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.
_____ 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: ____________________________________________
________ 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
Y/NPlease provide their contact information: _________________________________________________________________________________________________________
___________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: _____________________________________________________
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 ......................................................................................................._______ ____ 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........................................................................._______
