Priority Area: Chronic Disease - Strategies and Partners Matrix

County	Collaborating Hospitals	Collaborating Counties	Specific Focus Area	Strategies and/or Interventions	Partners
Albany	Albany Medical Center Albany Memorial Hospital Ellis Hospital Northeast Health Samaritan Hospital Seton Health St. Mary's Hospital St. Peter's Health Care Services	Rensselaer Schenectady	Reduce prevalence of diabetes and complication-specific hospitalizations Reduce CVD-related hospitalizations Reduce cancer mortality	The Albany County Strategic Alliance for Health will reduce the burden of chronic disease through sustainable, evidence-based chronic disease prevention and health promotion programs focusing on policy and environmental changes.	American Cancer Society Albany Medical Center American Dairy Association and Dairy Council Capital District Community Gardens Capital District Tobacco Free Coalition Capital District YMCA, North Albany Branch City of Albany City School District of Albany Community Cradle Cornell Cooperative Extension of Albany County Head Start of Albany County Koinonia Primary Care Price Chopper supermarkets Reality Check St. Peter’s Family Health Center Trinity Alliance of the Capital Region Whitney M. Young Jr. Health Center
Broome	United Health Services Our Lady of Lourdes Memorial Hospital		Obesity in children and adults Diabetes and diabetes-related hospitalizations. Avoidable hospitalizations due to heart failure.	Outreach and education to promote physical activity and nutrition. Intervention and prevention through engaging the community in health lifestyle and behavioral changes. Policy and systems level changes in schools and worksites including: Hospital-based diabetes education programs. Chronic disease self-management programs. Case management of patients with diabetes Provider-patient and provider-hospital initiatives to provide disease management to patients with congestive heart failure. Innovative home care programming and continuum of care to patients when they leave the hospital. Home health and telehealth monitoring services. Post-hospital discharge follow-up calls.	For each of the three Chronic Disease Priorities Areas, the county has identified their key partners, which appears to encompass virtually all of the community-based organizations, networks, various State agencies, clinical providers, the Strategic Alliance for Health, etc.
Cattaraugus	Bertrand Chaffee Memorial Hospital Olean General Hospital TriCounty Memorial Hospital Southern Tier Health Care System	Allegany	Increase the percent of adults being treated for pre-diabetes or diabetes	Refer smokers to NYS Quitline. Collaborate with Regional Cessation Coordinator to counsel home care and clinic clients about cessation. Educate pregnant mothers on dangers of second-hand smoke. Educate smokers on dangers of second-hand smoke. Collaborate with Tri-County Tobacco Coalition to reduce tobacco advertising and promote smoke-free worksites and play grounds.	Tri-County Tobacco Coalition Asthma Coalition
Chautauqua	TLC Health Network Brooks Memorial Hospital WCA Hospital Westfield Memorial Hospital		Chronic disease Diabetes	Promote and assist with the Consumer Engagement Associates Empower consumers to begin to make lifestyle changes by taking control of their health care plan. A Chautauqua County Diabetes and Chronic Disease Prevention Task Force will help increase the capacity to reduce the burden of chronic disease in the county.	Chautauqua County Health Network P2 Collaborative of Western New York
Chenango	Chenango Memorial Hospital		Coronary heart disease	Refer patients to Chenango Memorial Hospital (CMH). Distribute DVD “Every Woman Counts” to providers. Participate in Healthy Heart Coalition Participate in Chenango Health Network activities, radio interviews, PSAs, and health education activities. Hold blood pressure screenings. Use displays in various locations. Refer patients to CMH providers. Participate in CMH Healthy Heart Coalition program activities.	Chenango Memorial Hospital Chenango Health Network Chenago Tobacco Free Coalition Providers Community partners
Clinton	CVPH Medical Center Alice Hyde Medical Center Adirondack Medical Center Elizabethtown Medical Center	Essex Franklin	See Physical Activity/Nutrition
Columbia	Columbia Memorial Hospital		Increased physical activity and fruit and vegetable consumption	Complete the "Mobilizing for Action Through Planning and Partnership" (MAPP) process with local partners. Utilize media to promote physical activity and fruit and vegetable consumption. Consider a wellness center in a targeted ZIP code. Explore possibility of insurers covering fitness programs. Implement Healthy Restaurant Program to increase availability of low-fat, low-cost nutritious menu options.	WIC and local OB prividers Columbia Alliance for Heart Health Tobacco Free Coalition
Cortland	Cortland Regional Medical Center			Health education campaigns and continued collaboration with Seven Valley Health Coalition, Regional Medical Center, and other community partners to focus on the impact of other risk factors like smoking and obesity and the importance of preventive medicine and good nutrition.	Cortland Regional Medical Center Seven Valleys Health Coalition United Way of Cortland Cortland County Health Department Institute of Civic Engagement at SUNY Cortland Local church groups Business members Cortland County Community Action Program YMCA YWCA Daycare Coalition Cortland County Area Agency on Aging Cortland County Mental Health Cortland County and City Youth Bureaus
Dutchess	Vassar Brothers Medical Center Northern Dutchess Hospital St. Francis Hospital		Heart disease Cancer Arthropod disease Physical activity and nutrition	Increase awareness about heart disease, cancer and arthropod disease Increase the number of schools and youth programs by at least 3 that promote healthy behaviors and establish an environment that provides nutrition education and encourages physical activity	All organizations in the coalition: Chamber of Commerce Diabetes coalition members Cornell Cooperative Extension Children Services Council and Children’s Health Initiative members Food service workers in schools
Erie	Catholic Health System Kaleida Health Erie County Medical Center Sheehan Memorial Hospital		Diabetes	Provide diabetes prevention education. Work with schools and educational institutions to promote healthy nutrition and physical activity. Increase awareness about diabetes. Increase access to screening, education and related services.	Niagara Health Quality Coalition Schools
Essex	Adirondack Medical Center Alice Hyde Medical Center CVPH Medical Center Elizabethtown Medical Center Inter-Lakes Hospital (Moses Ludington)	Clinton Franklin	Adult diabetes Coronary heart disease Congestive heart failure Cerebrovascular disease Colorectal cancer	Spectrum of prevention activities including policy changes to improve environment.	Hospitals Providers Community-based organizations Not for profit organizations Government agencies Faith-based organizations Schools Insurance providers Rural health networks Businesses Others as appropriate
Genesee	United Memorial Medical Center Medina Medical Hospital Wyoming County Health Care System	Wyoming Orleans	Chronic diseases Congestive heart failure		Broad range of organizations.
Herkimer	Little Falls Hospital Bassett Healthcare Faxton-St. Luke's Hospital St. Elizabeth Hospital	Oneida		Educate residents about decreasing the time to recognize the signs and symptoms of heart disease and stroke. Provide diabetes and cancer screening. Improve public awareness of emergency care for heart attacks and strokes, the benefits of prenatal care, and the benefits of cancer and diabetes screening.
Jefferson	Samaritan Medical Center Carthage Area Hospital River Hospital		Decrease coronary heart disease hospitalizations	Provide resources for educating clientele via partner agency contacts. Use media and partnerships to promote heart health. Participate in local government conference in March 2010 sponsored by the Tug Hill Commission. Sustain the Alexandria consortium through capacity-building efforts.	Cornell Cooperative Extension of Jefferson County Local employers Watertown Family YMCA North Country Children's Clinic Morth Country Prenatal/Perinatal Council Physician practices Media
Lewis	Lewis County General Hospital		Diabetes	Health education
Livingston	Noyes Memorial Hospital FF Thompson Hospital		Changing behaviors related to diet, activity level and tobacco use since they are major contributors of obesity, diabetes and cardiac health.	Establish diabetes and cardiac support groups. Promote worksite wellness.	Genesee Valley Health Partnership Livingston County Wellness Partnership Livingston County Chamber of Commerce Noyes Memorial Hospital
Madison	Oneida Healthcare Center Community Memorial Hospital	Oneida Herkimer	Cancer screening Nutrition Obesity Diabetes	Provide cancer screening with Cancer Services Program Partnership Oneida-Herkimer-Madison counties. Participate in Healthy Living Partnership. Conduct the following Eat Well Play Hard grant activities: Work with farmers markets on initiatives using Electronic Benefits Transfer machines; Promote use of fruits and vegetables; Conduct nutrition and physical activity self-assessments; Develop nutrition and physical activity projects with center-based daycare centers; Offer annual Eat Well Play Hard family fun day emphasizing healthy eating and physical activity, TV turnoff promotion, and Healthy Start breastfeeding promotion. Implement Childhood Obesity Prevalence Project, a collaborative partnership between Madison-Oneida BOCES, Morrisville State College BSN program, and Madison County Department of Health to conduct prevalence study on childhood obesity. Obtain BMI data on school-aged children. Provide on diabetes management with the Diabetes Prevention Partnership. Offer "Living Well at Work" Awards to local agencies and organizations for commitment to promoting healthy eating and physical activity in worksites.	Hospitals Provider offices and clinics Other health departments Community-based organizations Daycare centers Government agencies Schools and colleges Madison Oneida BOCES Cornell Cooperative Extension CBOs Employers
Monroe	Lakeside Rochester General Strong Memorial Unity Health System			Participate in 2020 Performance Commission and explore potential interventions to decrease preventable hospitalizations by improving management of chronic disease. Hospitals will work with other organizations in the community to develop a program whereby primary care physicians will receive National Committee for Quality Assurance (NCQA) certification in diabetes care.	Finger Lakes Health Systems Agency Monroe County Medical Society Private physicians Business community Health insurers Hospitals and health systems Community based organizations
Niagara	DeGraff Memorial Hospital (Kaleida) Eastern Niagara Hospital Mount Saint Mary’s Hospital Niagara Falls Memorial Medical Center		Diabetes	Niagara Falls Memorial Medical Center will develop a diabetes resource guide and a pre-diabetes and diabetes lecture series. Promote resource guide via newspapers, flyers and TV. Provide lecture series sponsored by each hospital.	Mt. St. Mary’s Hospital DeGraff Memorial Hospital Eastern Niagara Hospital (Lockport and Newfane sites) Niagara Falls Memorial Memorial Medical Center
Oneida	Faxton-St. Luke's Healthcare Rome Memorial Hospital St. Elizabeth Medical Center	Herkimer Madison	Tobacco use	Increase the number of healthcare organizations and providers that effectively implement the Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence. Advance tobacco-free policies and provision of tobacco dependence treatment in all healthcare settings, including hospitals and physician practices, substance abuse treatment facilities, mental health treatment and support settings, adult care facilities and HIV care settings. Support employer provision and promotion of tobacco dependence treatment for employees and adoption of tobacco-free campuses. Increase the number of public and private health insurance plans that provide comprehensive, lifetime coverage of tobacco dependence treatment. Expand and sustain efforts to promote the New York State Smokers’ Quitline website.	Faxton-St. Luke’s Healthcare St. Elizabeth Medical Center Mohawk Valley Heart Institute Oneida Healthcare Rome Memorial Hospital Little Falls Hospital Community Memorial Hospital Slocum Dickson Medical Group BRiDGES to Prevent Tobacco
Ontario	Clifton Springs Hospital FF Thompson Hospital Geneva General Hospital	Seneca Schuyler Steuben Yates Wayne		Implement best practices related to heart disease prevention and treatment. Focus on reducing the number of people with indicators for heart disease by implementing best practice nutrition and physical activity initiatives in the schools, community and worksites as well as through providers and the hospitals.	S2AY Rural Health Network Geneva General Hospital FF Thompson Hospital Clifton Springs Hospital Finger Lakes Health System Agency Chemung County Public Health MVP Healthcare Excellus Monroe Plan
Orange	Bon Secours Charity Health System (3 sites) Orange Regional Medical Center (2 sites) St. Luke's/Cornwall Hospital (2 sites)	Dutchess Putnam Rockland Sullivan Ulster Westchester	CVD	Healthy Orange will collaborate with Orange Regional Medical Center to conduct heart screenings. The population served includes adults in Orange County with emphasis on low-income, uninsured.	American Heart Association Orange Regional Medical Center
Orleans	Medina Memorial Health Care System United Memorial Medical Center Wyoming County Health Care System	Genesee Wyoming	Diabetes CVD	Orleans County Health Department (OCHD) is meeting every third Thursday of the month with Medina Memorial Health Care System (MMHCS), Genesee County Health Department, United Memorial Medical Center, Wyoming County Health Department and Wyoming County Community Hospital to explore the tri-county needs in access to quality health care and chronic disease. Collaborate to apply for grants to MPHSP 2010-2013 MPHSP Part A Conduct follow-up on discharges from the three hospitals in order to prevent readmissions into the hospitals. Meet with local partners to identify all current health, social service and educational resources available to community to determine gaps in services, and to identify where resources can be shared. The same approach will be used to improve health literacy to enhance wellness, prevention and early intervention by promoting health literacy for chronic disease management as part of our program to address congestive heart failure and diabetes mellitus.	Lake Plains Community Care Network
Oswego	Oswego Hospital		Diabetes CVD	Work with the Tobacco Free Network to promote policy and environmental changes that address point-of-sale marketing of tobacco products and smoke-free outdoor areas (e.g. playgrounds and worksite grounds). Conduct outreach and education to promote physical activity and good nutrition in schools and worksites.	Rural Health Network Oswego Health Oswego County Opportunities Northern Oswego County Health Services, Inc.
Putnam	Putnam Hospital Center			Collaborate with Putnam Hospital Center to promote awareness of signs and symptoms of stroke. Provide information on health risks of smoking and second-hand smoke at health fairs attended throughout the year. Participate as Steering Committee members in the POW’R Against Tobacco Coalition to provide media campaigns and PSAs. Promote smoking cessation resources to Putnam County residents including the NYS Quitline and cessation classes offered in Putnam County at all health fairs, clinics, through PSAs and other media outlets. Provide at least one PSA and one press release promoting healthy lifestyle choices to avoid the onset of chronic disease. Utilize NYSDOH’s Active 8 and Healthy Heart Program materials at all health fairs. Through the Putnam County Wellness Program, employees are offered a variety of strategies to adopt a healthy lifestyle including increasing consumption of fruits and vegetables, increasing physical activity, and maintaining a healthy weight in order to avoid onset of chronic diseases. Strategies include a walking program, nutrition lectures, exercise classes, weight reduction classes, and others. Encourage Putnam County residents to participate in the online Nutrition Quiz.	Putnam Hospital Center POW’R Against Tobacco American Cancer Society WIC Program, Putnam County Wellness Program Committee Carmel Central School District Wellness Committee
Rockland	Nyack Hospital Good Samaritan Hospital	Dutchess Ulster Putnam Orange Westchester Sullivan	Heart Disease Cancer Physical activity and nutrition	Expand Healthy Meetings Guidelines to all county organizations and non-profit organizations. Provide materials and easy-to-use healthy eating and exercise prescriptions to health care providers and service providers for use for their patients and clients. Publicize and recognize healthy businesses and restaurants and stores. Work with Rockland County Chapter American Cancer Society of the Rockland County Cancer Institute and community partners to build on successful healthy living partnership.	Public Health Priorities Steering Committee
St. Lawrence	Canton-Potsdam Hospital EJ Noble Hospital Claxton-Hepburn Hospital Massena Memorial		Chronic obstructive pulmonary disease Congestive heart failure	Establish a baseline for comparisons. Make referrals to St. Lawrence County Health Initiative Self Care Program. Uniform educational materials will be used.	Hospitals and St. Lawrence County Health Initiative County Emergency Medical Services (both voluntary and proprietary services)
Saratoga	Saratoga Hospital Adirondack Medical Center Glens Falls Hospital Nathan Littauer Hospital Elizabethtown Community Hospital Moses-Ludington Hospital	Essex Hamilton Warren Fulton Washington	Diabetes	Establish a collaborative group of diabetes experts to coordinate inpatient care of diabetes. Identify gaps in existing programs and services, and then recommend interventions. Develop standardized protocols and procedures for the management of diabetic patient care, starting with hospital care through discharge, and into the community. Expand access to diabetes support services in Saratoga County.	Saratoga Hospital staff Nutritionists Diabetes Regional Center Dr. Malone Cornell Cooperative Extension
Schenectady	Ellis Medicine Sunnyview Rehab Hospital Albany Medical Center Northeast Health/Samaritan Hospital/Albany Memorial Hospital Seton Health/St. Mary’s Hospital St. Peter’s Health Care Services	Albany Rensselaer	Primary prevention of chronic diseases	Engage the community in projects to address primary prevention measures for chronic diseases. Make policy and environmental changes to decrease the chronic disease burden in Schenectady County.	Capital District Community Gardens Capital District Tobacco-free Coalition Cornell Cooperative Extension – Schenectady County Schenectady Inner-city Ministry Martin Luther King, Jr. Elementary School
Schoharie	Cobleskill Regional Hospital Bassett Hospital		See Physical Activity/Nutrition
Seneca	Geneva General Hospital Finger Lakes Health			Reduce the number of people with heart disease by implementing best practice nutrition and physical activity initiatives in the schools, community and worksites, as well as through providers and hospitals.	S2AY Rural Health Network Finger Lakes Health Finger Lakes Health Systems Agency MVP Healthcare Excellus BlueCross BlueShield Monroe Plan Finger Lakes Health
Steuben	Corning Hospital St. James Hospital Ira Davenport Hospital	Seneca Wayne Schuyler Ontario Yates	Reduce overweight and obesity.	Implement policy and environmental changes that address physical activity and nutrition objectives.	Schools Worksites Cornell Cooperative Extension Rural health networks Hospitals
Tompkins	Cayuga Medical Center		Asthma Cardiovascular disease and diabetes Breast cancer and other cancers	Provide education about prevention and management of asthma. Promote asthma action plan to providers, schools, parents, people with asthma. Promote chronic disease self-management program. Note: See Physical Activity and Nutrition priority for additional strategies.	Asthma Action Committee Health Planning Council, a program of the Human Services Coalition Tompkins County Office for the Aging (COFA) Cancer Resource Center of the Finger Lakes Tobacco Control Program Community Partnership
Washington	Glens Falls Hospital Adirondack Medical Center Saratoga Hospital Elizabethtown Community Hospital Moses Ludington Hospital Nathan Littauer Hospital and Nursing Home		Diabetes Congestive heart failure Cancer	Provide health education to increase awareness about chronic diseases and their risk factors. Increase screening and early detection. Promote regular preventive care physician encounters	Private providers Health agencies Adirondack Rural Health Network
Wayne	Newark-Wayne Community Hospital	Seneca Schuyler Steuben Ontario Yates	Diabetes Obesity Heart Disease Cancer	Promote health care literacy campaign and chronic disease self-management by providing referrals to such programs.	Wayne County Rural Health Network Wayne Community Action Program
Westchester	Blythedale Childrens Hospital Burke Rehabiliation Hospital Community Hospital at Dobbs Ferry Hospital Hudson Valley Hospital Center Lawrence Hospital Center Mount Vernon Hospital New York Presbyterian Hospital - Westchester Northern Westchester Hospital Phelps Memorial Hospital Association Sound Shore Medical Center of Westchester St. John's Riverside Hospital St. Joseph's Hospital St. Vincent's Westchester Catholic Medical Center Westchester Medical Center White Plains Hospital Center		Reduce sodium intake	Recruit more schools to enroll in the NYSDOH grant-funded Fit Kids school-based obesity prevention program to promote wellness policies that promote healthy nutrition at schools. Approximately 60 Westchester County schools have been recruited to date. Promote school participation in annual No Junk Food Week in March. Promote sodium reduction and healthy nutrition through health education provided at schools, health fairs, cultural festivals, community events and nontraditional health settings (e.g., housing authority buildings, hair salons, faith-based organizations) by the Chronic Disease Prevention Program Promote sodium reduction and healthy nutrition to WIC clients through nutrition education and food demonstrations in the WIC waiting rooms. Collaborate with the Department of Senior Programs and Services to promote sodium reduction and healthy nutrition through annual wellness activities. Provide the general public with education and information to promote sodium reduction and healthy nutrition through the Westchester County Health Department webpage. Undertake a community asset assessment that would locate or identify public options available for healthy food at the community level. Coordinate efforts to address the Prevention Agenda priorities with all 16 hospitals in Westchester County. Direct the Healthy Communities Capacity Building Initiative grant to build infrastructure in the community for chronic disease prevention.	Schools Faith-based organizations (various) Community agencies (various) Municipal Housing Authorities Hair salons (various) Youth-serving organizations WestCOP Planned Parenthood American Heart Association County Department of Senior Programs and Services Westchester County hospitals Schools Faith-based organizations (various) Community agencies (various) Municipal Housing Authorities Hair salons (various) Youth-serving organizations Westchester Community Opportunity Program Planned Parenthood American Heart Association County Department of Senior Programs and Services Westchester County hospitals
Wyoming			Cancer Diabetes	Promote availability of mammography and colorectal cancer screening. Reduce diabetes prevalence in adults by increasing knowledge of diabetes risk factors (family history, overweight and obesity, low physical activity)	Wyoming County community health system Local providers American Cancer Society Susan G. Komen for the Cure Livingston County Health Department Cancer Prevention Partnership
Yates	Finger Lakes Health	Seneca Schuyler Steuben Ontario Wayne	Tobaaco use Lung cancer Diabetes Coronary heart disease Congestive heart failure Stroke	Reduce heart disease and diabetes by implementing school based and worksite initiatives. The population served is families with preschool or school aged children and worksites enrolled in county worksite wellness program.	Finger Lakes Health (including Soldiers & Sailors Memorial Hospital) School districts S2AY Rural Health Network Yates Health Planning Council Members