2005-2010 Community Health Assessment Checklist

COVER PAGE

Local Health Department/Unit Address: _________________________________________

________________________________________________

Telephone: _______________________ Fax: ____________________________

Submitted by: __________________________ E-MAIL: ________________________

Prepared by: ____________________________

GENERAL COUNTY INFORMATION

<Health Department Type (please check one):

______Full Service ______Less than Full Service

<Organization Type (please check one):

______Single Agency ______Multiple Agency,

(Health Only) please list: __________________________

 __________________________

Please list below (using additional sheets, as necessary) those entities or individuals with whom you partner and briefly describe the nature of your work together (i.e., health assessment, health planning, health education, etc.).

This checklist/index identifies the elements of a comprehensive CHA as described in the Guidance and Format Document (Appendix D of the Public Health Agenda Interim Report). The checklist should be used as a companion to the Guidance and Format Document, which provides greater detail than does the checklist. The checklist is a list of ideal elements rather than a list of requirements. The checklist has many uses: it will show the portions of the CHA that have been included, identifying the page locations for the material submitted; it provides a reference for all the activities undertaken to support community health assessment; it provides a quick reference for responding to inquiries and making updates; it will also assist us in identifying potential technical assistance and training needs.

Please use the following conventions for the lines preceding the sections and sub - sections:

X - to denote information provided

N/A - to denote information that is not available

N/S - to denote information that is not submitted

Please use the index to identify the placement of the information within the CHA document, whether you follow the order of the checklist or use another format. If you have any questions please contact Lucy Mazzaferro at (518) 473 - 4223.

<Addition for 2005-10 CHA

<____ Section One - Populations at Risk ______

____ A. Demographic and Health Status Information —

narrative and statistical description of the county ______

____ 1. overall size ______

____ 2. breakdowns by

a) ____ age ______

b) ____ sex ______

c) ____ race______

d) ____ income levels (esp.percent at poverty level)______

e) ____ percent employed ______

f) ____ educational attainment.______

g) ____ housing ______

h) ____ other relevant characteristics______

____ 3. natality ______

____ 4. morbidity ______

____ 5. mortality ______

____ 6. other relevant demographic data compiled and analyzed,

using small areas, such as minor civil divisions, zip codes

or census tracts within counties, wherever possible

and meaningful. ______

____ 7. particular emphasis placed on interpreting demographic

trends for the relationship to poor health and needs

for public health services.______

For your convenience, a listing of service areas and programs has been included. Please note, that the CHA does not require data for environmental health programs. If the LHD is performing environmental health programs that are not described in 10NYCRR40-2 or 3 please include the data in support of those programs.

Programs:

____ Dental Health Education ______

____ Primary and Preventive Health Care Services______

____ Lead Poisoning ______

____ Prenatal Care and Infant Mortality ______

____ Family Planning ______

____ Nutrition ______

____ Injury Prevention ______

Programs:

____ Sexually Transmitted Diseases ______

____ Tuberculosis ______

____ Communicable Diseases ______

____ Immunization ______

____ Chronic Diseases ______

____ Human Immunodeficiency Virus (HIV) ______

____ Dental Health Services______

____ Home Health Services ______

____ Medical Examiner______

____ Emergency Medical Services ______

____ Laboratories ______

___ B. Access to Care — general discussion of health resources ______

____ 1. Description of the availability of

a) ____ hospitals ______

b) ____ clinics ______

c) ____ private providers ______

d) ____ information about access to health care providers ______

____ 2. Discussion of primary care and preventive health services

utilization (Possible date source: The Behavioral Risk

Factor Survey)______

____ 3. Discussion of commonly-identified barriers and affected

sub-groups ______

____ a) Financial barriers — inadequate resources to pay

for health care, inadequate insurance, Medicaid

eligibility vs. Medicaid enrollment vs. access to

providers ______

____ b) Structural barriers — insufficient primary care

providers, service sites, or service patterns ______

____ c) Personal barriers — the cultural, linguistic,

educational, or other special factors that impede

access to care ______

____ C. Behavioral Risk Factors ______

____ 1. Statewide, community-specific and/or locally-developed

estimates for the prevalence of health risk behaviors can

be used to identify and discuss population subgroups that

are at increased risk due to unhealthy behaviors ______

____ 2. Local circumstances related to priority health concerns

identified in <Communities Working Together for a

<Healthier New York

____ . The Local Health Care Environment ______

____ 1. Identification and discussion of aspects of the environment

that influence the attitudes, behaviors, and the risks of

community residents for poor health within the following

categories:

a) ____ physical ______

b) ____ legal ______

c) ____ social ______

d) ____ economic ______

____ 2. Other components of the health-related environment include:

a) ____ institutions (e.g., schools, work sites, health care providers) ______

b) ____ geography (e.g., air, water quality) ______

c) ____ media messages (e.g., TV, radio, newspapers)______

d) ____ laws and regulations (smoking policies)______

<____ Section Two - Local Health Unit Capacity Profile -

program resources available for public health activity in the county.

(Suggested Resource: APEXPH) ______

____ 1. Profile of the local agency's infrastructure, includes:

a) ____ organization ______

b) ____ staffing and skill level ______

c) ____ adequacy and deployment of resources ______

d) ____ expertise and technical capacity to perform a community

health assessment _______

<____ Section Three - Problems and Issues in the Community

____ A. Profile of Community Resources - community resources

available to help meet the health-related needs of the county _______

____ 1. Groups that may have the capacity and interest to

work either individually or in collaboration with

the local health unit to improve the health status of

the community. ______

____ 2. Collaborative efforts on

a) ____ development of hospital community service plans (CSP) ______

b) ____ assessments ______

c) ____ collaborative planning processes ______

____ 3. Assessment of services for:

a) ____ availability ______

b) ____ accessibility ______

c) ____ affordability ______

d) ____ acceptability ______

e) ____ quality ______

f) ____ service utilization issues such as:

(1)____ hours of operation ______

(2)____ transportation ______

(3)____ sliding fee scales ______

(4)____other ______

____ 4. Discussion of significant outreach or public health

education efforts and whether they are targeted to

the general population or identified high-risk

populations. ______

____ 5. A summary of the available clinic facilities and

private provider resources for Medicaid recipients

should also be discussed.

(Suggested resource: The PATCH model.) ______

____ B.Profile of Unmet Need for Services

____ 1. Identification and discussion of additions to and

changes in services that will improve the health

of the identified at-risk groups. ______

____ 2. Discussion of types of changes to better serve

the target group (e.g., lower/no cost, better hours,

transportation assistance, increased sensitivity to

populations in need, language, increased acceptance of

Medicaid, and integration and/or co-location of services)______

____ 3. Identification of gaps in services and their location

(e.g., township, city or census tract)______

____ 4. Discussion of problems that might be encountered

in providing these services ______

____ 5. Disease control program sections specifically assess

needed changes to public health law and codes ______

<____ Section Four - Local Health Priorities -

of public health which rank as high local priority identified by more recent

collaborative efforts between the local health unit/department and other

community-based organizations, health care providers, consumers ______

____ 1. Description of current strategies ______

____ 2. General evaluation of the effectiveness of current strategies ______

____ 3. Assessment substantiated by data, critical incident, client

reports, etc _ _____

____ 4. Summary of the process for public health priority(ies) identification:

a) ____ how recent ______

b) ____ who was involved ______

c) ____ how were priorities determined ______

____ 5. Discussion of noteworthy accomplishment for both the local

health unit/department and other community public health

partners. ______

____ 6. Citation of efforts that have fostered new partnerships at the

community level among schools, health agencies, etc. to

maximize local assets that contribute to successful outcomes.

(The topic(s)/problem area(s) may not be the areas of high

priority throughout NYS or in any other county in the state.)______

<____ Section Five - Opportunities for Action -

sections, opportunities that the local health unit/department, solely or

in partnership, can pursue are identified to alleviate the priority public

health problems. ______

____1. Opportunities include the contribution/role played by:

a) ____ community-based organizations ______

b) ____ businesses ______

c) ____ labor and work sites ______

d) ____ schools ______

e) ____ colleges and universities ______

f) ____ government ______

g) ____ health care providers ______

h) ____ health care insurers ______

i) ____ the food industry ______

j) ____ the media ______

(These actions would not have to be implemented by the LHD alone or at all. These actions are proposed so members or groups within the community might seize the opportunity to implement these activities or other activities that could reduce or eliminate the priority public health issue(s).)

<[Section Six — Report on Statewide Performance Measures —

to be provided]

____ <Section Seven — Community Report Card

____ A. Report card attached ______

____ B. Explanation of document distribution___ ____