Prevention Agenda 2019-2024: Prevent Chronic Diseases Action Plan

Prevent Chronic Diseases Action Plan (PDF, 1.0MB, 38pp.)

Table of Contents

Overview

Chronic diseases such as cancer, diabetes, heart disease, stroke, asthma and arthritis are among the leading causes of death, disability and rising health care costs in New York State (NYS). However, chronic diseases are also among the most preventable. Three modifiable risk behaviors - unhealthy eating, lack of physical activity, and tobacco use - are largely responsible for the incidence, severity and adverse outcomes of chronic disease. As such, improving nutrition and food security, increasing physical activity, and preventing tobacco use form the core of the Preventing Chronic Diseases Action Plan. The plan also emphasizes the importance of preventive care and management for chronic diseases, such as screening for cancer, diabetes, and high blood pressure; promoting evidence-based chronic disease management; and improving self-management skills for individuals with chronic diseases.

Some organizations and communities 1,2 have found the 3-4-50 framework a helpful way to focus interventions on the three behaviors (unhealthy eating, lack of physical activity, and tobacco use) that contribute to four chronic diseases (cancer, heart disease and stroke, type 2 diabetes and chronic lung diseases) that cause over 50 percent of all deaths worldwide.

Additional information about the burden of chronic diseases, underlying risk factors, associated disparities, and social determinants of health can be found at: Link to the burden documents.


Focus Area 1. Healthy Eating and Food Security

Overarching Goal Reduce obesity and the risk of chronic disease

Goal 1.1 Increase access to healthy and affordable foods and beverages

Goal 1.2 Increase skills and knowledge to support healthy food and beverage choices

Goal 1.3 Increase food security

Target 13.0%
Baseline 13.7%
Baseline Year 2016
Data Source PedNSS
Data Level State (by age, race/ethnicity), county
Target 16.4%
Baseline 17.3%
Baseline Year 2014-16
Data Source SWSCR
Data Level State, school district
Target 19.4%
Baseline 20.4%
Baseline Year 2015-16
Data Source NYC Fitnessgram
Data Level City, borough
Target 24.2%
Baseline 25.5%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 29.0%
Baseline 30.5%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 36.2%
Baseline 38.1%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 22.0%
Baseline 23.2%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 28.5%
Baseline 31.7%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 29.6%
Baseline 31.2%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 39.1%
Baseline 41.2%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 39.1%
Baseline 41.2%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 90.6%
Baseline 86.3%
Baseline Year 2015
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region)
Target 80.2%
Baseline 76.4%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 61.4%
Baseline 55.8%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Evidence and Resources

Evidence base:

Resources:

Age Range All Ages
Social Determinants Addressed Education
Food Security
Built Environment
Lead Sectors Employers, businesses and unions
Colleges and Universities
Policy makers and elected officials
Contributing Sectors Governmental Public Health Agencies
Media
Schools (K-12)
CBOs and Human service agencies
Urban planning agencies
Intermediate-level Measure Example

Number of entities that adopt policies or implement practices to reduce consumption of sugary drinks.

Evidence and Resources

Evidence base:

Resources:

Age Range Children, 6 weeks up to age 6 years
Social Determinants Addressed Built Environment
Lead Sectors Policy makers and elected officials
Governmental Children's Agencies
Child care Centers
Day Care Homes
Contributing Sectors Governmental Public Health Agencies
Community or neighborhood residents
Intermediate-level Measure Example

Number of early care and education sites that improve nutrition policies and practices

Evidence and Resources

Evidence base:

Resources:

Age Range Adolescents (13-21), Adults (21-60), Older Adults (60+)
Social Determinants Addressed Built Environment
Health Care
Lead Sectors Employers, businesses and unions
Contributing Sectors Governmental Public Health Agencies
Healthcare Delivery system
Insurers
Intermediate-level Measure Example

Number of worksites that improve nutrition policies and practices.

Evidence and Resources

Evidence base:

Resources:

Age Range Children up to age 11, Adolescents (13-21)
Social Determinants Addressed Education
Food Security
Community Cohesion
Lead Sectors Schools (K-12)
Policy makers and elected officials
Governmental Education Agencies
Governmental Agricultural Agencies
Agricultural Organizations
Contributing Sectors Governmental Public Health Agencies
Media
Community or neighborhood residents
CBOs and Human service agencies
Transportation agencies
Intermediate-level Measure Example

Number of schools that improve nutrition policies and practices.

Evidence and Resources

Evidence base:

Resources:

Age Range All ages
Social Determinants Addressed Food Security
Lead Sectors Governmental Public Health Agencies
Governmental Social Support Agencies
Governmental Agricultural Agencies
Contributing Sectors Healthcare Delivery system
CBOs and Human service agencies
Intermediate-level Measure Example

Number of programs that adopt policies and practices to increase consumption of fruits and vegetables.

Evidence and Resources

Evidence base:

Resources:

Age Range All ages
Social Determinants Addressed Food Security
Lead Sectors Healthcare Delivery system
CBOs and Human service agencies
Intermediate-level Measure Example 1) Number of health practices that screen for food insecurity and facilitate referrals to supportive services
Additional Intermediate-level Measure Example(s)

2) Percent of eligible New Yorkers participating in SNAP
3) Percent of eligible New Yorkers participating in WIC.

Focus Area 2. Physical Activity

Overarching Goal Reduce obesity and the risk of chronic diseases

Goal 2.1 Improve community environments that support active transportation and recreational physical activity for people of all ages and abilities.

Goal 2.2 Promote school, child care and worksite environments that increase physical activity

Goal 2.3 Increase access, for people of all ages and abilities, to indoor and/or outdoor places for physical activity.

Target 13.0%
Baseline 13.7%
Baseline Year 2016
Data Source PedNSS
Data Level State (by age, race/ethnicity), county
Target 16.4%
Baseline 17.3%
Baseline Year 2014-16
Data Source SWSCR
Data Level State, school district
Target 19.4%
Baseline 20.4%
Baseline Year 2015-16
Data Source Fitnessgram
Data Level City, borough
Target 24.2%
Baseline 25.5%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 29.0%
Baseline 30.5%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 36.2%
Baseline 38.1%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income educational attainments, disability and region), county
Target 77.4%
Baseline 73.7%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county
Target 58.7%
Baseline 53.4%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county
Target 60.6%
Baseline 55.1%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county
Target 75.9%
Baseline 69.0%
Baseline Year 2016
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county
Target 21.0%
Baseline 20.0%
Baseline Year 2015
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region)
Target 12.0%
Baseline 10.9%
Baseline Year 2015
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region)
Target 10.5%
Baseline 9.5%
Baseline Year 2015
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region)
Target 18.0%
Baseline 16.4%
Baseline Year 2015
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region)
Target TBD
Baseline TBD
Baseline Year 2018
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county
Target TBD
Baseline TBD
Baseline Year 2018
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county
Target TBD
Baseline TBD
Baseline Year 2018
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county
Target TBD
Baseline TBD
Baseline Year 2018
Data Source BRFSS
Data Level State (by sex, age, race/ethnicity, income, educational attainment, disability and region), county
Target 24.4%
Baseline 23.2%
Baseline Year 2017
Data Source YRBS
Data Level State (by sex, grade-level, race/ethnicity)
Target 18.7%
Baseline 17.0%
Baseline Year 2017
Data Source YRBS
Data Level State (by sex, grade-level, race/ethnicity)
Target 20.1%
Baseline 18.3%
Baseline Year 2017
Data Source YRBS
Data Level State (by sex, grade-level, race/ethnicity)

2.1 Improve community environments that support active transportation and recreational physical activity for people of all ages and abilities.

Evidence and Resources

Evidence base:

Resources:

Age Range All Ages
Social Determinants Addressed Economic Stability
Transportation
Community Cohesion
Built Environment
Lead Sectors Governmental Public Health Agencies
Contributing Sectors Insurers
Media
Colleges and Universities
Schools (K-12)
Community or neighborhood residents
CBOs and Human service agencies
Policy makers and elected officials
Transportation agencies
Housing agencies
Economic development agencies
Natural environment agencies
Urban planning agencies
Intermediate-level Measure Example Number of places that implement new, or improve existing, community planning and transportation interventions that support safe and accessible physical activity

2.2 Promote school, child care and worksite environments that increase physical activity

Evidence and Resources

Evidence base:

Resources:

Age Range Children up to age 11, Adolescents (13-21)
Social Determinants Addressed Education
Community Cohesion
Lead Sectors Governmental Public Health Agencies
Contributing Sectors Media
Colleges and Universities
Schools (K-12)
Community or neighborhood residents
CBOs and Human service agencies
Policy makers and elected officials
Housing agencies
Economic development agencies
Intermediate-level Measure Example Number of schools with Comprehensive School Physical Activity Programs
Evidence and Resources

Evidence base:

3.1.3.1: Active Opportunities for Physical Activity

3.1.3.4: Caregivers'/Teachers' Encouragement of Physical Activity

2.2.0.3: Screen Time/Digital Media Use

Resources:

Age Range Infants and Toddlers up to age 5
Social Determinants Addressed Education
Community Cohesion
Lead Sectors Governmental Public Health Agencies
Contributing Sectors Media
Colleges and Universities
Schools (K-12)
Community or neighborhood residents
CBOs and Human service agencies
Housing agencies
Economic development agencies
Intermediate-level Measure Example Number of early care and education sites that improve physical activity policies and practices using an evidence-based assessment tool
Evidence and Resources

Evidence base:

Resources:

Age Range Adolescents (13-21), Adults (21-60), Older Adults (60+)
Social Determinants Addressed Economic Stability
Health Care
Lead Sectors Governmental Public Health Agencies
Contributing Sectors Healthcare Delivery system
Employers, businesses and unions
Insurers
Intermediate-level Measure Example Number of worksites that improve physical activity policies and practices using an evidence-based assessment tool

2.3 Increase access, for people of all ages and abilities, to indoor and/or outdoor places for physical activity.

Evidence and Resources

Evidence base:

Resources:

Age Range All Ages
Social Determinants Addressed Economic Stability
Transportation
Community Cohesion
Natural Environment
Built Environment
Lead Sectors Governmental Public Health Agencies
Contributing Sectors Insurers
Media
Colleges and Universities
Schools (K-12)
Community or neighborhood residents
CBOs and Human service agencies
Policy makers and elected officials
Transportation agencies
Housing agencies
Economic development agencies
Natural environment agencies
Urban planning agencies
Intermediate-level Measure Example Number of indoor and/or outdoor facilities that can be accessed by walking, biking, or wheeling.

Focus Area 3. Tobacco Prevention

Goal 3.1 Prevent initiation of tobacco use

Target 19.7%
Baseline 25.4%
Baseline Year 2016
Data Source NYS YTS
Data Level State (race/ethniity, gender, grade level, NYC/ROS)
Target 3.3%
Baseline 4.3%
Baseline Year 2016
Data Source NYS YTS
Data Level State (race/ethniity, gender, grade level, NYC/ROS)
Target 15.9%
Baseline 20.6%
Baseline Year 2016
Data Source NYS YTS
Data Level State (race/ethniity, gender, grade level, NYC/ROS)
Target 9.1%
Baseline 11.7%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, SES, gender, region), and by county when expanded
Target 7.0%
Baseline 9.1%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, SES, gender, region), and by county when expanded
Target 30
Baseline 15
Baseline Year 2018
Data Source CAT
Data Level State, municipality
Evidence and Resources

Resources: [Best Practices]; 2016 Independent Evaluation Report of the New York Tobacco Control Program

https://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm
Age Range All age groups
Social Determinants Addressed Health Care
Social and Community Context
Lead Sectors Advocates
state government
Intermediate-level Measure Example Raise program funding to $52 million, approximately 25 percent of recommended full funding.
Evidence and Resources

Resources: The Community Guide: The Role of the Media in Promoting and Reducing Tobacco Use https://www.thecommunityguide.org/topic/tobacco

Age Range All
Social Determinants Addressed Social and Community Context: Social Cohesion
Lead Sectors Media
State and local health departments
Intermediate-level Measure Example Evidence of increasing support for effective tobacco control measures that would reduce youth initiation.
Evidence and Resources

Resources: Public Health Law Center, http://www.publichealthlawcenter.org/sites/default/files/resources/tclc-guide-pos-policy-WashU-2014.pdf

Age Range Birth — 18, All
Social Determinants Addressed Neighborhood and Environment: Environmental Conditions
Lead Sectors Local government
Intermediate-level Measure Example Evidence of increasing support for effective tobacco control measures that would reduce youth initiation.
Evidence and Resources

Resources: Public Health Law Center

http://www.publichealthlawcenter.org/sites/default/files/resources/tclc-guide-pos-policy-WashU-2014.pdf

Age Range All
Social Determinants Addressed Neighborhood and Environment: Environmental Conditions
Lead Sectors Local government
Intermediate-level Measure Example Evidence of increasing support for effective tobacco control measures that restrict tobacco company practices that decrease the real price of tobacco products through industry discounts.
Evidence and Resources

Resources: Public Health Law Center

http://www.publichealthlawcenter.org/sites/default/files/resources/Regulating-Flavored-Tobacco-Products-2017.pdf
Age Range Birth — 18, All
Social Determinants Addressed Neighborhood and Environment: Environmental Conditions
Lead Sectors local government
Intermediate-level Measure Example Evidence of increasing support for effective tobacco control measures that would restrict the sale of flavored tobacco products and flavored liquids used in electronic vapor products.
Evidence and Resources

Resources: University of California, San Francisco, https://smokefreemovies.ucsf.edu/

Age Range Birth - 18
Social Determinants Addressed Social Cohesion
Lead Sectors Entertainment
Intermediate-level Measure Example Evidence of increasing support for effective tobacco control measures that would eliminate youth exposure to tobacco imagery and marketing in youth-rated movies.

Goal 3.2 Promote tobacco use cessation

Target 60.1%
Baseline 53.1%
Baseline Year 2017
Data Source NYS ATS
Data Level State (race/ethniity, gender, SES, NYC/ROS)
Target 11.0%
Baseline 14.2%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, SES, gender, region), and by county when expanded
Target 15.3%
Baseline 19.8%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, SES, gender, region), and by county when expanded
Target 14.9%
Baseline 19.2%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, SES, gender, region), and by county when expanded
Target 20.1%
Baseline 26.0%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, SES, gender, region), and by county when expanded
Target 14.9%
Baseline 19.3%
Baseline Year 2014-2016 pooled
Data Source BRFSS
Data Level state (by race/ethnicity, SES, gender, region), and by county when expanded
Target 15.6%
Baseline 20.1%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, SES, gender, region), and by county when expanded
Target 26.2%
Baseline 20.5%
Baseline Year 2016
Data Source Medicaid Program
Data Level state, NYC/ROS
Evidence and Resources

Resources: https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

https://talktoyourpatients.health.ny.gov/

Age Range 18 years and older
Social Determinants Addressed Health Care
Access to Health Care
Lead Sectors FQHCs
CHC
Behavioral Health Clinics
Provider Practices
Intermediate-level Measure Example Health care providers exhibit greater propensity to provide counseling and medications where appropriate to treat tobacco dependence in their patients.
Evidence and Resources

Resources:

https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html

https://talktoyourpatients.health.ny.gov/

https://www.nysmokefree.com/

Age Range 18 years and older
Social Determinants Addressed Health Care
Health and Health Care: Access to Health Care
Lead Sectors State Health Department, local health departments
Intermediate-level Measure Example Promote and educate smokers about the benefits of evidence-based quitting approaches.
Evidence and Resources

Resources: https://talktoyourpatients.health.ny.gov/

Age Range 18 years and older
Social Determinants Addressed Health Care
Health and Health Care: Access to Health Care
Lead Sectors Health Care Organizations and Providers
NYS Smokers' Quitline
Community Based Organizations
Intermediate-level Measure Example Work with departmental health system grantees to promote the delivery of evidence-based cessation services by health care providers.
Evidence and Resources

Resources: CDC: https://www.cdc.gov/mmwr/volumes/67/wr/mm6713a3.htm

Age Range 18 years and older
Social Determinants Addressed Health Care
Health and Health Care: Access to Health Care
Lead Sectors Medicaid Offices
County Health Departments
Intermediate-level Measure Example Increase awareness of Medicaid benefits for tobacco use cessation among Medicaid enrollees and health care providers.

Goal 3.3 Eliminate exposure to secondhand smoke

Target 27.2%
Baseline 35.2%
Baseline Year 2017
Data Source NYS ATS
Data Level State (race/ethniity, gender, SES, NYC/ROS)
Target 17.9%
Baseline 23.1%
Baseline Year 2016
Data Source NYS YTS
Data Level State (race/ethniity, gender, grade level, NYC/ROS)
Target
Baseline
Baseline Year
Data Source CAT
Data Level State, municipality
Evidence and Resources

Resources: HUD Smoke Free Public Housing https://www.hud.gov/program_offices/healthy_homes/smokefree

Age Range All
Social Determinants Addressed Neighborhood and Environment: Environmental Conditions
Lead Sectors Housing agencies
Intermediate-level Measure Example Increase the number of 100% smoke-free public housing units. Increase the proportion of leases that require that smoking policies be transparent.
Evidence and Resources

Resources: Public Health and Tobacco Policy Center

http://tobaccopolicycenter.org/tobacco-control/tobacco-free-outdoor-areas/
Age Range All
Social Determinants Addressed Neighborhood and Environment: Environmental Conditions
Lead Sectors Government
business
educational institutions
healthcare institutions
Intermediate-level Measure Example Increasing support for or actual policies passed that increase the number of smoke-free parks, beaches, playgrounds and other public spaces.
Evidence and Resources

Resources: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/general_facts/index.htm

Age Range All
Social Determinants Addressed Neighborhood and Environment: Environmental Conditions
Lead Sectors Business
government
educational institutions
Intermediate-level Measure Example Number of times decision makers were educated about secondhand smoke and aerosol/emissions
Additional Intermediate-level Measure Example(s) Number of community education forums or media campaigns conducted.

Focus Area 4. Chronic Disease Preventive Care and Management

Goal 4.1 Increase cancer screening rates

Target 79.7%
Baseline 75.9%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, gender, and region), and by county
Target 80.0%
Baseline 76.1%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, gender, and region), and by county
Target 80.0%
Baseline 68.5%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, gender, and region), and by county
Target 63.7%
Baseline 60.7%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, gender, and region), and by county
Target 66.3%
Baseline 63.1%
Baseline Year 2016
Data Source BRFSS
Data Level state (by race/ethnicity, gender, and region), and by county
Evidence and Resources Evidence: The Community Guide
Age Range adults ages 21-75
Social Determinants Addressed Health Care
Lead Sectors Healthcare Delivery system
Insurers
Contributing Sectors Governmental Public Health Agencies
Intermediate-level Measure Example
  • Number of health systems that implement or improve provider and patient reminder systems

  • Number of patients reached through patient reminder systems

  • Compliance with screening guidelines among patients reached through patient reminder systems/among patients of health systems that adopted systems

  • Provider, clinic or insurer breast, cervical and colorectal cancer screening rates

Evidence and Resources Evidence: The Community Guide
Age Range adults ages 21-75
Social Determinants Addressed Education
Lead Sectors Governmental Public Health Agencies
Healthcare Delivery system
CBOs and Human service agencies
Contributing Sectors Employers, businesses and unions
Insurers
Community or neighborhood residents
Intermediate-level Measure Example
  • Number of individuals reached through one-on-one or group education that were referred to health providers for cancer screening

  • Change in knowledge and awareness of need for cancer screening among individuals reached through one-on-one or group education

  • Compliance with screening guidelines among individuals that were reached through one-on-one or group education

Evidence and Resources Evidence: The Community Guide
Age Range adults ages 21-75
Social Determinants Addressed Education
Lead Sectors Governmental Public Health Agencies
Healthcare Delivery system
Insurers
CBOs and Human service agencies
Contributing Sectors Employers, businesses and unions
Intermediate-level Measure Example
  • Number and type of locations where materials were distributed

  • Change in knowledge and awareness of need for cancer screening among groups reached through small media dissemination

Evidence and Resources Evidence: The Community Guide
Age Range adults ages 21-75
Social Determinants Addressed Health Care
Lead Sectors Healthcare Delivery system
Insurers
Contributing Sectors Governmental Public Health Agencies
Intermediate-level Measure Example
  • Number of health systems or providers that adopt or improve provider assessment and feedback systems for cancer screening

  • Provider or clinic-level breast, cervical, and colorectal cancer screening rates

Evidence and Resources Evidence: The Community Guide
Age Range adults ages 21-75
Social Determinants Addressed Transportation
Health Care
Lead Sectors Governmental Public Health Agencies
Healthcare Delivery system
Employers, businesses and unions
CBOs and Human service agencies
Transportation agencies
Intermediate-level Measure Example Number of organizations that adopt practices and policies that reduce structural barriers to cancer screening
Evidence and Resources Evidence: The Community Guide
Age Range adults ages 21-64
Social Determinants Addressed Economic Stability
Health Care
Lead Sectors Governmental Public Health Agencies
Healthcare Delivery system
Employers, businesses and unions
Insurers
CBOs and Human service agencies
Policy makers and elected officials
Intermediate-level Measure Example Change in the percent of NYS population that has health insurance coverage

Goal 4.2 Increase early detection of cardiovascular disease, diabetes, prediabetes and obesity

Target 71.7%
Baseline 68.3%
Baseline Year 2016
Data Source BRFSS
Data Level state (by gender, income, and region), and by county
Target 67.4%
Baseline 64.2%
Baseline Year 2016
Data Source BRFSS
Data Level state (by gender, income, and region), and by county
Target 80.6% [HMO]; 80.6% [MMC]
Baseline 77% [HMO]; 77% [MMC]
Baseline Year 2016
Data Source QARR
Data Level state (by health plan)
Evidence and Resources Resources: Million Hearts
Age Range Adult, with a focus over 45 years
Social Determinants Addressed Health Care
Lead Sectors Healthcare Delivery system
Insurers
Contributing Sectors Governmental Public Health Agencies
Intermediate-level Measure Example
  • number of health systems with policies/practices to identify patients with undiagnosed HTN

  • number/percentage of patients served by health systems with policies/practices in place

  • number of patients identified with undiagnosed HTN

Evidence and Resources

Resources:

Age Range Adult, with a focus over 45 years
Social Determinants Addressed Health Care
Lead Sectors Healthcare Delivery system
Insurers
Contributing Sectors Governmental Public Health Agencies
Intermediate-level Measure Example
  • number of health systems with policies/practices to identify patients with diabetes or prediabetes

  • number/percentage of patients served by health systems with policies/practices in place

  • number of patients identified with diabetes/prediabetes

Goal 4.3 Promote evidence-based care to prevent and manage chronic diseases including asthma, arthritis, cardiovascular disease, diabetes and prediabetes and obesity

Target 26.6% [HMO]; 31.4% [MMC]
Baseline 28% [HMO]; 33% [MMC]
Baseline Year 2016
Data Source QARR
Data Level state (by health plan, age, race/ethnicity)
Target 38.0%
Baseline 40.0%
Baseline Year 2016
Data Source QARR
Data Level state (by health plan)
Target 39.0%
Baseline 41.0%
Baseline Year 2016
Data Source QARR
Data Level state (by health plan)
Target 66.2% [HMO]; 65.1% [MMC]
Baseline 63% [HMO]; 62% [MMC]
Baseline Year 2016
Data Source QARR
Data Level state (by health plan, age, race/ethnicity)
Target 56.7%
Baseline 54.0%
Baseline Year 2016
Data Source QARR
Data Level state (by health plan)
Target 52.5%
Baseline 50.0%
Baseline Year 2016
Data Source QARR
Data Level state (by health plan)
Target 0-4: 177.1; 0-17: 130.2; all: 77.7
Baseline 0-4: 186.4; 0-17: 137.1; all: 81.8
Baseline Year 2016
Data Source SPARCS
Data Level Statewide; County
Target 0-4: 39.2; 0-17: 21.2; all: 10.3
Baseline 0-4: 43.5; 0-17: 23.5; all: 11.4
Baseline Year 2016
Data Source SPARCS
Data Level Statewide; County
Target 5-18: 59%; 19-64: 75%
Baseline 5-18: 54%; 19-64: 68%
Baseline Year 2016
Data Source QARR
Data Level Statewide; health plan; county
Target 5-18: 69%; 19-64: 62%
Baseline 5-18: 63%; 19-64: 56%
Baseline Year 2016
Data Source QARR
Data Level Statewide; health plan; county
Target 80.70%
Baseline 76.9%
Baseline Year 2016
Data Source BRFSS
Data Level state (by gender, race/ethnicity, income and region), and by county
Target 66.6%
Baseline 63.4%
Baseline Year 2015
Data Source BRFSS
Data Level state (by gender, age, region)
Evidence and Resources

Resources:

Age Range All ages
Social Determinants Addressed Health Care
Lead Sectors Healthcare Delivery system
Contributing Sectors Governmental Public Health Agencies
Insurers
Intermediate-level Measure Example
  • number of health systems that implement policies/practices to promote team-based care

  • number/percentage of patients in health systems with policies/practices in place

Evidence and Resources

Resources:

Age Range All ages
Social Determinants Addressed Health Care
Lead Sectors Healthcare Delivery system
Contributing Sectors Governmental Public Health Agencies
Insurers
Intermediate-level Measure Example
  • number of health systems that implement policies/practices to promote guideline-concordant chronic disease care

  • number/percentage of patients in health systems with policies/practices in place

Evidence and Resources Resources: Merit-Based Incentive Payment System (MIPS)
Age Range All ages
Social Determinants Addressed Health Care
Lead Sectors Healthcare Delivery system
Contributing Sectors Governmental Public Health Agencies
Insurers
Intermediate-level Measure Example
  • number of providers using a registry to identify patients with a chronic condition

  • number/percentage of health systems with certified EHRs

  • number/percentage of health systems with connections to a Qualified Entity

  • number/percentage of patients served by health systems with a certified EHR and/or QE connected health system

Evidence and Resources

Resources:

Age Range All ages
Social Determinants Addressed Health Care
Lead Sectors Healthcare Delivery system
Contributing Sectors Governmental Public Health Agencies
Insurers
Intermediate-level Measure Example
  • number of health systems that implement policies/practices to encourage self-management behaviors, including adherence to medication

  • number of health systems that include pharmacists as members of the care team

  • number/percentage of patients served by health systems with policies/practices related to self-management behaviors, including adherence to medication

  • #number of patients identified with a self-management plan

Evidence and Resources

Resources: http://clinical.diabetesjournals.org/content/36/1/14

Age Range Adults, including those over 65 years old.
Social Determinants Addressed Health Care
Lead Sectors Healthcare Delivery system
Contributing Sectors Governmental Public Health Agencies
Insurers
CBOs and Human service agencies
Intermediate-level Measure Example
  • number of health systems that have policies/practices for identifying and referring patients to National DPP programs

  • number of National DPP programs in community settings

  • number of patients referred to National DPP

  • number of patients who participate in National DPP

  • percentage of patients who complete National DPP

Evidence and Resources

Resources: https://www.cdc.gov/mmwr/volumes/67/wr/mm6717a2.htm?s_cid=mm6717a2

Age Range Adults with arthritis, including those over 65 years old.
Social Determinants Addressed Health Care
Lead Sectors Healthcare Delivery system
Contributing Sectors Governmental Public Health Agencies
Employers, businesses and unions
Insurers
Media
Colleges and Universities
Community or neighborhood residents
CBOs and Human service agencies
Policy makers and elected officials
Transportation agencies
Housing agencies
Natural environment agencies
Urban planning agencies
Intermediate-level Measure Example
  • number of health systems that have policies/practices for identifying and counseling patients with arthritis on PA

  • number patient with arthritis identified and counseled

  • number of patients referred to evidence-based walking programs

  • number evidence-based walking programs in the community

  • number of patients who participate in programs/% who complete

Goal 4.4 In the community setting, improve self-management skills for individuals with chronic diseases, including asthma, arthritis, cardiovascular disease, diabetes and prediabetes and obesity

Target 10.60%
Baseline 10.1%
Baseline Year 2016
Data Source BRFSS
Data Level state (by gender, age, race/ethnicity, income), and by county
Target 0-17: 53.1%; 18+: 26.6%
Baseline 0-17: 48.3%; 18+: 24.21%
Baseline Year 2011-2013 (0-17); 2014 (18+)
Data Source BRFSS Asthma Call-Back Survey
Data Level State
Evidence and Resources

Resources:

Age Range All, with focus on ages 0-17
Social Determinants Addressed Housing
Health Care
Lead Sectors CBOs and Human service agencies
Contributing Sectors Governmental Public Health Agencies
Employers, businesses and unions
Insurers
Media
Colleges and Universities
Community or neighborhood residents
Policy makers and elected officials
Transportation agencies
Housing agencies
Economic development agencies
Intermediate-level Measure Example
  • number of providers trained on NAEPP Guidelines including ASME and home-based interventions

  • number of health systems that have policies/practices for referring patients with asthma to home-based services

  • number of patients referred to home-based services

Evidence and Resources

Resources:

Age Range All, including those over 65 years old and children age 0-17 for asthma only
Social Determinants Addressed Health Care
Lead Sectors CBOs and Human service agencies
Contributing Sectors Governmental Public Health Agencies
Employers, businesses and unions
Insurers
Colleges and Universities
Community or neighborhood residents
Policy makers and elected officials
Transportation agencies
Housing agencies
Economic development agencies
Intermediate-level Measure Example
  • number of health systems that have policies/practices for identifying and referring patients to evidence-based self-management education (EBSMPs) programs

  • number and type of EBSMP programs in community settings

  • number patients referred to EBSMP

  • number of patients who participate in EBSMP

  • percentage of patients who complete EBSMP

  • number of schools using the NYSDOH Guide for Asthma Management in Schools

Evidence and Resources

Resources: https://www.cdc.gov/sixeighteen/diabetes/index.htm

Age Range Adults, including those over 65 years old.
Social Determinants Addressed Health Care
Lead Sectors CBOs and Human service agencies
Contributing Sectors Governmental Public Health Agencies
Employers, businesses and unions
Insurers
Community or neighborhood residents
Intermediate-level Measure Example
  • number of health systems that have policies/practices for identifying and referring patients to National DPP programs

  • number of National DPP programs in community settings

  • number patients referred to National DPP

  • number of patients who participate in National DPP

  • percentage of patients who complete National DPP

Notes

  1. Vermont 3-4-50
  2. San Diego County 3-4-50