563 20 beds

Kalet's Adult Home 504 Delaware Street Syracuse, NY 13204 Phone: (315) 479-7514 45 beds Keepsake Village at Greenpoint 138 Old Liverpool Road Liverpool, NY 13088 Phone: (315) 451-4567 57 beds Loretto EHP #1 Bernardine Apartments 417 Churchill Avenue Syracuse, NY 13205 Phone: (315) 469-7786 148 beds, 70 assisted living program beds Loretto EHP #3 Nottingham 1301 Nottingham Road Jamesville, NY 13078 Phone: (315) 445-9242 64 beds Loretto Village Apts. Enriched Housing Site #5 750 East Brighton Avenue Syracuse, NY 13205 Phone: (315) 492-1329 79 beds, 38 assisted living program beds Manlius Home for Adults 215 East Pleasant Street Manlius, NY 13104 Phone: (315) 682-6725 40 beds, 26 assisted living program beds McHarrie Pointe 7740 Meigs Road Baldwinsville, NY 13027 Phone: (315) 638-2521 47 assisted living residence beds, 27 special needs assisted living beds New Sunnyside Adult Home 7010 Collamer Road East Syracuse, NY 13057 Phone: (315) 656-7218 20 beds Park Terrace at Radisson 2981 Town Center Road Baldwinsville, NY 13027 Phone: (315) 638-9207 65 beds, 17 assisted living program beds Sedgwick Heights 1100 James Street Syracuse, NY 13203 Phone: (315) 475-4388 154 beds, 120 assisted living program beds The Athenaeum of Skaneateles 150 Genesee Street Skaneateles, NY 13152 Phone: (315) 685-1400 16 beds The Hearth at Greenpoint Senior Living 150 Old Liverpool Road Liverpool, NY 13088 Phone: (315) 453-7911 130 beds The Hearth on James 830 James Street 60 beds

Syracuse, NY 13203 Phone: (315) 422-2173 Wynwood of Manlius 100 Flume Road Manlius, NY 13104 Phone: (315) 682-9261 86 enhances assisted living residential beds Indigent and Hospice Care Name of Service Address, contact info Service population Services provided, potential barriers to access i.e. cost, location, hours Notes on relevance to indicators of interest Syracuse Community Health Center Inc. Federally Qualified Health Center FQHC NYS Article 28 819 S. Salina St. Syracuse, NY 13202 (315) 476 7921 Hours: M-F 7a-11p Sat 9a-9p Sun 9a-5p Volume: 190,000 visits a year Patient base: 39,000 Multispecialty for primary care 15 locations including 5 school based health centers Provides services through: adult medicine, pediatrics, ob gyn, dental care, eye care, podiatry, HIV services, mental health, family and individual counseling, outpatient addiction services for alcohol and drugs, urgent care extended hours, radiology, lab, and surgery consultation. This health center can cover services such as checkups, treatment, pregnancy care (where applicable), immunizations and child care where applicable), prescription medicine and mental and substance abuse where applicable. University Health Care Center Outpatient for the SUNY University Hospital 90 Presidential Plaza Syracuse, NY 13202 (315) 464 4357 Hours: 4:30 pm Monday- Friday 8am- Child Abuse Referral and Evaluation Immunizations Newborn care Pediatric International Health Clinic [medical home for refugee children] Primary care Adult Medicine Women Health Medical Subspecialties Neurology Psychiatry Surgical Subspecialties Outpatient clinic of St Joseph Hospital 216 Seymour Street Syracuse, NY 13204 (315) 703-2600 Hours: Monday, Tuesday, Thursday, Friday, 8:30 a.m. to 5:00 p.m Wednesdays 9:30 a.m. to 6:00 p.m. Volume: 12,000 patients per year The center provides primary health care for children and adults and offers 24-hour physician coverage, seven days a week. well and sick visits Adult and Pediatrics immunizations physical examinations, including on-site laboratory work

obstetrics and gynecology newborn care referrals to specialists, as needed social work services as well as financial and nutritional counseling Poverello Health Center 808 North Salina St Syracuse, NY 13208(315) 423-9961 ext. 22. Hours: Monday 5-7 PM Wednesday 5-7PM Volume: 3000 visits per year, only for those without insurance Free medical care to people without medical insurance in the Central New York area. Staffed by volunteer physicians, nurse practitioners and nurses, as well as a chiropractor and optometrist by appointment. Physical examinations for preemployment and college/vocational schools are available by appointment only. The Health Center provides clients with Prescription Assistance through various pharmaceutical companies. Diabetic Teaching, Dietary Counseling, Social Service Counseling, and Hypertension Monitoring are also offered. Diabetic and Hypertension Workshops and a Health Management Fair (annual). Amaus Health Services at the Cathedral of the Immaculate Conception 262 East Onondaga Street Syracuse, NY 13104 315-424-1911 Hours: Wednesday/Friday: 10:30 AM to 1:30 PM Volume: 1800 visits a year Interim adult primary care at no charge to the patient, occasionally patient will have to get generic prescriptions filled and cover the cost, discounted blood work. Social services and advocacy. Pediatric physical exam clinics. Employment physicals on a limited basis. Walk in, sickest served first Rescue Mission Clinic 120 Gifford St. Syracuse, NY 13202 (315) 701-3870 Hours: 6 hours per week Volume: 200 visits per year Checkups, treatment, pregnancy care (where applicable), immunizations and child care (where applicable), prescription medicine and mental and substance abuse where applicable Rahma Health Clinic NYS Article 28 free clinic 3100 South Salina Street Syracuse, NY 13205 (315) 565 5667 Hours: Wednesday: 5:30-7 pm Saturday: 11am- 2pm Volume: 400 visits per year (projected) Adult Medicine only Primary care services for acute and chronic conditions Prevention and Education Routine diagnosis and treatment of illnesses Screening / Counseling Medication monitoring Laboratory work and x-rays (referrals only) Christian Health Service of Syracuse 3200 Burnet Ave. Syracuse, NY 13206 (315) 433 9999 Volume expected at 13,000 per year Urgent/Same-day appointments always available for existing Patients. Doctor on call 24 hours a day

NYS Article 28 clinic Hours: M-F: 8:30a - 5:00p Sat.: 8:30a - Noon Adult Medicine Pediatrics Counseling and education Immunization Screening Hospice of Central New York Hospice & Palliative Care Associates 990 Seventh North Street Liverpool, NY 13088 Telephone: 315-634-1100 Volume: 1050 patients per year Audiology Baseline Services - Hospice Bereavement Clinical Laboratory Service Home Health Aide Homemaker Housekeeper Inpatient Services Medical Social Services Medical Supplies Equipment and Appliances Nursing Nutritional Pastoral Care Personal Care Pharmaceutical Service Physician Services Psychology Therapy - Occupational Therapy - Physical Therapy - Respiratory Therapy - Speech Language Pathology Urgent Care Name of Service Address, contact info Service population Services provided, potential barriers to access i.e. cost, location, hours Notes on relevance to indicators of interest North Medical Urgent Care Syracuse Community Health Center Urgent Care Crouse Prompt Care 5100 W. Taft Rd. Liverpool, NY 13090 (315) 452-2333 819 South Salina Street Syracuse, NY 13202 (315) 476 7921 739 Irving Avenue Syracuse, NY 13210 (315) 7 days a week 7:00 a.m. 11:00 p.m. M- F 7am- 11pm Sat 9 am- 9 pm Sun 9 am 5 pm 7 days a week 9:00 a.m. 11:00 p.m.

Immediate Medical Care Associates 470-2951 5700 West Genesee Street Camillus, NY 13031 (315) 488-6393 M F 9:00 a.m. 6:00 p.m. S S 8:00 a.m. 2:00 p.m. Northeast Medical Urgent Care Finger Lakes Medical Care - Skaneateles 4000 Medical Center Dr # 4103 Fayetteville, NY 13066 (315) 637-7800 803 Genesee Street (Route 20) Skaneateles, NY 13152 (315) 685-9355 7 days a week 7:00 a.m. 11:00 p.m. M F 9:00 a.m. 12:00 p.m. and 1:00 p.m. 6:00 p.m. S S 8:00 a.m. 1:00 p.m.

Appendix 5. Report on Findings of Community Forums Findings from 2011 Community Health Needs Assessment Forums: Syracuse, New York January, 2012 INTRODUCTION Title IX of the Patient Protection and Affordable Care Act of 2010 requires charitable hospitals to meet certain provisions related to community benefit in order to maintain their tax-exempt status. Among those requirements is that every three years they are to conduct a community health needs assessment (CHNA) that includes community and public health input. Local health departments in New York State are required to conduct periodic community health assessments (CHA) in order to ensure that their programming remains consistent with community needs. These two community planning processes run parallel and have similar attributes. The Central New York Masters in Public Health Program, run jointly by the State University of New York Upstate Medical Center and Syracuse University, initiated a process of community engagement that can support the hospital s CHNA and the Onondaga County Health Department s CHA. Students in the program s Public Health Administration course coordinated and facilitated five forums convened in October and November 2011 and analyzed data collected during those forums as their semester s project. The Lerner Center for Public Health Promotion at the Maxwell School for Citizenship and Public Affairs at Syracuse University provided logistical support and assistance with recruiting forum participants in collaboration with the Onondaga County Advisory Board of Health, the Syracuse City Schools, and Say YES to Education. The forums were held at the Central New York Community Foundation Philanthropy Center; the school-focused forum was held at the Say Yes to Education offices. Altogether, 92 people participated in the forums. APPROACH The forums were conducted using a small-table format that included five to seven participants per table as well as two students from the public health administration course a facilitator and a scribe (for transcribing ideas onto newsprint). Each table, regardless of the type of representatives present, was presented with a common set of core questions/topics. These consisted of an exercise in composing a picture of an ideal community; describing that community succinctly in narrative form; identifying strengths and weaknesses of the current public health situation in our community; issues needing attention in the domains of the public health system and the health status of individuals; and, based upon what they had identified in previous portions of the session, recommendations for local public health priorities. Each session was designed to last two hours. Lerner Center for Public Health Promotion Page 1 of 8 Community Health Needs Findings

The data used for the analysis presented in this report consist of responses given during the portion of the sessions devoted to identifying issues needing attention in the domains of the public health system and the health status of individuals. The analysis process, carried out by an independent researcher assigned to the project as well as public health experts from the Lerner Center, consisted of thematically coding the responses inductively into categories that are consistent with dimensions targeted by the public health field. The following presentation of findings is divided into those representing systemlevel needs and those representing health status issues. The report s final section attempts to draw conclusions regarding public health priorities for the next three years. System-Level Issues FINDINGS Chart 1 shows the distribution of responses among the four main categories that emerged from the data regarding system-level issues. Social conditions generally consists of responses in which people indicated that public health priorities should target community-level factors that are not directly related to the delivery of health, such as the economy, the school system, the public transportation system, and policies affecting safety. The remaining responses generally can be categorized as relating to the public health system s capacity to provide needed care, the difficulties many people have in accessing healthcare either due to problems with the availability of affordable health insurance or in obtaining clear, useful, and unbiased information about healthcare. Chart 1 Percent of Responses Related to Four Main Categories (N=141) 36.2 34.0 17.0 12.8 Social Conditions Access to Care: Capacity Access to Care: Financial Access to Care: Information Lerner Center for Public Health Promotion Page 2 of 8 Community Health Needs Findings

Based upon the number of responses that comprise the social conditions category (see Chart 2), forum participants apparently are concerned that the City and County are not favorable locations in which healthcare and health can thrive. Over half of the responses in this category indicate needs for stronger policies regarding safety (especially crime prevention), jobs, and access to healthy food. 21.6 Chart 2 Percent of Responses Related to the Theme "Social Conditions" (N=51) 15.7 15.7 11.8 9.8 9.8 9.8 5.9 Charts 3, 4, and 5 present the distribution of responses within each of the Access to Care categories shown in Chart 1. Chart 3 shows that most (77%) of the responses are related to the healthcare system s inability to accommodate consumers healthcare needs, particularly primary and mental health care. Forum participants placed relatively little emphasis on dental care and options for eldercare. 41.7 Chart 3 Percent of Responses Related to the Theme "Access to Care: Capacity" (N=48) 35.4 14.6 8.3 Primary Care Mental Health and Substance Abuse Dental Eldercare Options Lerner Center for Public Health Promotion Page 3 of 8 Community Health Needs Findings

Chart 4 shows that between the private insurance market and public coverage (largely Medicaid), it is the private market that caused the most concern to forum participants. Individual responses in the private category primarily focused on coverage and cost while those in the public category mainly focused on a lack of providers that accept Medicaid. Chart 4 Percent of Responses Relating to the Theme "Access to Care: Financial" (N=24) 66.7 33.3 Private Insurance System Public Insurance System Chart 5 shows that forum participants who mentioned problems with obtaining information about healthcare were mostly concerned about a general lack of consumer information. They mentioned information overload, a lack of communication about healthcare opportunities such as free screenings, and a general lack of consumer education. Political responses included mentions of public officials lack of knowledge about local health concerns, politics driving of healthcare decisions, and difficulties posed by the state regulatory environment. 44.4 Chart 5 Percent of Responses Related to the Theme "Access to Care: Information" (N=18) 22.2 22.2 11.1 Consumer Information Cultural Competency Less Political Easier-to-navigate Healthcare System Healthcare System Lerner Center for Public Health Promotion Page 4 of 8 Community Health Needs Findings

Health Status Issues Chart 6 presents the distribution of responses across four general categories impacting health status. Over half of the responses are captured in the chronic disease, mental health and substance abuse, and physical activity and nutrition categories. Chart 6 Percent of Individual-level Responses Included in Each Main Category (N=188) 21.8 18.6 17.6 15.4 13.8 12.8 Chronic Disease Mental Health Physical Activity and Substance and Nutrition Abuse Maternal and Child Health Social Determinants Other Conditions Chart 7 shows that the forum participants identified the need for prevention and treatment of chronic disease to be of importance to the local community. They particularly mentioned asthma as needing attention. 31.7 Chart 7 Percent of Responses Relating to Chronic Disease (N=41) 24.4 22.0 22.0 Respiratory Disease Diabetes Cancer Cardiovascular Disease Lerner Center for Public Health Promotion Page 5 of 8 Community Health Needs Findings

Chart 8 shows that forum participants identified obesity as the status in this category that is most in need of attention. They also are concerned about hunger and poor nutrition among people of all ages. The accessibility category consists of responses in which people identified difficulties people have in getting good food and exercise. Chart 8 Percent of Responses Related to Physical Activity and Nutrition (N=33) 51.5 24.2 15.2 9.1 Obesity Nutrition Accessibility Fitness Chart 9 shows that participants regard mental health for both children and adults as important issues. Substance abuse, including prescription drugs and smoking are also seen as problems. Chart 9 Percent of Responses Related to Mental Health and Substance Abuse (N=36) 60.0 28.6 11.4 Mental Health Substance Abuse Smoking Lerner Center for Public Health Promotion Page 6 of 8 Community Health Needs Findings

Chart 10 shows that almost all of the responses in the maternal and child health category consisted of infancy-related problems. Mentions of infant mortality and low birth weight predominated within this category. Chart 10 Percent of Responses Related to Maternal and Child 86.2 Health (N=29) 13.8 Infancy-related Teen/unplanned Pregnancy Chart 11 presents information about the distribution of other conditions that arose during the sessions. Other conditions mainly include infectious diseases (especially STDs), injuries (especially falls among elderly people), and general oral health. Other conditions within this overall category that were mentioned by forum participants were diseases of the eye, seasonal affective disorder, and allergies. Chart 11 Percent of Responses Related to Other Conditions (N=24) 25.0 20.8 16.7 12.5 12.5 12.5 Infectious Disease Injuries Dental Health Disability Aging Other Lerner Center for Public Health Promotion Page 7 of 8 Community Health Needs Findings

Chart 12 presents findings regarding social factors that are connected to health status. Most responses related to violence mentioned crime or domestic violence, including child abuse; most responses in the education category mentioned either the cost of education or low rates of achievement; all of the responses in the income category either mentioned the cost of health insurance or poverty; and lead poisoning was mentioned by three people. Chart 12 Percent of Responses Related to Social Determinants of Health Status (N=26) 38.5 26.9 23.1 11.5 Violence Education Income Lead Poisoning Overall Assessment of Public Health Issues When the health system and health status issues are considered together, social conditions is the set of factors that are most frequently cited as impacting overall health of the community. These social issues are wide ranging and clearly demonstrate the enormous effect of social and environmental conditions on health. Interventions to address these issues are also broad and would include economic development and expansion of educational opportunities. Access to health care is also a dominant theme. Access is defined broadly and includes financial access and capacity as well as the degree to which consumers are a partner in their health care. In particular, access to primary care and mental health care were identified as problematic. Health status was also negatively impacted by a number of variables including physical activity and nutrition which drives, in large measure, chronic disease, another area of concern frequently cited. Other health concerns relate to mental health and substance abuse as well as maternal and child health, problems exacerbated by limited access to care and poor social conditions. Lerner Center for Public Health Promotion Page 8 of 8 Community Health Needs Findings

Appendix 6. Community Health Assessment Meetings COMMUNITY HEALTH ASSESSMENT MEETINGS 2012 1/4/12 Morrow/Dennison 5/15/12 Morrow/ Dennison 6/5/12 Health Advisory Board 9/11/12 Health Advisory Board 2013 2/12/13 Dr. McCabe, Bob Marzella, Leola Rogers at Upstate 2/19/13 Kathy Ruscitto & Dr. Kronenberg 2/27/13 Mike Melara Partnership Programs 3/5/13 Health Advisory Board (Morrow/Dennison) 4/23/13 CHA Status at Setnor (Morrow/Dennison/Shultz) 4/30/13 CHIP/CHNA & CSP at Setnor (Morrow/Dennison/Shultz) 4/30/13 CHA Technical Assistance Workshop HealtheConnections (Shultz) 5/2/13 Thursday Morning Roundtable State of Our County s Health (Morrow/Dennison) 5/16/13 CNY Safety Net Assessment (Morrow/ Shultz) 6/4/13 Health Advisory Board (Morrow/Dennison) 6/5/13 Upstate Pediatric Grand Rounds: State of Children s Health (Morrow) 6/11/13 Onondaga County Medical Society (Morrow) 6/17/13 HANYS webinar: Quality Improvement and the Prevention Agenda (Shultz) 6/19/13 CHNA NYS Health Foundation (Dennison) 9/3/13 Health Advisory Board (Morrow/Dennison) 9/13/13 Central Region Prevention Agenda Meeting Rome, NY - HealtheConnections (Shultz) 9/18/13 FOCUS Academy 9/19/13 CHA lecture, 1159 W. Hall (Morrow) 10/1/13 CNYMPH conference room 10/15/13 Community Presentation: State of Our County s Health 10/22/13 CHA/CHIP CNYMPH conference room 11/1/13 Upstate OB/GYN Grand Rounds: State of County s Health-Focus on Mothers, Infants, and Children (Morrow)

Appendix 7. State of the County s Health Overview: The State of Our County s Health: An Assessment of Onondaga County s Health Cynthia B. Morrow, MD, MPH Commissioner of Health, Onondaga Thomas H. Dennison, PhD The Maxwell School Syracuse University Why are we here today? New York State Department of Health Accreditation Our county s health: The good, the bad, and the ugly Where do we go from here? How can you help us? Objectives: Describe the CHA, the CHIP, the Prevention Agenda Identify at least two strengths and two challenges in Onondaga s CHA Identify a strategy to get involved in your community s CHA or CHIP New York State Department of Health (NYSDOH) Local Health Departments (LHDs): Community Health Assessment/ Community Health Improvement Plan Hospitals: Community Service Plans Prevention Agenda: Five priority areas Prevent chronic disease Promote a healthy and safe environment Promote healthy women, infants, and children Promote mental health and prevent substance abuse Prevent HV,STD, VPD and health care associated infections Public Health Accreditation (PHAB) Strategic Plan Community Health Assessment OCHD s Mission, Vision, Values: Mission: To improve and protect the health of all Onondaga County residents Community Health Improvement Plan Standards are based on the 10 Essential Services as well as Governance and Administration

The Process to Date: Community Focus Groups Community focus groups Meetings with hospital CEOs Internal and external review of readily available data NOW, let s dive into the data! A place to call home for every person Populatio n Diversity What Does a Healthy Community Look Like? Opportunities To make a Decent living Open Community Forum #1 Access to healthcare Kindness and Respect Ample food for all Low violence /crime Areas to Play & enjoy Trees and plants The Demographics Total population: 466,852 81.8% White 11.4% Black 3.2% Asian 0.9% American Indian / Alaska Native 2.6% Two or more races 4.3% Hispanic (all races) Source: U.S. Bureau of the Census, Population Estimates Program, 2011 Race Syracuse vs. Onondaga County Onondaga County City of Syracuse The median household income for Onondaga County is more than $20,000 greater than the City of Syracuse. In Syracuse, 32.3% of residents live below the poverty line. Nearly 40% of Syracuse children live in poverty. The high school graduation rate for SCSD ranges from 41% to 57%. By comparison, HS graduation rates for suburban schools range from 95% (FM) to 65% (Lafayette). Source: U.S. Bureau of the Census, Population Estimates Program, 2011 Sources: U.S. Census Bureau, ACS 5-year estimates (2007-2011) New York State Education Department (2008-2009 school year)

The Framework: The Five Prevention Agenda Priorities Prevent chronic disease Promote a healthy and safe environment Promote healthy women, infants, and children Promote mental health and prevent substance abuse Prevent HV,STD, VPD and health care associated infections Prevent Chronic Disease Areas of interest: Heart disease Cancer Obesity Sources: http://www.health.ny.gov/statistics/chac/indicators/chr.htm http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=21 http://www.cdc.gov/nchs/fastats/deaths.htm Leading Causes of Mortality in Onondaga County In 2005, the leading cause of death in Onondaga County shifted from Diseases of the Heart Malignant Neoplasms. Very few counties in NYS have made this shift. Mortality from heart disease has been decreasing more quickly than mortality from cancer. Incidence is Increasing, Mortality is Decreasing For Onondaga County Residents: >52 individuals are diagnosed with cancer each week >19 individuals die from cancer each week Source: http://www.acscan.org/ovc_images/file/action/states/ny/ny_cancer_burden_report_2012.pdf Note: Rates are per 100,000, age-adjusted to the 2000 US Standard Population

Incidence Rates (2007-2009) Breast, Lung & Prostate Cancer Mortality Rates (2007-2009) Breast, Lung & Prostate Cancer Source: http://seer.cancer.gov/csr/1975_2009_pops09/browse_csr.php?section=36&page=sect_a_table.03.html NYSDOH County Health Assessment Indicators, Cancer, 2007-2009 Note: Rates are per 100,000, age-adjusted to the 2000 US Standard Population Source: http://seer.cancer.gov/csr/1975_2009_pops09/browse_csr.php?section=36&page=sect_a_table.03.html NYSDOH County Health Assessment Indicators, Cancer, 2007-2009 Note: Rates are per 100,000, age-adjusted to the 2000 US Standard Population Obesity* Rates in Children and Adults Source: Adults NYSDOH Expanded BRFSS, 2008-2009, NHANES 2005-2008, Children / Adolescents Student weight status category reporting system, 2010-2012, NHANES 2005-2008 *Obesity is defined as weight category 95th percentile among children and as BMI 30.0 among adults Promote a Healthy and Safe Environment Promote a Healthy and Safe Environment Areas of interest: Asthma Shigellosis Injury Access to Healthful Foods Source: NYSDOH County Health Assessment Indicators, 2008-2010 Healthy People 2020 Objectives: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=21

Promote a Healthy and Safe Environment Promote a Healthy and Safe Environment Shigellosis outbreak beginning in June 2012 246 cases reported in 2012 compared to 4 cases in 2011 32 cases have been reported through March 2013 Early clusters identified in child care settings Indicator Unintentional injury mortality rate per 100,000 (age adjusted) Unintentional injury hospitalization rate per 10,000 (age adjusted) Onondaga County New York State Significant Difference? 33.7 22.4 Yes 49.1 64.5 Yes Source: NYSDOH County Health Assessment Indicators, Injury, 2008-2010 Homicide Death Rate, 2008-2010 (Age-adjusted per 100,000) Access to healthful foods In Onondaga County: 6.3% of children have low access to a grocery store 5.5% of low income residents have low access to a grocery store (NYS 2.5%) Community Commons 2.0 Starter Map, Community Health Needs Assessment Source: Health Indicators Warehouse via National Vital Statistics System Mortality, 2008-2010: http://healthindicators.gov/indicators/homicide-deaths-per-100000_1041/profile/data Source: USDA Food Environment Atlas, 2010 Promote Healthy Women, Infants and Children Infant mortality disparities Breastfeeding rates Teen births

Infant Mortality, 2010 2012* Breastfeeding rates, 2008-2010* Locality Infant Deaths per 1,000 Live Births Onondaga County 5.5 White 4.3 Black 12.4 Hispanic 8.3 Syracuse 6.7 White 4.6 Black 11.5 Hispanic 7.8 Source: Statewide Perinatal Data System, OCHD Bureau of Surveillance and Statistics *2011 and 2012 data are provisional Source: NYSDOH Community Health Assessment Indicators, Maternal and Infant Health: http://www.health.ny.gov/statistics/chac/chai/docs/mih_31.htm *Onondaga County rates are significantly different than NYS rates for each indicator shown Teen Births per 1,000 females, 2008-2010* Teen Births per 1,000 females by select zip codes, 2008-2010 Locality Birth rate among ages 15 19 years Onondaga County 28.7 13202 164.7 13203 123.7 13204 168.5 13205 172.9 13206 96.3 13207 130.7 13208 138.2 13224 84.7 Source: NYSDOH Community Health Assessment Indicators, Family Planning/Natality: http://www.health.ny.gov/statistics/chac/chai/docs/fp_31.htm *Onondaga County rates are significantly different than NYS rates for each indicator shown Source: NYS County/Zip Code Perinatal Data Profile, NYSDOH Bureau of Biometrics and Statistics http://www.health.ny.gov/statistics/chac/perinatal/county/onondaga.htm Promote Mental Health and Prevent Substance Abuse Areas of interest Self-inflicted injury Newborn drug-related hospitalizations

Self-inflicted injury, 2008-2010 Newborn drug-related hospitalizations Indicator Onondaga County New York State Self-inflicted injury 7.6 5.1 hospitalization rate per 10,000 (age-adjusted) Self inflicted injury hospitalization rate per 10,000 (ages 15-19) 14.8 9.7 Source: NYSDOH County Health Assessment Indicators, Injury, 2008-2010 Prevent HIV, STD, VPD, and Health Care Associated Infections Areas of interest Influenza Gonorrhea

Appendix 8.a Community Health Needs Assessment and Community Engagement 1 The Patient Protection and Affordable Care Act (PPACA) establishes a set of new requirements for non-profit hospitals. Included is a requirement that hospitals conduct a community health needs assessment (CHNA) every three years and adopt an implementation strategy to meet the community health needs identified through such assessment. The CHNA must take into account input from public health experts and individuals in the community who represent the broad interests of the community. A copy of the CHNA must be made available to the public. In order to meet the requirement to take into account input from persons who represent the broad interests of the community served by a hospital facility, the Treasury and the IRS intend to provide that a CHNA must, at a minimum, take into account input from (IRS 2010): 1) persons with special knowledge of or expertise in public health; 2) federal, tribal, regional, State, or local health or other departments or agencies, with current data or other information relevant to the health needs of the community served by the hospital facility; and 3) leaders, representatives, or members of medically underserved, low income, and minority populations, and populations with chronic disease needs, in the community served by the hospital facility. A single person may meet more than one of these requirements and therefore satisfy both concurrently. For example, you may include certain government officials with expertise in areas of public health and thus fulfill the requirements stated in paragraphs 1 and 2. Hospital organizations will want to develop an elite team to address these new requirements. A team of qualified individuals working collectively through these new requirements will ensure the best possible outcomes. A main requirement of section 501(r)(3) is that there must be both community and public health input.

2 Below is a list of some potential beneficial members to include: Community-based organizations Business Associations (Chambers of Commerce) Food Pantries Law enforcement/public Safety Agencies Health Insurers/ Managed care organizations Nonprofit organizations Elected government officials Institution of higher learning, such as schools of public health Hospitals Private businesses Community health centers Local health department Appointed government officials Religious organizations School systems Both the Community Health Needs Assessment and the Implementation Strategy need to be completed by the end of the organization s tax year that starts after March 23, 2012, or in either of the two immediately preceding taxable years. (Tax year 2010, 2011 or 2012.) If the fiscal year is the calendar year, then by December 31, 2013. IRS Notice 2011-52 considers a CHNA as being conducted in the taxable year that the written report of its findings is made widely available (posted on the organization s website). IRS Notice 2011-52 further advises that an implementation strategy is considered as being adopted on the date that the implementation strategy is approved by an authorized governing body of the hospital organization. The Notice further advises that the Implementation Strategy must be adopted by the end of the same taxable year in which it conducts its CHNA. The timetable for the local CHNA is displayed below: Dates September 2011- December 2011 January 2012 April, 2012 May 2012 July 2012 August 2012 November 2012 December 2012 Activity Community Engagement Process Data Collection and Analysis Priority Setting/CHNA Document Action Planning/Implementation Plan Adoption/Publishing Plans Specifically, the community engagement process would contribute to: 1. Understanding the public health priorities of key community constituents; and 2. Identifying key community constituents who could collaborate to design and introduce initiatives that address these key public health priorities.

3 Process MPH 607 (Public Health Administration) students will be split into 4 groups of 7 members. Each group will be assigned to coordinate and facilitate one of the below sessions in the months of October or November, and produce a final report as the final project of the course. A total of 4 community sessions will be facilitated by the student groups: Two (2) sessions with leadership of local organizations, one group of human service/health professionals and another of business and government executives; and Two (2) groups of community members, one group of members at large invited through the media and one group of community members recruited through the Syracuse City Schools, intended to engage parents and teens. Staff from the Lerner Center for Public Health Promotion will provide, in consultation with the Onondaga County Advisory Board of Health, a listing of individuals to be invited to the two local leadership sessions. The Lerner Center will also provide support through social media venues to assist with recruitment of community members at large. The Syracuse City Schools and Say YES to Education will be asked to support identification of participants in the school session. The Lerner Center will also assist in securing venues for the sessions and fund refreshments and materials. Training One class session will be dedicated to a facilitator training, conducted by Tina Nabatchi, Assistant Professor of Public Administration, which will introduce the students to the skills and approaches employed in facilitation of community meetings. All students are to follow the facilitation process and design as taught, such that the process is comparable across groups so that there is some degree of intergroup comparability. There will be standard questions asked at each group (to be given), though other questions will vary depending on the type of group and intended participation. Timing The timing of the engagement process is below: Months Activity September 13, 2011 Facilitation Training September 20, 2011 Presentation of Core Questions/Topics Discussion of Venue September/October, 2011 Planning and Recruitment of Participants October/November,2011 Conduct Sessions November/December, 2011 Synthesize Findings December, 2011 Present Findings

4 Content A common set of core questions/topics will be drafted and provided to the student groups on September 20, 2011; students will add questions during the planning phase and will present them before the facilitated sessions to ensure some degree of comparability yet have questions/topics tailored to the characteristics and interests of the audience. Group Responsibilities Become well versed with the Onondaga County Health Department 2010 Community Health Assessment, chronic disease data, health disparities, and socioeconomic data for the county and City of Syracuse. Develop forum specific questions/topic areas for discussion. Manage RSVPs for the session. Upon advice/assistance from Lerner Center Staff, make the arrangements for forum space and supplies Facilitate the forums and collect qualitative data. Write up the forum talking points. Produce a final report in a standardized format. Present the findings.

Appendix 8.b. 7.b Lerner Center and MPH Program Community Engagement Forums The Lerner Center for Public Health Promotion and the CNY Master of Public Health Students invite you to participate in a community engagement process about health needs in Onondaga County. Overview: We are assisting the Onondaga County Health Department and local hospitals respond to the health needs of the community by involving YOU. Forums will be held this fall and are intended to engage a diverse range of people. We want to hear your thoughts on health needs and priorities in Onondaga County, so we can help the county health department and hospitals respond with the services and programs you value. CNY Master of Public Health students will serve as forum organizers and facilitators for the sessions. Please join us at one of the following five sessions. To help us plan accordingly, you must RSVP. Space is limited! The following four sessions will be held the CNY Philanthropy Center Ballroom (2 nd Floor), 431 E. Fayette Street. Light refreshments will be served. For Business Representatives and Elected Officials Date & Time: Monday, October 24 th from 5:00pm to 7:00pm RSVP with Dorothy Shuldman: dshuldman789@gmail.com Open General Community Session 1: (This session is open to any interested citizen!) Date & Time: Thursday, October 27th from 6:00pm to 8:00pm RSVP with Sarah Irish: irishs@upstate.edu For Not-for Profits, Health Department, & Hospital Representatives: Date & Time: Thursday, November 3 rd from 9:00am to 11:00am RSVP here: http://www.doodle.com/6w338vihgz5ii99m Open General Community Session 2: (This session is open to any interested citizen!) Date & Time: Thursday, November 10 th from 6:00pm to 8:00pm RSVP with Bethany Stewart: bestewar@syr.edu Street parking can be found in and around the Fireman s Park on the street in front of the building. Please do not park in the space that is marked for Joseph s Carriage House. This session is intended to draw teachers, parents, and teens. Light refreshments will be served: Open Community Session 3: Date & Time: Monday, November 7th from 6:00pm to 8:00pm Location: Say Yes to Education Community Room, 109 Otisco Street, 2 nd Floor (between Otisco & Tully Streets. Free parking lot on the Tully Street entrance). RSVP with Christine Welker: cmwelker@twcny.rr.com Maxwell School of Syracuse University 406c Eggers Hall Syracuse, NY 13244-1020 Ph: 315-443-4526 Fax: 315-443-1081 Web: lernercenter.syr.edu

Appendix 9. Neonatal Abstinence Syndrome in Onondaga County In approaching this problem, a deep understanding of addiction is necessary. With independence and without constraints, this freedom of thought allowed me to think of the larger picture of one specific issue in the context of public health. I first approached the syndrome by attempting to understand the patients and social stressors. I spent a month in Madison, Wisconsin enrolled in an addiction medicine elective. Behavioral and societal characteristics of these patients suffering from addiction, revealed underlying psychosocial pressures that were both unique and paradoxically non-unique under the public health microscope. I anecdotally recall struggling with the idea of personal choice versus societal responsibility in difficult patients diagnosed with various Axis 1 and Axis 2 disorders as well as addiction. I found their behavioral characteristics unique, as I had negative intuitive reactions to patients who I felt were confrontational and entitled, while some patients were extremely intelligent and insightful; at times the patients were a mixture of all these characteristics. When treating diabetic or hypertensive patients, the target behaviors that need adjustment are generally similar (diet and exercise); addiction seemed like an entirely different animal. I briefly struggled with questions aimlessly pontificating on the abstract. More specifically, I wondered whether these patients were a product of their environment or slaves to their impulses. The question was important because both society and the individual took different roles in treatment. What is the best role for the patient to take? What role should public health policies have in treating mothers addicted to illicit drugs? Could treatment be tailored for subsets of patients with similar behavioral or socio-economic traits? Is there an implicit human similarity between all of these patients? I decided that the last question was the most interesting, but also impossible. The human factor added a variable which could not be quantified. But the realization of this, led me to ponder the role of a humanistic physician. I understand primary care physicians to be knights of the public health realm. Primary care doctors have the responsibility of carrying out the orders based on evidence based scripture. Self-inflating romanticism aside, I found the same, non-unique socio-economic inequalities prevalent in Onondaga County s population suffering from neonatal abstinence syndrome. As an individual physician, saving the indigent population from every disease borne from socioeconomic inequality is unrealistic and perhaps too idealistic. In treatment, the recognition of those factors proved to be important nonetheless.

Avenues for improvement emerged through a thoroughly personal immersion in addiction medicine and available literature. With these experiences I was able to learn of social pressures shaping the decisions of patients. I found, given appropriate resources, research, and a politically permissive environment, that many of these social pressures can be alleviated through public health measures which include the individual physician.

Neonatal Abstinence Syndrome in Onondaga County I. Introduction Neonatal abstinence syndrome (NAS) is defined as the presence of withdrawal symptoms in the newborn caused by prenatal maternal use of illicit drugs. This syndrome is primarily caused by maternal opiate use (1). Adverse neonatal outcomes including low birth weight and increased morbidity and mortality have been associated with illicit drug use and specifically the dependence of opioids during pregnancy (1-5). In neonates, the withdrawal symptoms are similar to those experienced by adults and include feeding intolerance, seizures, emesis, and respiratory distress (1,6). This syndrome reflects a growing concern over the prescription drug abuse epidemic in the United States. The national incidence of NAS increased from 1.2 (95% CI 1.04-1.37) to 3.39 (95% CI 3.12-3.67) per 1000 births from 2000 to 2009 (1). During the same period, the number of mothers using or dependent on opiates at the time of birth, increased from 1.19 (95% CI 1.01-1.35) to 5.63 (95% CI 4.4-6.71) per 1000 births (1). The 3 fold increase in NAS diagnosis and 5 fold increase in maternal opiate use have significantly increased health care expenditures nationwide. In hospitals across the United States, newborns diagnosed with NAS were associated with a 35% increase in hospital expenses when compared to the 30% increase in expenses for all other hospital births. Total hospital charges for NAS were estimated to have increased from 190 million dollars to 720 million dollars after adjusted for inflation (1). The Centers for Disease Control and Prevention found that sales and deaths related to opiate pain relievers quadrupled between 1999 and 2008 (1,7). Onondaga County has not been spared in this epidemic. According to the New York State Health Department, Onondaga County has the highest rate of newborn drug-related-discharges in the state with 250.7 discharges per 10,000 births compared to the state average of 58.4 (8). Although these numbers do not take into account the differing screening methods and protocols per county, the numbers do represent the increasing number of infants physiologically dependent on drugs of abuse and more specifically opiates (See Figure 2). The primary objective of this report was to examine the maternal characteristics of infants and mothers born with a positive drug screen in Onondaga County. Based on these

characteristics, a multifaceted approach towards improving the health of Onondaga County was sought. To briefly outline the following text, Section III includes preliminary data on maternal characteristics. The population of interest is divided into three separate groups, mothers or infants who tested positive for illicit drug use based on clinical suspicion versus the overall number of births in Onondaga County. Positive drug screen was associated with NICU admission and likely NAS (see Fig. 1) Section IV summarizes the maternal characteristics in the context of public health while suggesting possible solutions through public health policy and the physician. II. Materials and Methods Onondaga County s birth database dating from January to May 2012 was examined. Mothers and infants were tested based on clinical suspicion. In these preliminary studies, no statistical analyses were performed. III. Results: Maternal Characteristics

IV. Discussion A) Drug Monitoring Programs, Physician Education and Research In this study, we set out to test the null hypothesis that the mothers of the neonates born with abstinence syndrome were not demographically different than the other females who gave birth during the same period in Onondaga County. One characteristic we found to be significant between these two populations was that the mothers were likely to be on Medicaid (Fig. 3 and 4). Although not the only significant finding, Medicaid implicates the role of public health. In the national study, Patrick et al. found that newborns were likely to be covered by Medicaid and reside in low income zip codes (1). Medicaid was also found to be primary payer for most hospital charges attributed to NAS and maternal opiate abuse (1). These findings are similar to those found in our study as the majority patients with a positive drug screen were found to be on Medicaid. Consequently, the burden of drug abuse on state Medicaid budgets necessitates attention from public health officials, including Onondaga County. In an editorial

regarding the prescription opiate abuse epidemic, Hayes and Brown cite that state and federal systems may pay in the future because of the special services required for the neonates affected (9,10). However, characterizing fetal exposure to opiates and other drugs and deducing risk of NAS is extremely complex (9). Given this complexity, protocols for treatment and prevention must focus on a wide array of services including methadone treatment retention, psychiatric care, and those that focus on psychosocial stressors. At a state and county level, physician education and drug monitoring programs may be effective public health measures. In a response to growing prescription drug abuse, the White house issued a federal response stressing the importance of drug tracking and monitoring. (11,12). Gugelman and Perrone cited a study demonstrating benefits associated with prescriber accessible monitoring programs. In one such prospective study, access of the drug monitoring database resulted in 61% of the queries with decreased or no opioid prescriptions without an indiscriminate decrease in administration (11,13). This real time access also illustrated the diversion of drugs from original intended use and physician shopping by patients (11,13). In Gugel and Perrone s commentary, it was reported that drug monitoring programs are associated with volume reduction of schedule 2 opioids in communities. The Department of Justice suggested that the reduced supply should reduce the likelihood of opioid abuse (11, 14). Despite the optimism, some drug monitoring programs account for no significant mortality reduction which has been attributed to significant differences amongst programs (11, 15). Public health officials in Onondaga County should advocate for a statewide, streamlined and uniform drug monitoring program. To implement a uniform prescription drug monitoring program (PDMP) in Onondaga County, recommendations issued by the American Society of Addiction Medicine (ASAM) should be acknowledged. Problems with PDMPs include the lack of consistent funding and disjointed programs across states (16). ASAM recommended that PDMPs should be available for review by clinicians across state boundaries, include real time data, and should be considered confidential health information (16). ASAM also stated that this information should be protected from release to law enforcement, courts, employers and family members but access should be granted to medical examiners, public health authorities, quality assurance agencies and state licensure board in order to assess trends and to ensure that professional standards are met (16). Other recommendations issued by ASAM included suggestions promoting prescriber education and future research. With respect to future research, ASAM suggested that CDC and

other research should be expanded to provide data on patterns of manufacturing, distribution and sales of drugs which have potential for abuse (16). Local pharmacies in Onondaga County may be of benefit in this regard. Concerning prescriber education, ASAM suggested that the Controlled Substances Act should be amended to require all DEA registrants to obtain training on the use of controlled substance. Educational programs should be specific to drug classes and include general principles on prescribing, assessment of risk for potential addiction, and how to recognize addiction and appropriately intervene (16). Before such an endeavor is taken in Onondaga County, physician prescribing practices should be studied in the future to better target educational requirements. The Federal response issued by the White House focused on goals similar to ASAM s, such as patient and clinician education, proper medication disposal as well as drug monitoring. While promotion of research dollars, prescriber education and drug monitoring programs fall under the realm of public health, physicians have a unique role in this epidemic. The primary and most effective patient educator is the physician. Understanding the psychosocial situation of these patients is imperative in effectively screening patients and communicating goals of treatment. B) The Physician s Duty to Understand It can be concluded from our data that the patient population susceptible to NAS (those who tested positive on drug screen) are exposed to a variety of psychosocial stressors. To summarize the findings, mothers who are 24 years of age and younger, have a high school degree/equivalent or less, participate in WIC, and lack paternal support have a higher association with NAS. In Onondaga County, black race appears to be a risk factor as well. Lastly, patients who reported illegal drug and tobacco use were also more likely to test positive for a drug screen. Given that black race is a risk factor, the majority of NAS susceptible patients are on Medicaid, younger, obtain less education, and participate in WIC, socioeconomic disparity appears to be an obvious factor determining risk for NAS. To address these larger social determinants of health, multidisciplinary approaches must be taken. The Commission on Social Determinants of Health, a 250 page document issued by the World Health Organization, in an effort to reduce health inequities recommends the health sector of Government develop, relevant skills and capacity among the health workforce and providing reward structures for intersectoral working. According to the Commission, taking a social

determinants approach will require an enhancement of skills, knowledge and capacity; reasoning that: This is due to the necessity to diversify and target the set of interventions to cater for the specific needs and circumstances of different population groups (17) Discussing urban planning, statewide education, universal healthcare, social protection systems, political and market responsibilities, financing and social justice is beyond the scope of a physician s capability. However, the acknowledgement of these issues and the necessity to cater to specific needs and circumstances of unique population groups is a professional responsibility. The enhancement of skills and knowledge lies in proper physician prescribing of opiates, and a better understanding of the population at risk. C) A multidisciplinary approach starting with the Physician Evaluation of psychosocial functioning and aberrant drug taking behaviors by the physician is a step toward improved understanding of the population at risk for developing NAS (18). Difficulties in psychosocial functioning can be caused by lack of paternal support, financial status, and education. Understanding that the Onondaga County population at risk for NAS are more likely to experience these psychosocial difficulties should increase awareness of the physician during routine prenatal care and when prescribing medication. As the national growing epidemic is concerned mainly about opiate prescription abuse, the following discussion will focus on said opiate abuse. When treating patients with opioid analgesics, it must be acknowledged that there is a legitimate need for opioids in a subset of patients, but the public health implications of abuse must be recognized (19). The American Academy of Pain Medicine (AAPM) issued guidelines for treatment of chronic non-cancer pain with opiate analgesics and made numerous recommendations. The recommendations relevant to this discussion include those involving patient selection and stratification. For example, the AAPM recommended that before initiating opioid therapy, clinicians should conduct a history that includes risk of substance abuse, misuse or addiction (19). In our population of interest, patients who reported prior use of illegal drugs or even tobacco use were more likely to be at risk for NAS. The history may also reveal a somatoform disorder, unresolved compensation or legal issues which predict poor response to

chronic opioid therapy (19). In studies cited by the AAPM guidelines, younger age and presence of psychiatric conditions are associated with aberrant drug related behaviors (19). In Onondaga County, patients who were younger were more likely to test positive on drug screen (Fig. 8 and 9). Based on findings in the history, the patient may be stratified into either an uncomplicated patient, a patient with comorbid psychiatric or coping difficulties, or a patient with addiction (18). Patients with comorbid psychiatric disorders or coping difficulties may have behavior that resembles that of an addict (18). For these patients who may self-medicate, socialize around the drug, or use it as a coping method, Passik and Kirsh recommend psychiatric involvement and drug treatments that reduce the meaning of medications (18). This requires a multidisciplinary approach with psychiatrists and psychologists involved in patient care. Moreover, patients with addiction or at a high risk should have the most structure around treatment plans, including frequent visits, limited prescription supply, opioids with little street value, required participation in recovery programs, and urinary toxicology screens (18). The many disciplines involved reiterates the WHO s statement advocating for a social determinant approach. Furthermore, when drug related behaviors are identified, a multidisciplinary approach may be taken to prevent further abuse or drug diversion. Aberrant drug behaviors include feeling over sedated or intoxicated, motor vehicle accident on opioids, requesting early refills, increasing dosage without physician consent, misplacement, requesting multiple physicians, using opioids for reasons other than pain, the use of alcohol to deal with pain, hoarding medications and missing appointments (20). Physicians should be cognizant of these behaviors, in the context of the patient s psychosocial stressors. For example, a patient may live quite a distance from the physician or lack transportation, resulting in a request for early refills. However, four or more aberrant behaviors have a strong relationship to substance use disorders (20). To prevent some of these behaviors, pharmacies may be of use through drug monitoring programs. Physicians may also require one prescriber and pharmacy, scheduled pill counts, and enumeration of behaviors that would lead to the discontinuation of opioid treatment (20). Regardless of patient stratification, each patient should be advised to safely lock away the medications as they do firearms. V. Conclusions

In anticipating an increase of Neonatal Abstinence Syndrome in Onondaga County, a variety of approaches can be taken. At a state level, advocating for the funding of uniform drug monitoring programs with the help of pharmacies would be helpful. Targeted campaigns, educating physicians on how to prescribe properly, or patients on adverse effects of drug use on an infant in areas at risk for NAS may also be helpful. At a national level, initiatives describing misplaced opiate prescriptions akin to firearms may be effective in reducing the supply (advertising campaigns advising patients to lock their medicine cabinets). Focused or advanced physician training in opiate prescription may be an inevitable requirement. Until then, physician prescribing methods must acknowledge social and psychological circumstances unique to patients at risk for NAS with a health system allowing for multidisciplinary communication and treatment. VI. Limitations The aim of this study was to examine possible avenues to improve health outcomes in NAS. One of the large limitations inherent in this project was the lack of actual NAS diagnoses. The patients studied were at risk for NAS because of positive drug screening tests. Clinician bias in choosing which patients to screen may have underestimated the population at risk. This may have confounded population characteristics. In order to better characterize these patients retrospectively, an actual diagnosis of NAS may be required in the future. Without definitive characterizations, it is difficult to suggest concrete solutions and guidelines. VII. Future Directions Relevant health information that may be included in future studies should address comorbid psychiatric conditions and possible factors affecting paternal support. It is feasible to suggest that underlying societal and cultural issues affecting patient well-being may be exposed when examining the interplay between various maternal characteristics. Furthermore, participation in WIC (fig. 11) may be a valuable location for patient education and incentives as many of these patients appear to be at higher risk for NAS given their socioeconomic status. Examining geographic data may also be of use in order to target public health initiatives to the most effective locations. For example, a county wide initiative informing patients to lock

up their medicine cabinets can be heavily targeted in zip codes with higher rates of NAS (see Fig. 13 below) Fig. 13 Geographic Rates with Test Denominator>40 Positive Test Rate 0.1 0.08 0.06 0.04 0.02 0 13205 13208 13207 13203 13209 13204 13069 13210 13202 Zip Codes

References 1) Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: US, 2000-2009. JAMA. 2012;307 (18): 1934-1940) 2) Hulse GK, Milne E, English DR, Holman CDJ. The relationship between maternal use of heroin and methadone and infant birth weight. Addiction. 1997; 92 (11): 1571-1579 3) Madden JD, Chappel JN, Zuspan F, Gumpel J, Mejia A, Davis R. Observation and treatment of neonatal narcotic withdrawal. Am J Obstet Gynecol. 1977; 127(2):199-201. 4) Dryden C, Young D, Hepburn M, Mactier H. Maternal methadone use in pregnancy: factors associated with the development of neonatal abstinence syndrome and implications for healthcare resources. BJOG. 2009; 116(5): 665-671. 5) Minozzi S, Amato L, Vecchi S, Davoli M. Maintenance agonist treatments for opiate dependent pregnant women. Cochrane Database Syst Rev. 2008;(2): CD006318 6) American Academy of Pediatrics Committee on Drugs. Neonatal drug withdrawal. Pediatrics. 1998; 101 (6):1079-1088 7) Signs V; Centers for Disease Control and Prevention (CDC). Vital signs; overdoses of prescription opioid pain relievers-us. 1999-2008. MMWR Morb Mortal Wkly Rep. 2011; 60 (43):1487-1492. 8) www.healthy.ny.gov/statistics/chac/hospital/v3drug.htm 9) Hayes MJ, Brown MS. Epidemic of prescription opiate abuse and neonatal abstinence. JAMA. 2012; 307(18): 1974-1975. 10) Hunt RW, Tzioumi D, Collins E, Jeffery HE. Adverse neurodevelopmental outcome of infants exposed to opiate in-utero. Early Hum Dev. 2007;84(1):29-35. 11) Gugelman HM, Perrone J. Can prescription drug monitoring programs help limit opioid abuse? JAMA. 2011; 306 (20): 2258-2259 12) Epidemic: Responding to America s Prescription drug abuse crisis. April 2011. http//www.whitehouse.gov/sites/default/files/ondcp/issues-content/prescription-drugs/rx_abuse_plan_0.pdf. 13) Baehren DF. Marco CA, Droz DE, Sinha S, Callan EM, Akpunonu P. A state-wide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010; 56(1):19-23. 14) Simeone R, Holland L. An Evaluation of Prescription Drug Monitoring Programs. Washington DC: US Dept of Justice, Office of Justice Programs;2006. 15) Paulozzi LJ, Kilbourne EM, Desai HA. Prescription drug monitoring programs and death rates from drug overdose. Pain Med. 2011; 12(5):747-754. 16) Measures to counteract prescription drug diversion, misuse and addiction. http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statement /2012/01/26/measures-to-counteract-prescription-drug-diversion-misuse-and-addiction. 17). Closing the gap in a generation. The Commission on Social Determinants of Health. http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf

18) Passik SD, Kirsh KL. Assessing aberrant drug-taking behaviors in the patient with chronic pain. Current Pain and Headache Reports. 2004; 8:289-294 19) American Pain Society. Clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain. The Journal of Pain. 2009; 10 (2): 113-130. 20) Fleming MF, Davis J, Passik SD. Reported lifetime aberrant drug-taking behaviors are predictive of current substance use and mental health problems in primary care patients. Pain Med. 2008;9 (8):1098-1106

LWW/JPHMP PHH200388 August 26, 2011 17:2 Appendix 10. Onondaga County Health Department s Journey to the Summit A Local Health Department s Journey to the Summit: A Case Study of a Decade of Quality Improvement Cynthia B. Morrow, MD, MPH; Quoc V. Nguyen, MD; Rebecca G. Shultz, MPH; Jill M. Murphy, PhD; Michelle A. Mignano, MPA Asthe interest in quality improvement (QI) efforts in public health agencies gathers momentum, organizations looking to initiate or strengthen QI processes may benefit from learning about existing programs. This article serves as a case study for other agencies to consider as they embark upon their QI journey. Specifically, this article reviews more than a decade of QI efforts in a mid-sized local health department and highlights areas of success (including an annual QI summit), barriers to implementation of QI, and areas needing improvement. KEY WORDS: local health departments, quality improvement Over the past few years, there has been growing interest in public health quality improvement (QI), as evidenced by the recent publication of consensus definitions of quality in public health and QI. 1,2 Furthermore, participation in the voluntary national accreditation process has the potential to improve the public s health and transform local health departments (LHDs) into high-performing organizations that value continuous QI. Drawing from over 10 years of experience in formal QI activities, this article presents an overview of the QI process at a mid-sized LHD. It is intended to provide a possible framework for other LHDs that are considering establishing a formal QI plan or expanding their current QI plan. According to the 2008 National Profile of Local Health Departments Study, more than half of LHDs surveyed intended to seek voluntary national accreditation. 3 The LHDs indicated that the promotion of high performance and continuous QI were among J Public Health Management Practice, 2011, 00(00), 1 7 Copyright C 2011 Wolters Kluwer Health Lippincott Williams & Wilkins the top benefits for those seeking accreditation. 3 The standards and measures set forth by the Public Health Accreditation Board include 1 domain specifically addressing the development and implementation of QI in public health processes, programs, and interventions, while also infusing QI across all domains. 4 For an LHD to move toward accreditation, it will be imperative to establish and implement a QI process within the agency; yet, only half of the LHDs surveyed in 2008 reported performing any formal QI activities. Mid-sized and large LHDs were disproportionately involved in QI activities. 4 There are many challenges faced by LHDs seeking to institute a QI program, including prioritization of limited resources. This article addresses some of the challenges faced by an LHD, as it transforms its organizational culture to embrace QI as a means to improve its services and the community s health. The Onondaga County Health Department (OCHD), located in Syracuse, New York, is a full-service LHD that serves more than 467 000 residents in central New York. 5 (Refer to Figure 1 for an organizational chart for [F1] OCHD.) In 2011, OCHD employed 280 full-time and 20 part-time employees and had an adopted budget of $79 million, of which $26 million (including $10 million in grants) were for core public health activities. The institutional review board was consulted, and it was determined that this study did not need to be reviewed, because it did not meet institutional review board s definition of Human Subject Research. Author Affiliations: Onondaga County Health Department, Syracuse, New York (Drs Morrow and Nguyen and Mss Shultz and Mignano); and Department of Public Health and Preventive Medicine, Upstate Medical University, Syracuse, New York (Drs Morrow and Murphy). Disclosure: The authors report no conflicts of interest. Correspondence: Cynthia B. Morrow, MD, MPH, Onondaga County Health Department, 421 Montgomery St, Syracuse, NY 13202. DOI: 10.1097/PHH.0b013e31822f6296 [AQ1] [AQ2] [AQ3] 1 Copyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

LWW/JPHMP PHH200388 August 26, 2011 17:2 2 Journal of Public Health Management and Practice FIGURE 1 Onondaga County Organizational Chart A History of Quality Assurance and Improvement Efforts Quality assurance In 1989, OCHD founded a quality assurance (QA) committee, which was charged with reviewing issues pertaining to aspects of New York State s Public Health Law. This committee primarily focused on reviews to ensure that the clinical functions of the LHD complied with regulations concerning the use of pharmacologic agents or the accreditation of health care workers. Quality improvement: the path to the summit In 1998, the leadership of OCHD convened the first annual QA summit in which programs presented their main QA projects. Within a few years, the focus shifted from solely QA to both QA and QI, as there was increasing recognition of the need to improve certain problematic areas and to become more responsive to client satisfaction. By 2000, the first annual QI summit was held. The intent of the QI summit was to encourage OCHD program directors across the department to develop, implement, evaluate, and present the results of focused interventions to improve programs effectiveness or efficiency. While no formal tools for QI were required to be used, a 4-step format involving collection of baseline data, implementation of a specific intervention, postintervention data collection, and analysis of pre- and postintervention data was emphasized to staff involved in QI projects. In retrospect, these early QI efforts were representative of Small qi by Riley et al 6 (small, incremental improvements), but they did not yet reflect the organization s cultural shift to the large, meaningful changes or Big QI. 6 To ensure the success of the summit, a Quality Improvement Methodology Committee (QIMC) was established to provide support to program directors. The QIMC includes OCHD staff members, trained in QI methods and processes, who provide the framework and the support system necessary for the endeavor. The program directors are responsible for selecting and proposing a potential project for the QI summit. The QIMC then reviews each project to ensure that it has a sound design, a plausible intervention, and measurable outcomes that are amenable to statistical analysis. An emphasis is placed on the relevance and significance of the project s potential impact on the public s health. After projects meeting these criteria are identified, the QIMC presents the proposed project list to the leadership of the OCHD for further feedback and final approval. Once a project is approved, a QIMC member provides ongoing guidance to the project staff on study design, data collection, statistical methods, presentation aids, and any other necessary supports. The QIMC convenes monthly throughout the project period to report on progress and to identify and mitigate any problems. [AQ4] Copyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

LWW/JPHMP PHH200388 August 26, 2011 17:2 A Local Health Department s Journey to the Summit 3 [T1] [T2] In preparation for the QI summit, each project team develops a Powerpoint presentation summarizing the project and prepares to deliver the presentation. The QI summit is organized as a day-long event held at an offsite location to showcase the projects. All health department staff, local leaders from County Executive s Office, the health advisory board, and the legislature are invited. On average, approximately 50 individuals attend the summit every year. A brief review of more than a decade of QI summits Between 1998 and 2010, 212 individual projects were presented at the annual summit. Table 1 provides a broad overview of the distribution of projects by the Division or Bureau. For the first 3 summits, project involvement was limited to core public health programs. However, in 2000, the leadership of OCHD recognized the importance of having administration participate as well. Since then, staff members from the fiscal office, information technology, and other administrative support services have implemented projects with the understanding that management practice directly impacts program performance. Further descriptions of projects from the 2010 summit, including their findings and their potential impact, are presented in Table 2. The brief project descriptions illustrate the broad range of projects selected. In an effort to encourage broad staff participation in the QI summit, some projects approved for presentation may not have involved the improvement of an existing process or service. Over the years, cross-cutting projects involving collaboration of different programs have been encouraged as a means of promoting coordination of services among programs targeting the same population. These collaborative efforts result in improved efficiency and TABLE 1 Distribution of QI Projects by Division or Bureau, 1998-2010 Bureau or Division Number of Projects a Administration 21 Center for forensic science 19 Correctional health 12 Disease control 20 Environmental health 37 Family planning 11 Health promotion 42 Maternal and child health 48 Surveillance and statistics 2 a Projects resulting from collaboration between 2 or more programs were counted once. The Bureau of Surveillance and Statistics routinely provides support to other QI projects. shared expertise. As an example, in 2005, the Lead program teamed with the Early Intervention (EI) program to implement an intervention designed to increase lead testing rates among EI participants. It has also become evident over time that some projects require longer data collection or intervention periods to produce more meaningful results. For this reason, multiyear projects have been encouraged when appropriate and feasible. For example, in 2009, the fiscal office implemented a new procedure for processing contract requisitions. The postintervention data collection required waiting for enough contracts to be initiated or renewed to accurately assess the new procedure. The baseline data and intervention were presented at the 2009 summit, while results were presented in 2010. Such scalable projects provide more opportunities for program directors to implement meaningful projects. Occasionally, when sufficient resources are available, an LHD can adopt a more robust approach to QI. In 2010, OCHD was awarded a grant to improve perinatal outcomes in Medicaid recipients. With this grant support, a partnership was formed with Shaffer Consulting to utilize a WorkOut process to identify, implement, and measure specific strategies to improve OCHD s effectiveness in this area. In 100 days, referrals to home-visitation services dramatically increased and those gains have been sustained. (Refer to Text box 1 [b1] for additional details about the WorkOut.) Summit evaluation While the QI summit has been held annually since 2000, formal evaluation of the QI summit did not occur until recently. In 2009 and 2010, an online survey was administered to staff following the QI summit. The purpose of the survey was to measure satisfaction with the QIMC, assess the perceived importance of the QI process, and solicit feedback on ways to improve future experiences. More than 100 people attended the summit in either 2009 or 2010. Of these, 57% responded to the online survey. The results are limited by a poor response rate, but 80% of respondents who were directly involved in the QI summit projects reported that they agreed or strongly agreed that the QI process was important both to their bureaus and to the health department s mission. In addition, 16 of the 17 attendees who were not directly involved in QI projects agreed or strongly agreed with the statement The QI process is important to the Health Department s mission. Feedback from open-ended survey questions on how to improve the QI summit process, such as obtaining earlier approval of projects and moving the summit to a less-active time of the year, resulted in changes that were recently implemented. Copyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

LWW/JPHMP PHH200388 August 26, 2011 17:2 4 Journal of Public Health Management and Practice TABLE 2 Overview of Projects Presented at the 2010 QI Summit Year Program Project Summary Significant Findings Program Impact 2010 Medical Examiners Office 2010 Disease Control: Sexually Transmitted Disease 2010 Health Promotion: Lead 2010 Administration: Fiscal Unit 2010 Environmental Health: Animal Disease Control Reviewers compared traditional and digital radiographs for quality both in image and in technical process (marker placement, processing artifacts). A client-centered prevention counseling tool based on a Centers for Disease Control tool was developed and implemented in an effort to decrease repeat STD clinic visits. Revised form and procedure for completing LHCP to increase compliance with completion of the LHCP by property owners/managers. Use of Lotus Notes database/staff training to decrease steps and days to complete contract requisitions. Changed guidance and implementation for after-hours call service to reduce unnecessary calls to rabies staff. 2010 Family Planning Staff used different appointment reminder tools to compare show rates of clients using standard (mailed reminders) reminder tool compared with other reminder tools such as call to cell phone or text message. Clients chose preferred method of contact. 2010 Maternal and Child Health: WIC 2010 Environmental Health: PH Engineer 2010 Administration: Facilitated Enrollment Changed in paperwork and development of chartless system to reduce clinic throughput time to see provider. Developed new system to improve identification of compliance with sanitary code requirements that public pools notify the LHD if modifications are made to the pool system. Developed new reminder process for materials needed to successfully complete an application for public health insurance. An increase in image quality but not in the technical process. A moderate decrease was seen in repeat visits, however, did not meet statistical significance. An increase in compliance in completing and submitting the LHCP. Number of days to completion decreased. Fewer steps were needed to complete a contract requisition. A decrease in unnecessary calls. No difference in show rates was detected between different methods of contact. Clinic throughput time was reduced by 16% (13 minutes). Baseline data: Identified that 50% pools had systems modified without informing OCHD. No significant improvement in completed applications noted. Improved image quality, decreased technician time, and lower cost associated with digital radiographs support transition to digital radiograph systems. Based on preliminary data, use of this tool will continue to assess impact on longer term basis with a larger population. Increased compliance with completion of the LHCP may result in decreased exposure to lead during remediation; however, further evaluation of practical implications is needed. Improved workflow, reduction in paper use, and shortened turnaround time for contract processing, all indicate improved efficiency. The decrease in unnecessary calls to the on-call staff resulted in a 50% reduction of compensation time earned by the involved staff. Overall show rates were not impacted; however, significantly more staff time (5 hours per week) was devoted to trying to contact clients with new methods; therefore, this effort was discontinued. This time savings resulted in an increase in the average amount of time that could be spent on nutrition education rather than paperwork processing. Next step in this QI process is to identify mechanism to assist pool operators meet sanitary code requirements. Other interventions will need to be developed and evaluated to improve application completion rates. (Continues) [AQ5] [AQ6] Copyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

LWW/JPHMP PHH200388 August 26, 2011 17:2 A Local Health Department s Journey to the Summit 5 TABLE 2 Overview of Projects Presented at the 2010 QI Summit (Continued) Year Program Project Summary Significant Findings Program Impact 2010 Administration: Information Technology 2010 Maternal and Child Health: Healthy Families 2010 Maternal and Child Health: EI Use technology to reduce processing time and staff time on Lead FOIL requests. Implement new system, including in-service training and new referral forms, to increase referrals from the Department of Social Services Children s Division. Required parent signature on physician referrals in an effort to increase acceptance of EI services. Baseline data gathered for time study. Abbreviations: EI, early intervention; LHCP, Lead Hazard Control Plans; STD, sexually transmitted disease. The number of referrals of high-risk clients to maternal and child health services dramatically increased. No significant difference in acceptance rate identified. If successful, this intervention has the potential to significantly reduce staff time dedicated to processing FOIL requests. If high-risk families are referred and then engaged in evidenced-based maternal and child services such as Nurse Family Partnership, poor perinatal outcomes may be reduced. Need to consider alternative approaches to increasing family s acceptance rates of physician referrals to EI. The transformation of small qi into big QI Recently, Riley and Brewer 7 introduced the concept of Small qi and Big QI, with the former representing the actual conduct of improving a process at the microsystem level using an integrated set of QI methods and techniques... and the latter, complete organizational involvement. 7 While the first few years of QI efforts were centered on an annual presentation of QI projects at a summit, more recently, OCHD has begun to shift from an organizational culture emphasizing Small qi to the one addressing Big QI. Small qi continues to anchor QI efforts at the OCHD. However, changes in the leadership s priorities with growing recognition of the critical importance of QI in strategic planning, in preparing for accreditation and in addressing personnel policies, have elevated the relative importance of QI throughout the department. In 2002, in recognition of the growing emphasis on QI, the QA Committee was changed to a QI/QA Committee. Staffed by senior representatives from most OCHD programs, the committee meets at least 10 times a year. The committee is charged with addressing both QA and QI issues, which are inherent in all functions of OCHD. Its scope includes timely evaluation of core services, review of policies, adoption of new and improved ways of offering services, and examination of errors and evaluation of remedial actions. Because each item/topic is presented to a cross-section of bureau representatives, this process naturally fosters collaboration across areas of the OCHD. The majority of TEXT BOX 1 A Different Kind of Quality Improvement Quality Improvement WorkOut: A Different Kind of QI In 2010, the OCHD Division of Maternal and Child Health (MCH) received funding to address factors associated with poor birth outcomes. With assistance from Schaffer Consulting, OCHD implemented the WorkOut process, which Schaffer codeveloped at General Electric in the 1980s for the then-ceo, Jack Welch. The WorkOut process is designed to improve performance in a compressed time frame while identifying new ways of working to drive cultural change all within 100 days or less. The objectives of the MCH WorkOut were to (1) increase referral sources and referrals for home visitation services, (2) increase the acceptance of antepartum home visitation services, (3) enhance the image and cultural sensitivity of staff, and (4) improve prenatalrisk screening. During the design phase, key stakeholders developed measurable indicators and set goals for each objective. The planning process culminated in a 2-day formal launch session, where community stakeholders convened to brainstorm interventions, and previously identified decision makers were called upon to approve or disapprove the interventions on the spot. Approved changes included rebranding MCH services, reducing the paperwork burden on clients and staff, and building relationships with other agencies. A 100-day push was made to implement the approved interventions to achieve the objectives. After the intervention period, outcomes were evaluated and presented to key stakeholders. The results of one of the interventions to increase referrals for home visitation services in 100 days were presented at the 2010 QI summit. The intervention involved fostering a close relationship between MCH and Child Protective Services (CPS) in the Department of Social Services through combined staff training. At the start of the implementation period, the team committed to a very aggressive model month goal to maximize performance. In only 1 month, the number of referrals MCH received from CPS was equal to the total number of referrals received in the entire previous calendar year. The number of referrals has remained at much higher levels than those received before the intervention. Having the ability to identify and offer services to a high-risk population is critical to the MCH mission. The training and relationship building have continued and are now part of the routine operations of both agencies. Copyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

LWW/JPHMP PHH200388 August 26, 2011 17:2 6 Journal of Public Health Management and Practice activities of this committee are still QA; however, the venue also provides an opportunity to present smallscale QI projects that are important to a program s services but do not carry enough weight to be considered for the QI summit. Another example of efforts to expand the culture of QI throughout the department occurred in fall 2010. At that time, individual performance measures were introduced as part of the annual performance evaluations for every public health care worker on staff. The performance measures are intended to be closely related to program impact. Previously, only certain staff members had performance measures, which were required by outside entities (eg, Early Intervention program or Special Supplemental Nutrition Program for Women, Infants, and Children). To ensure consistency across the department, every employee of the OCHD will have at least 2 performance measures integrated into their annual performance evaluations by the end of 2011. When indicated by the measures, targeted support will be provided to ensure that public health care workers are successful in meeting their specific measures. Discussion The degree to which public health agencies can ensure that QI is achievable in their organization is heavily dependent on their ability to establish and sustain a strong QI process. More than 10 years ago, OCHD held its first formal annual summit. Since that time, the QI process at this mid-sized LHD has been refined to introduce a more rigorous QI methodology, accommodate more collaboration between programs, increase the impact of the projects, and promote integration of QI across the department. Many factors have contributed to the success of the QI process, although barriers to its full integration still remain. Several authors have addressed the necessary components of, and some of the barriers to, the success of QI in a health department. 6 9 The following factors contributed to successes in integrating QI at OCHD: A top-down approach with strong support and vision to devote resources to the QI summit. The core administrative team and the senior staff members are encouraged to promote the culture of QI in routine activities. Over the years, several local legislators and officials from the County Executive s Office have attended the summit, sending a clear message to staff about the importance of QI. A bottom-up approach to Small qi projects to encourage the participation of all levels of staff. The QI summit projects are initiated and developed by program staff to ensure buy-in. Furthermore, staff members from every program participate in reviews through the QA/QI committee. Support for a broad range of QI activities, including small monthly projects for the QA/QI committee, projects for the QI summit, and grant-supported more elaborate QI projects. This flexibility accommodates different program and staff needs and allows for a gradual introduction to QI for staff members who may feel intimidated by large QI projects. Culminating annual presentations that provide an opportunity for staff to learn about and learn from other programs within OCHD, while showcasing the impact that QI has on the organization. A QIMC with skills and training in QI methodologies to provide guidance and support to program staff. Despite the previous factors, OCHD staff members have identified the following as barriers to the implementation of Big QI : Inadequate resources necessary to ensure full integration. The most significant resource required is staff time. With LHDs across the country experiencing significant budget cuts, providing dedicated time for staff to carry out projects and attending trainings are increasingly challenging. According to the National Association of County and City Health Officials, 44% of LHDs reported that they had lost staff between 2008 and 2010, resulting in an approximate 19% reduction in the nationwide LHD workforce. 10 Inconsistent buy-in: While the majority of senior staff members welcome the QI experience, some individuals still feel that QI is not important to their daily work. These individuals may undermine the QI process. Securing total buy-in from frontline workers has been challenging as some may view QI projects as an added burden to their already busy day. Suboptimal QI summit participation: All health department employees are invited by the leadership to attend the summit; however, very few do so unless they are directly involved in a project. This may reflect the frontline staff s lack of recognition of the value of QI and/or supervisors lack of support for their program staff to take time away from daily work duties to attend the summit. Future directions for OCHD While OCHD continues its efforts with Small qi, further changes still need to occur before OCHD can consider its transformation to Big QI complete. This article describes the efforts this LHD has taken to foster a culture of QI across all aspects of its functions as well Copyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

LWW/JPHMP PHH200388 August 26, 2011 17:2 A Local Health Department s Journey to the Summit 7 as to prepare for accreditation. To achieve this transformation, OCHD will take the following steps: Ensure that QI is integrated into strategic plans. Increase training opportunities to expand the program staff s knowledge base of QI methodologies. Training sessions on topics such as the essential role of QI, tips for how to select a meaningful project, established QI tools, basic data analysis, and hints for an effective presentation will be open to all OCHD staff. This is an effort to increase the staff s comfort level with the QI process and improve the quality of future projects. Ensure that all future projects selected for the QI summit use specific tools, such as Deming s Plan- Do-Check-Act tool, to enhance the rigor of the projects, with greater emphasis on multidimensional interventions. 11 Moving forward, the bar will be raised to make certain that all projects presented at the summit involve staff buy-in, implementation of a specific QI tool, significant impact to the program, and more robust interventions. Ensure that future QI projects are linked to the County s Community Health Assessment, performance measures, or other sources of data. Adopt a stricter evaluation of both the QI summit and Small qi projects to ensure the utilization of QI tools and selection of appropriate QI initiatives. The results of such evaluations can inform OCHD leadership and QIMC in ongoing efforts to improve the QI process. Seek grant funding for QI activities, including providing opportunities for training of key staff and for increasing staff participation (potentially through incentives, awards, or other means of recognition). The OCHD has a collaborative relationship with both SUNY Upstate Medical University and with Syracuse University, which will enhance the opportunity for training and grant funding to further QI efforts. Conclusion Quality in public health is the degree to which policies, programs, services, and research for the population increase desired health outcomes and conditions in which the population can be healthy. 1 There are many reasons for LHDs to move toward comprehensive agency-wide QI. As LHDs gain experience in the implementation of QI, either through the accreditation process or through self-initiated efforts, the evidence base for successful QI programs will follow. This article characterizes the evolution of QI efforts at a midsized LHD over more than a decade. Although barriers to the full implementation of the QI process such as suboptimal and inconsistent staff buy-in and limited resources persist, OCHD has found success by combining a top-down and bottom-up approach to encourage staff involvement, supporting a broad range of scalable projects, hosting a culminating annual summit event, and forming a committee to support QI activities. Other LHDs may consider this OCHD case study as they embark upon their own QI journey. REFERENCES 1. Honoré P, Wright D, Berwick D, et al. Creating a framework for getting quality into the public health system. Health Aff. 2011;30(4):737-745. 2. Riley WJ, Moran JW, Corso LC, Beitsch LM, Bialek R, Cofsky A. Defining quality improvement in public health. J Public Health Manag Pract. 2010;16(1):5-7. 3. Beitsch LM, Leep C, Shah G, Brook RG, Pestronk RM. Quality improvement in local health departments: results of the NACCHO 2008 survey. J Public Health Manag Pract. 2010;16(1):49-54. 4. PHAB Proposed Local Standards and Measures. http:// dl.dropbox.com/u/12758866/phab%20standards%20and %20Measures%20Version%201.0.pdf. Accessed July 14, 2011. 5. U.S. Census Bureau. http://2010.census.gov/2010census/ data. Accessed May 9, 2011. 6. Riley W, Parsons HM, Duffy GL, Moran JW, Henry B. Realizing transformational change through quality improvement in public health.jpublic Health Manag Pract. 2010;16(1):72-78. 7. Riley W, Brewer R. Review and analysis of quality improvement techniques in police departments: application for public health. J Public Health Manag Pract. 2009;15(2):139-149. 8. Gunzenhauser JD, Eggena ZP, Fielding JE, Smith KN, Jacobson DM, Bazini-Barakat N. The quality improvement experience in a high-performing local health department: Los Angeles County. J Public Health Manag Pract. 2010;16(1): 39-48. 9. Leep C, Beitsch LM, Gorenflo G, Solomon J, Brooks RG. Quality improvement in local health departments: progress, pitfalls, and potential. J Public Health Manag Pract. 2009;15(6):494-502. 10. NACCHO. Local Health Department Job Losses and Programs Cuts: 2008-2010. http://www.naccho. org/topics/infrastructure/lhdbudget. Accessed May 16, 2011. 11. Katkowsky S, Kent L, Divine S, et al. Using QI Tools to Make a Difference in H1N1 Flu Immunization Clinics: A Local Health Department s Experience. http//www. phf.org/resourcestools/pages/using_qi_tools_for_h1n1 Clinic.aspx. Accessed April 7, 2011. [AQ7] Copyright 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Appendix 11. Prevention Quality Indicators by Zip Code, Onondaga County, 2008-2009 Hospital Discharge Rates per 100,000 population Zip code Angina % Expected CHF % Expected HTN % Expected Diabetes % Expected Asthma % Expected COPD % Expected 13027 4 13% 223 63% 13 17% 76 34% 50 28% 143 79% 13029 0 0% 248 70% 24 33% 23 10% 45 26% 204 113% 13030 28 87% 95 27% 0 0% 86 38% 58 33% 143 79% 13031 0 0% 223 63% 15 21% 46 20% 32 18% 137 76% 13039 17 52% 214 61% 9 12% 77 34% 25 14% 117 65% 13041 0 0% 180 51% 0 0% 58 26% 55 31% 88 49% 13057 0 0% 297 84% 8 11% 96 43% 65 37% 131 73% 13060 0 0% 450 128% 0 0% 126 56% 85 48% 254 140% 13063 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 13066 18 55% 129 37% 9 12% 65 29% 0 0% 49 27% 13078 0 0% 223 63% 0 0% 25 11% 13 7% 99 55% 13080 0 0% 190 54% 0 0% 74 33% 0 0% 113 63% 13082 0 0% 197 56% 53 73% 52 23% 0 0% 104 58% 13084 0 0% 279 79% 0 0% 56 25% 0 0% 233 129% 13088 5 16% 263 75% 16 22% 118 52% 38 22% 159 88% 13090 5 15% 217 62% 20 28% 93 42% 47 27% 127 70% 13104 0 0% 121 34% 17 23% 50 22% 17 10% 75 41% 13108 0 0% 132 38% 22 30% 21 10% 86 49% 191 106% 13110 0 0% 176 50% 0 0% 0 0% 0 0% 111 61% 13112 0 0% 147 42% 0 0% 70 31% 0 0% 143 79% 13116 0 0% 279 79% 0 0% 105 47% 0 0% 67 37% 13120 0 0% 163 46% 0 0% 247 110% 49 28% 107 59% 13152 0 0% 208 59% 0 0% 28 12% 0 0% 51 28% 13159 0 0% 330 94% 0 0% 104 46% 26 15% 55 31% 13164 0 0% 149 42% 0 0% 70 31% 72 41% 217 120% 13202 37 115% 1000 284% 187 260% 887 396% 233 132% 439 242% 13203 9 28% 446 127% 34 47% 264 118% 109 62% 290 160% 13204 8 26% 421 120% 56 78% 337 150% 278 158% 403 223% 13205 7 23% 556 158% 74 103% 374 167% 181 103% 307 169% 13206 0 0% 218 62% 22 31% 160 71% 54 30% 224 124% 13207 0 0% 452 128% 33 46% 307 137% 135 77% 164 90% 13208 7 21% 312 89% 58 80% 310 138% 166 94% 319 176%

Zip code Angina % Expected CHF % Expected HTN % Expected Diabetes % Expected Asthma % Expected COPD % Expected 13209 0 0% 318 90% 28 38% 66 29% 48 27% 155 86% 13210 0 0% 285 81% 39 55% 347 155% 77 44% 231 128% 13211 0 0% 243 69% 0 0% 203 91% 41 23% 270 149% 13212 6 18% 286 81% 29 40% 83 37% 18 10% 156 86% 13214 0 0% 217 62% 0 0% 124 55% 58 33% 124 55% 13215 0 0% 290 82% 8 11% 57 25% 25 14% 139 77% 13219 7 21% 277 79% 6 9% 54 24% 50 28% 119 66% 13224 0 0% 248 70% 15 20% 147 66% 44 25% 153 85% County 7 21% 284 81% 25 35% 145 65% 68 39% 171 95% NYS 32 352 72 224 176 181

Appendix 12: Tree of Health