4 Introduction
4.1 Prevention Agenda
The Prevention Agenda 2025–2030 is New York State’s Health Improvement Plan, a six-year strategic initiative designed to improve public health and serve as a blueprint for state and local health departments to enhance the health of all residents (1). The main strategy of the Prevention Agenda is to promote health equity for populations who experience health disparities through prevention of chronic disease and barriers to health care access. Achieving well-being and good quality of life requires a strong focus on prevention, with health behaviors, access to care, and social determinants of health playing key roles in promoting long-term health outcomes.
The Prevention Agenda has five domains with specific action plans developed for each area. The five domains, based on Healthy People 2030’s Social Determinants of Health (2), are Economic Stability, Social and Community Context, Neighborhood and Built Environment, Health Care Access and Quality, and Education Access and Quality.
Since 2012, the New York State Department of Health (NYSDOH) has required LHDs to collaboratively work with their local hospitals and community partners in the development of the Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP).
4.2 Community Health Assessment
The CHA serves as the foundation of essential services provided by local public health departments, enabling the assessment and monitoring of population health status, influencing factors, and community needs and assets. CHAs are a comprehensive assessment of a community’s health status, challenges, and strengths. Data are compiled from a collection of local, state, and federal resources to ensure a complete picture is captured. With a comprehensive review of the community’s health, this data aids in identifying populations at higher risk of poor health outcomes.
This document guides public health planning, program development, policy changes, resource coordination, funding applications, and innovative ways to collaboratively leverage community assets. Once completed, the information is shared with community members and stakeholders to initiate health improvement planning and development.
4.3 Community Health Needs Assessment and Community Service Plan
For hospitals classified as charitable organizations, they must meet general requirements for tax exemption under Section 501(c)(3) (3) and Revenue Ruling 69–545 (4). They must also meet the requirements imposed by Section 501(r) (5) on a facility-by-facility basis in order to be treated as an organization described in Section 501(c)(3). This involves completing a Community Health Needs Assessment (CHNA) and a Community Service Plan (CSP) every three years.
The CHNA must define the community that it serves including the geographic area, target populations, and any focus on specialty areas or targeted diseases. It must also assess the health needs of the defined community including social determinants of health. As part of this process, they should include input from partners, stakeholders, and those with knowledge of the community’s health needs. As with the CHA, the CHNA should be shared widely.
Through the CHNA, CHA, and partnership with the LHDs, the hospitals develop a CSP. The CSP, like the CHIP, develops and implements effective approaches to health promotion and disease prevention at the community level. The plan involves the use of evidence-based programs that target health areas identified in the CHNA that are of particular concern to their hospital service areas. For those hospitals that partner with LHDs, these areas are of concern to the greater county or regional efforts.
4.4 Community Health Improvement Plan
The CHIP is a strategic plan for developing targeted interventions for issues identified in the CHA. The purpose of a CHIP is to describe how the local public health system, led by the LHDs and hospitals, will work together to improve the health of their community. The document sets priorities, identifies programs and policies for implementation, outlines partner responsibilities, directs use of assets, and sets measurable strategic goals, all within a community driven process.
4.5 Partnership
The seven Mid-Hudson (M-H) Region LHDs have vast experience with assessing health and developing partnerships to advance the health of their communities. The LHDs lead the CHA and CHIP process via partnerships and follow the requirements of the NYSDOH.
The CHA and CHIP process allows health departments to work with a network of partners and stakeholders focused on health improvement. Collaboration ensures that this process is dynamic and evolves with what is happening to residents. Engaging the community is key to understanding, supporting, and implementing strategies and ensuring successful outcomes.
4.6 Data Sources and Indicator Selection
To create this document, the following data sources were utilized. In certain instances, data were obtained by request and are not readily available to the public.
American Community Survey (ACS): A nationwide survey conducted by the US Census Bureau to gather information about the social and economic need of communities, reaching over 3.5 million addresses each year. Secondary source
American Medical Association (AMA) Online Data Collection Center: The AMA allows licensed physicians to update their AMA listing and credentialing. Secondary source
Area Health Resource Files: A database maintained by the Health Resources and Services Administration of the Department of Health and Human Services which provides data from over 50 sources on health care professions, health facilities, population characteristics, economics, health professions training, hospital utilization, hospital expenditures, and environment at the county, state, and national levels. Secondary source
Behavioral Risk Factor Surveillance System (BRFSS): An annual national phone survey coordinated and funded by the Centers for Disease Control and Prevention (CDC) and conducted by each State’s health department. Data includes health related behaviors, health conditions, and use of health services. Secondary source
National Provider Identifier (NPI) Standard: Overseen by the Centers for Medicare & Medicaid Services, the NPI is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. Secondary source
Comprehensive Housing Affordability Strategy (CHAS): Custom tabulations of ACS data about housing problems and housing needs from the US Census Bureau sent to the U.S. Department of Housing and Urban Development (HUD). HUD and local governments use this data to plan how to distribute their funds. Secondary source
County Health Rankings & Roadmaps: A collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. County Health Rankings and Roadmaps pulls from multiple sources to measure key health factors across counties in the US. Secondary source
Feeding America: Feeding America is the nation’s largest domestic hunger-relief organization, a network of food banks in every county in the world. Programs help provide meals to children, seniors, families, and survivors of natural disasters. Using sources such as the ACS, the Bureau of Labor Statistics, and the US Department of Agriculture, Feeding America conducts Map the Meal Gap, a county level analysis of food insecurity. Secondary source
Health Resources and Services Administration (HRSA) Data Warehouse: A database maintained by the Department of Health and Human Services which provides maps, data, reports, and dashboards about HRSA’s health care programs, including Health Professional Shortage Areas, Health Resource Files, and Medically Underserved Populations. Secondary source
Healthy People 2030: A collaborative process, guided by the Office of Disease Prevention and Health Promotion within HHS, that reflects input from a diverse group of individuals and organizations. Healthy People 2030 includes 10-year national objectives for improving the health of all Americans. Healthy People 2030 has established measurable objectives and monitors benchmark progress over time. Secondary source
Local Health Department Surveys: Surveys conducted by the counties to poll their residents on various aspects of health. Primary source
Mid-Hudson Community Partner Survey: An online survey distributed by the Hudson Valley Public Health Collaborative to those who provide services in the region. Primary source
Mid-Hudson Region Community Health Survey: A random digit dial and online survey conducted by Siena Research Institute (SRI). Created in collaboration with the HVPHC, local hospital partners, and SRI. Primary source
National Environmental Public Health Tracking Network: A data hub provided by the CDC which brings together health and environmental data. Secondary source
New York City Poison Center: A call center and research organization which provides poison emergency telephone management, poison information resources, public education, professional education, research and data collection, and toxicosurveillance in real time. Its coverage area includes all New York City (NYC) counties, Nassau, Suffolk, and Westchester counties. Secondary source
New York Citywide Immunization Registry: The NY Citywide Immunization Registry (CIR) keeps immunization records for all children and adults who live in NYC. CIR consolidates immunization information and shares it with health care providers, families and agencies concerned with public health. Secondary source
New York County/NYC Neighborhood Cancer Statistics Dashboards: The Cancer Statistics Dashboards provide easy access to a wide range of cancer statistics in the New York State, including cancer incidence, mortality, trends, stage at cancer diagnosis, survival, and prevalence information. The dashboards are organized according to the geography at which the statistics are available. Secondary source
New York State Cancer Registry: A registry which collects, processes, and reports information about New Yorkers diagnosed with cancer from all physicians, dentists, laboratories, and other health care providers who are required to report all cancers to the NYS Department of Health (DOH). Secondary source
New York State Childhood Lead Poisoning Prevention Program (CLPPP): The CLPPP is the largest in the country working to make homes safe from lead. It funds NYS local health departments (LHD) to approach high-risk housing to educate, inspect and control lead hazards. It looks for properties with lead paint hazards, then it takes action to make them lead safe, protecting children from lead poisoning. Blood lead testing data and blood lead levels are monitored through CLPPP. Secondary source
New York State Communicable Disease Annual Reports: Documents are released annually from NYSDOH containing mandated reports of suspected or confirmed communicable diseases. Secondary source
New York State Communicable Disease Electronic Surveillance System (CDESS): Reporting of suspected or confirmed communicable diseases is mandated under the NYS Sanitary Code (10NYCRR 2.10). Although physicians have primary responsibility for reporting, school nurses, laboratory directors, infection control practitioners, daycare center directors, health care facilities, state institutions, and any other individuals/locations providing health care services are also required to report communicable diseases. All reportable communicable disease data coming through the Electronic Clinical Laboratory Reporting System Introduction are reported to CDESS in a timely and complete manner. LHDs review each lab report for proper initiation of a case investigation. Once the investigation is created, the LHD may create a reportable case or may dismiss it if evidence does not support the case definition. Primary source
New York State Department of Health Bureau of Communicable Disease Control: This Bureau is responsible for preventing and controlling the spread of disease by conducting disease surveillance, epidemiological investigations, and disseminating public health information. Secondary source
New York State Department of Health Community Health Indicator Reports (CHIRS): The CHIRS Dashboard tracks about 350 indicators organized by 15 health topics and is updated regularly to include the most recent year of data available for these indicators. Each NYS County has their own dashboard allowing for comparison of each county’s data to regional and NYS totals. Visualizations include tables, maps, charts, and graphs at state and county levels. Secondary source
New York State Department of Health County Health Indicators by Race/Ethnicity (CHIRE): The CHIRE is a map-based tool that allows users to view health indicators by race and ethnicity in NYS and by county. It includes a variety of health indicators by race and ethnicity including mortality, vital statistics, injuries, chronic diseases, and substance abuse. Secondary source
New York State Department of Health Electronic Clinical Laboratory Reporting System (ECLRS): ECLRS provides laboratories that serve NYS with a single electronic system for secure and rapid transmission of reportable disease information to the NYSDOH, county health departments, and the NYC Department of Health and Mental Hygiene. ECLRS provides timely reporting, improving completeness and accuracy of reports, and generally facilitating the identification of emergent public health problems by monitoring communicable diseases, lead poisoning, HIV/AIDS, and cancer. Secondary source
New York State Department of Health Office of Sexual Health and Epidemiology: A special projects unit responsible for conducting Sexually Transmitted Infection (STI) surveillance activities related to screening, disease morbidity, and HIV/STI Partner Services disease intervention activities. Oversees surveillance activities for chlamydia, gonorrhea, and syphilis for NYS (excluding NYC). Secondary source
New York State Department of Health Rabies Laboratory: Located at Wadsworth Center’s Griffin Laboratory, provides monthly reports of the number of animals tested for rabies, as well as the number that tested positive for rabies in every NYS county. Secondary source
New York State Department of Health Wadsworth Center: Wadsworth Center is a science-based community committed to protecting and improving the health of New Yorkers through laboratory analysis, investigations, and research, as well as laboratory certification and educational programs. As the state’s public health reference laboratory, Wadsworth responds to urgent public health threats as they arise, develops advanced methods to detect microbial agents and genetic disorders, and measures and analyzes environmental chemicals. Secondary source
New York State Division of Criminal Justice: A criminal justice support agency which provides resources and services that inform decision-making and improve the quality of the criminal justice system. It maintains, analyzes, and publishes criminal and youth justice system data, including incidents of crimes and arrests and dispositions, as reported by police departments, sheriffs’ offices, probation departments, and the state Office of Court Administration. Secondary source
New York State Education Department: Website publicly reports educational data submitted by educational institutions. Secondary source
New York State HIV Surveillance System: An HIV surveillance system conducted by the AIDS Institute Bureau of HIV/AIDS Epidemiology that facilitates and monitors HIV-related laboratories and clinician reporting in NYS. Secondary source
New York State Immunization Information System: A web-based registry that provides immunization records that are easily accessible and promotes public health by documenting all individuals of appropriate age and risk. All health care providers are required to report all immunizations administered to persons less than 19 years of age, along with the person’s immunization histories, to the NYS Department of Health. Secondary source
New York State Medicaid Program: NYS’s Medicaid program provides comprehensive health coverage to more than 7.5 million lower-income New Yorkers (as of December 2023). Medicaid pays for a wide range of services, depending on a resident’s age, financial circumstances, family situation, or living arrangements. These services are provided through a large network of health care providers that can be accessed directly using Medicaid or through a managed care plan. Secondary source
New York State Office of Addiction Services and Supports (OASAS): The OASAS Office of Data Management, Research and Planning closely monitors substance use disorder data and trends to better anticipate and meet the needs of New Yorkers living with addiction. Data is made available to partners, providers, and localities to inform the collective efforts to understand and address addiction in NYS. Secondary source
New York State Opioid Data Dashboard: This is an interactive visual presentation of indicators tracking opioid data at state and county levels. It is a key resource for monitoring fatal and nonfatal opioid overdoses, opioid prescribing, opioid use disorder treatment, and the overall opioid overdose burden. It displays a view of current and historical data for 98 opioid-related indicators. Secondary source
New York State Prescription Monitoring Program Registry: This resource provides practitioners with direct, secure access to view dispensed controlled substance prescription histories for their patients. Patient reports include all controlled substances that were dispensed in NYS and reported by the pharmacy/dispenser for the past year. This information will allow practitioners to better evaluate their patients’ treatment with controlled substances and determine whether there may be abuse or non-medical use. Secondary source
New York State Prevention Agenda Tracking Dashboard: This is an interactive visual presentation of the most current tracking indicator data to track progress of the New York State’s Health Improvement Plan at state and county levels. It serves as a key source for monitoring progress that communities around the state have made regarding meeting the Prevention Agenda objectives. Secondary source
New York State Student Weight Status Category Reporting System: A system that collects weight status category data on children and adolescents attending public schools in NYS outside of NYC. Secondary source
New York Statewide Planning and Research Cooperative System (SPARCS): SPARCS is a comprehensive all-payer data reporting system established from cooperation between the health care industry and government. The system currently collects patient level data on characteristics, diagnoses and treatments, services, and charges for each hospital inpatient and outpatient visit. Secondary source
Data Small Area Health Insurance Estimates (SAHIE): SAHIE is a program of the US Census Bureau which estimates health insurance coverage for all states and counties nationally. Secondary source
United for ALICE: ALICE is an acronym that stands for Asset, Limited, Income Constrained, Employed. ALICE reports use a standardized methodology that assesses cost of living and financial hardship on a county level calculated by United Way of Northern New Jersey. Secondary source
Upstate New York Poison Center: A call center and research organization which provides poison emergency telephone management, poison information resources, public education, professional education, research and data collection, and toxicosurveillance in real time. Its coverage area includes all NYS counties except Westchester, NYC, and Long Island. Secondary source
US Census Bureau: The Census Bureau publishes population estimates and demographic components of change, such as births, deaths, and migration. This data can be sorted by characteristics such as age, sex, and race, as well as by national, state, and county location. Secondary source
US Department of Agriculture (USDA) Food Environment Atlas: An atlas from the USDA which assembles data regarding food environment factors, such as food choices, health and well-being, and community characteristics. Secondary source
US Department of Housing and Urban Development (HUD): HUD provides reports on programs provided by HUD or predecessor agencies that provide subsidized housing. These reports provide information to get a picture of subsidized households in the US. Secondary source
Vital Statistics of New York State: A registry of all births, marriages, divorces/dissolutions of marriage, deaths, induced termination of pregnancy/abortions, and fetal deaths that have occurred in NYS outside of NYC. It is maintained by the NYS Bureau of Vital Records, a branch of the NYSDOH. Secondary source
4.7 Data Notes
The following data notes provide the essential definitions of methodical standards used to ensure the accuracy and comparability of health indicators across the Mid-Hudson region. These guidelines establish a consistent framework for interpreting regional statistics, age-adjusted rates, and coding transitions, while maintaining high standards for data transparency and confidentiality.
Crude Rate versus Age-Adjusted Rate: A crude rate is defined as the total number of cases or disease events divided by the total population. The age-adjusted rates are rates that would have existed if the population under study had the same age distribution as the “standard” population. Therefore, they are summary measures adjusted for differences in age distributions. Age-adjusted rates are used when available and are calculated using the US 2000 standard population.
International Classification of Diseases: In 2015 the Department of Health and Human Services mandated those entities using ICD-9 codes transition to ICD-10 codes. Comparisons between data before and after 2015 cannot be made due to the many differences in the updated ICD-10-CM code set.
New York State excluding New York City (NYS excl NYC): The population of NYC is not similar to that of the Mid-Hudson Region. Therefore, comparing rates/percentages of counties to NYS excluding NYC, rather than to the whole of NYS, provides a more accurate comparison. When possible, measures for both NYS and NYS excluding NYC are provided. When NYS excluding NYC data are not available comparisons should be made with caution.
Rate: A rate is a measure of the frequency with which an event occurs in a defined population over a specified period of time.
Rate Denominators: Population estimates used to calculate rates sourced from data requests are from the U.S. Census Bureau’s 2023 American Community Survey (ACS) 5-Year Estimate, Table B01003. For all other rates, information on the denominator can be found at the original data source.
Suppressed and Unstable Data: Some rates/percentages based on small numbers are suppressed because they do not meet the criteria for confidentiality (notated by “s”). Other rates/percentages based on small numbers are presented but are not considered reliable since they can fluctuate greatly over time. These measures are indicated as unstable due to a small numerator (notated by “*”).
Three-Year Rate versus Single-Year Rate: When possible, rates are based on a three-year average rather than a single-year estimate to provide a more reliable comparison. Using a three-year average smooths out the data over multiple years to recognize that rates fluctuate from year to year and is particularly useful when small amounts of data are an issue.