2010-2013 Community Health Assessment Checklist

COVER PAGE

Local Health Department: _________________________________________________

______________________________________________________________________

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: __________________________

 ______________________________________________

CHA - Prevention Agenda Description and Priority Areas

This form provides a summary of the Prevention Agenda activities and priorities, which are described in more detail within the CHA document.

  1. _____ Hospitals: ______________________________________________

    ____________________________________________________________

    ____________________________________________________________

    _____ CBOs: _________________________________________________

    ____________________________________________________________

    ____________________________________________________________

    _____ Other local government agencies: ____________________________

    _____ Not for Profits: ___________________________________________

    _____ Other LHDs, please list: ____________________________________

    ________ Businesses

    ________ Faith organizations

    ________ HMOs

    ________ Primary/medical providers

    ________ Rural Health Networks

    ________ Schools

    ________ Others: ____________________________________________

  2. ________ Access to Quality Health Care

    ________ Chronic Diseases

    ________ Community Preparedness

    ________ Healthy Environment

    ________ Healthy Mothers, Healthy Babies, Healthy Children

    ________ Infectious Disease

    ________ Mental Health and Substance Abuse

    ________ Physical Activity and Nutrition

    ________ Tobacco Use

    ________ Unintentional Injuries


  3. Y/NPlease provide their contact information: ____________________________________

    _____________________________________________________________________

  4. ___________In-person meetings

    ___________Phone calls

    ___________Conference calls

    ___________Other

    Please briefly describe your process:

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    _____________________________________________________________________

    ________ Local Public Health Director/Commissioner

    ________ Nurses

    __________ Supervising

    __________ Line/program

    ________ Sanitarians/environmental engineers

    ________ Physicians/PAs

    ________ Community Planners

    ________ Health Educators

    ________ Others, please provide title: _____________________________________________________


  5. Board of Health member(s) _____Y _____N
    Member(s) of the county legislato _____Y _____N
    County Executive/Administrator _____Y _____N

CHA Checklist/Index

This checklist/index identifies the elements of a comprehensive CHA as described in the Guidance and Format Document. The checklist should be used as a companion to the Guidance and Format Document, which provides greater detail than does the checklist. 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.

_______ Section One - Populations at Risk ................................................................ _______

_______ _______ 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 ......................................................................................................._______

  1. Program:_____________________________________________ Page number: ________
  2. Program:_____________________________________________ Page number: ________
  3. Program:_____________________________________________ Page number: ________
  4. Program:_____________________________________________ Page number: ________
  5. Program:_____________________________________________ Page number: ________

____ 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. 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 -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. 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/barriers related to priority health concerns and/or disparities have been considered ................._______

____ C. 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 -

____ ____ 1. Listing and description of 2-3 priorities under the Prevention Agenda............ _______

____ ____ 2. Listing and description of additional priorities ................................................._______

____ ____ 3. 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 LHD and other community public health partners................................................................................................................................. _______

<____ Section Five - Opportunities for Action -

____ ____ 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).)

____

____ A. Report card attached ................................................................................................_______

____ B. Explanation of document distribution........................................................................._______